AN AMERICAN TEXT-BOOK 
 
 j 
 
 Diseases of children 
 
 INCLUDING 
 
 SPECIAL CHAPTEES ON ESSENTIAL SURGICAL SUBJECTS ; ORTHOPAEDICS ; 
 
 DISEASES OF THE EYE, EAR, NOSE, AND THROAT ; DISEASES OF THE 
 
 SKIN ; AND ON THE DIET, HYGIENE, AND GENERAL 
 
 MANAGEMENT OF CHILDREN. 
 
 BY ^MERIO^Llsr TEACHERS, 
 
 EDITED BY 
 
 LOUIS STAKE, M.D., 
 
 Consulting Paediatrist to the Maternity Hospital, Philadelphia ; Late Clinical Professor of 
 
 Diseases of Children in the Hospital of the University of Pennsylvania ; Member 
 
 of the Association of American Physicians and of the American 
 
 Pediatric Society ; Fellow of the College of 
 
 Physicians of Philadelphia, etc. 
 
 ASSISTED BY 
 
 THOMPSON S. WESTCOTT, M.D, 
 
 Instructor in Diseases of Children, University of Pennsylvania ; Visiting Physician to the 
 
 Methodist Episcopal Hospital; Physician to the Dispensary of the Children 'a 
 
 Hospital ; Fellow of the College of Physicians of Philadelphia ; 
 
 and Member of the American Pediatric Society. 
 
 SECOND EDITION, REVISER 
 
 PHILADELPHIA: 
 
 W. B. SAUNDERS, 
 
 925 Walnut Street. 
 
 L898. 
 
so 
 
 13679 
 
 Copyright, 1898, by 
 W. B. SAUNDERS, 
 
 ' m RgCIlVED. 
 
 ELECTROTYPED BY 
 WESTCOTT & THOMSON, PHILAOA. 
 
 PRINTED BY 
 W. B. SAUNDERS. PHILADA. 
 
PREFACE TO THE SECOND EDITION 
 
 To keep up with the rapid advances in the field of paediatrics and to round 
 into a more perfect treatise the work so admirably accomplished by the various 
 authors, most of whom labored entirely independently of one another, the 
 whole subject matter embraced in the first edition of this work has been care- 
 fully revised ; new articles have been added ; some of the original papers have 
 been emended, and a number have been entirely rewritten and brought up to 
 date. For greater accuracy in classification, the section on the Infectious 
 Diseases has been rearranged so as to embrace Tuberculosis and Malaria. 
 The new articles include " Modified Milk and Percentage Milk Mixtures.'' 
 "Lithaemia," and a section on Orthopaedics; those rewritten are "Typhoid 
 Fever," ".Rubella," "Chicken-pox, "Tuberculous Meningitis," "Hydro- 
 cephalus," and "Scurvy"; while more or less extensive revision has been 
 made in the chapters on Infant Feeding, Measles, Diphtheria, and Cretinism. 
 The volume has been thus increased in size by fully fifty pages of fresh 
 material. 
 
 The editor records with profound regret the decease of two of his most 
 valued collaborators — Dr. Charles Warrington Earle, of Chicago, and Dr. J. 
 Lewis Smith, of New York — to whose pioneer work in paediatrics the medical 
 profession owes a lasting debt of gratitude. 
 
 The editor gratefully acknowledges the flattering reception accorded the 
 first edition of the work, and expresses his thanks to Dr. Thompson S. Westeott 
 for his most efficient assistance in the preparation of the revision. 
 
 LOUIS STARR. 
 
PREFACE. 
 
 In the preparation of this volume the Editor's object has not been to add 
 unnecessarily to the number of encyclopedias already existing, but to present 
 to the profession a working text-book which shall be closely limited to. while 
 completely covering, the field of pediatrics. 
 
 To make such a book useful to the practitioner, who must too often read 
 as he runs, and to the student, who of necessity is unable to devote his study 
 hours to one branch of medical science, but must divide them between many 
 general and special subjects, it seems essential that certain conditions should 
 be closely adhered to. These are — first, careful condensation, without omission, 
 that the whole subject may be embraced between the covers of one readily 
 handled volume ; second, limitation of the subject-matter to such practical 
 points as Etiology, Symptomatology, Diagnosis, and Treatment including 
 Feeding, Hygiene, Therapeutics and the Prevention of Disease, while avoid- 
 ing, so far as possible, the insertion of references to journals or authorities, 
 of more interest to those engaged in research than to those in active practice : 
 third, the selection of a large staif of collaborators from the most important 
 medical centres of our country, to secure for each subject the care of the 
 authority best fitted to portray it, to give the work broadness and stamp it 
 with a national, rather than a sectional, imprint ; fourth, so to time the pub- 
 lication that, without undue haste, each article contributed should have the 
 same freshness, and the book as a whole be thoroughly abreast with the rapid 
 advance which is constantly made in this branch of our profession : finally, 
 the addition of chapters upon certain subjects which, though usually treated 
 specially and separately, constantly come under the notice of those who work 
 with, or study, the ills of childhood, such as diseases of the eve. the ear, 
 the skin, the nose and throat, and the anus and rectum ; circumcision, 
 tracheotomy, intubation, vesical calculus, venereal disease and allied sub 
 These conditions we have endeavored to fulfil. 
 
vi PREFACE. 
 
 In conclusion, the Editor desires to thank individually the collaborators he 
 has been so very fortunate in securing, and to tender them, in advance, the 
 greater share of whatever credit may attend the venture. His thanks are 
 also due to Dr. Thompson S. Westcott for his most efficient and interested 
 assistance. 
 
 LOUIS STARK. 
 
 1818 rlttenhouse square. 
 Philadelphia. 
 
LIST OF CONTRIBUTORS. 
 
 SAMUEL S. ADAMS, A. M., M. D., 
 
 Professor of Diseases of Infancy and Childhood, Georgetown University, Washing- 
 ton, D. C. 
 
 JOHN ASHHURST, Jr., M. D., 
 
 Barton Professor of Surgery, and Professor of Clinical Surgery, University of Penn- 
 sylvania. 
 
 A. D. BLACKADER, M. D., 
 
 Professor of Pharmacology and Therapeutics, and Lecturer on Diseases of Children, 
 McGill University, Montreal, Canada. 
 
 DAVID BOVAIRD, M. D., 
 
 Clinical Assistant to the Chair of Diseases of Children, Bellevue Hospital Medical 
 College, New York. 
 
 DILLON BROWN, M. D., 
 
 Adjunct Professor, Department of Diseases of Children, New York Polyclinic; Visiting 
 Physician to Episcopal Orphan Asylum, New York. 
 
 EDWARD M. BUCKINGHAM, M. D., 
 
 Instructor in Diseases of Children, Harvard University. 
 
 CHARLES W. BURR, M. D., 
 
 Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia. 
 
 WM. E. CASSELBERRY, M. D., 
 
 Professor of Laryngology and Rhinology in the Chicago Medical College. 
 
 HENRY DWIGHT CHAPIN, M. D., 
 
 Professor of Diseases of Children in the New York Post-Graduate Medical School and 
 Hospital. 
 
 W. S. CHRISTOPHER, M. D., 
 
 Professor of Paediatrics, College of Physicians and Surgeons, Chicago. 
 
 ARCHIBALD CHURCH, M. D., 
 
 Professor of Neurology, Chicago Polyclinic, and Professor of Mental Diseases 'and 
 Clinical Neurology in the Chicago Medical College 
 
 FLOYD M. CRANDALL, M. D., 
 
 Adjunct Professor, Department of Diseases of Children, New York Polyclinic. 
 
 ANDREW F. CURRIER, M. 1)., 
 
 Assistant Gynaecologist, Skin and Cancer Hospital, Now York; Visiting Gynecologist, 
 Out-door Poor Department, Bellevue Hospital. Now York; Consulting Gyi 
 
 Ogist, McDonough Memorial Hospital, Now York. 
 
 ROLAND G. CURTIN, M. D., 
 
 Consulting Physician to the Rush Hospital for Consumptives, St Timothy's, and 
 las Hospitals. Philadelphia. 
 
viii LIST OF CONTRIBUTORS. 
 
 J. M. DaCOSTA, M.D., LL.D., 
 
 Emeritus Professor of Practice of Medicine and Clinical Medicine, Jefferson Medical 
 College, Philadelphia. 
 
 I. N. DANFORTH, A.M., M.D., 
 
 Professor of Principles and Practice of Medicine and of Clinical Medicine, North- 
 western University, Woman's Medical School, Chicago. 
 
 EDWARD P. DAYIS, A. M., M. D., 
 
 Professor of Obstetrics, Jefferson Medical College, Philadelphia ; Professor of Obstetrics 
 and Diseases of Infancy, Philadelphia Polyclinic. 
 
 JOHN B. DEAVER, M.D., 
 
 Assistant Professor of Applied Anatomy in the University of Pennsylvania ; Professor 
 of Surgery in the Philadelphia Polyclinic. 
 
 GEORGE E. de SCHWEINITZ, M. D., 
 
 Professor of Ophthalmology, Jefferson Medical College, Philadelphia. 
 
 JOHN DORNING, M.D., 
 
 Instructor in Diseases of Children in the New York Post-Graduate Medical School and 
 Hospital ; Attending Physician to Demilt Dispensary, New York. 
 
 CHAS. WARRINGTON EARLE, M. D., 
 
 Late Professor of Diseases of Children, Woman's Medical College, Chicago. 
 
 WM. A. EDWARDS, M. D., 
 
 San Diego, Cal. 
 
 FREDERICK FORCHHEIMER, M. D., 
 
 Professor of Practice of Medicine and Diseases of Children, Medical College of Ohio. 
 
 J. HENRY FRUITNIGHT, A.M., M.D., 
 
 Attending Physician to St. John's Guild Hospital for Children, New York. 
 
 J. P. CROZER GRIFFITH, M.D., 
 
 Clinical Professor of Diseases of Children, University of Pennsylvania. 
 
 WM. A. HARD AW AY, A.M., M. D., 
 
 Professor of Diseases of the Skin and Syphilis, Missouri Medical College, St. Louis. 
 
 MARCUS P. HATFIELD, M. D., 
 
 Emeritus Professor of Diseases of Children, Chicago Medical College. 
 
 BARTON COOKE HIRST, M. D., 
 
 Professor of Obstetrics, L'niversity of Pennsylvania. 
 
 H. ILLOWAY, M.D., 
 
 Professor of Diseases of Children, Cincinnati College of Medicine and Surgery. 
 
 HENRY JACKSON, M. D., 
 
 Physician to Out-Patient Department, Boston City Hospital. 
 
 CHAS. G. JENNINGS, M.D., 
 
 Professor of Practice of Medicine and Diseases of Children, Detroit College of Medi- 
 
LIST OF CONTRIBUTORS. ix 
 
 HENRY KOPLIK, M. D., 
 
 Attending Physician, Good Samaritan Dispensary, New York; Adjunct Attending 
 Physician, Mt. Sinai Hospital (Children), New York. 
 
 THOMAS S. LATIMER, M. D., 
 
 Professor of Principles and Practice of Medicine, College of Physicians and Surgeons, 
 Baltimore. 
 
 ALBERT R. LEEDS, Ph.D., 
 
 Professor of Chemistry, Stevens Institute of Technology, Hoboken. 
 
 J. HENDRIE LLOYD, A.M., M. D., 
 
 Neurologist to the Philadelphia Hospital ; Physician to the Methodist Episcopal Hospi- 
 tal and to the Home for Crippled Children, Philadelphia. 
 
 GEO. ROE LOCKWOOD, M. D., 
 
 Professor of Principles and Practice of Medicine, Woman's Medical College of New 
 York Infirmary. 
 
 HENRY M. LYMAN, M. D., 
 
 Professor of the Principles and Practice of Medicine, Rush Medical College, Chicago. 
 
 FRANCIS T. MILES, M. D., 
 
 Professor of Physiology, and Clinical Professor of Diseases of the Nervous System, 
 University of Maryland. 
 
 CHAS. K. MILLS, M. D., 
 
 Professor of Mental Diseases and of Medical Jurisprudence, University of Pennsyl- 
 vania; Professor of Diseases of the Mind and Nervous System, Philadelphia 
 Polyclinic. 
 
 JAMES E. MOORE, M. D., 
 
 Professor of Orthopedia and of Clinical Surgery, University of Minnesota. 
 
 F. GORDON MORRILL, M. D., 
 
 Visiting Physician to Children's Hospital, Boston. 
 
 JOHN H. MUSSER, M. D., 
 
 Assistant Professor of Clinical Medicine, University of Pennsylvania. 
 
 THOMAS R. NEILSON, M. D., 
 
 Professor of Genito-urinary Surgery, Philadelphia Polyclinic. 
 
 WM. PERRY NORTHRUP, M. D., 
 
 Professor of Paediatrics, Bellevue Hospital Medical College, New York. 
 
 WM. OSLER, M.D., 
 
 Professor of the Principles and Practice of, Medicine, Johns Hopkins University 
 timore. 
 
 FREDERICK A. PACKARD, M. D., 
 
 Instructor in Clinical Medicine, University of Pennsylvania, and Visiting Physician to 
 the Children's Hospital, Philadelphia. 
 
 WM. PEPPER, M.D., LL.D., 
 
 Professor of the Theory and Practice of Medicine in the University of Pennsylvania. 
 
 FREDERICK PETERSON, MD., 
 
 Clinical Professor of Mental Diseases. Woman's Medical College of the Nei 
 Infirmary. 
 
x LIST OF CONTRIBUTORS. 
 
 WM. T. PLANT, M.D., 
 
 Emeritus Professor of Paediatrics, Syracuse University, New York. 
 
 WM. M. POWELL, M.D., 
 
 Attending Physician to the Mercer Memorial Home, Atlantic City. 
 
 B. K. RACHFORD, M.D., 
 
 Professor of Physiology and Clinician to Children's Clinic, Medical College of Ohio. 
 
 B. ALEXANDER RANDALL, A.M., M. D., 
 
 Clinical Professor of Diseases of the Ear, University of Pennsylvania. 
 
 EDWARD 0. SHAKESPEARE, A.M., M. D., Ph.D., 
 
 Late Pathologist to the Philadelphia Hospital ; late United States Commissioner to In- 
 vestigate Cholera; late United States Commissioner to the International Sanitary 
 Conference of Paris. 
 
 FREDERICK C. SHATTUCK, M. D., 
 
 Jackson Professor of Clinical Medicine in Harvard University. 
 
 J. LEWIS SMITH, M.D., 
 
 Late Professor of Diseases of Children, Bellevue Hospital Medical College, New York. 
 
 M. ALLEN STARR, M. D., 
 
 Professor of Diseases of the Mind and Nervous System, College of Physicians and Sur- 
 geons, New York. 
 
 LOUIS STARR, M. D., 
 
 Consulting Psediatrist to the Maternity Hospital, Philadelphia ; Late Clinical Professor 
 of Diseases of Children, University of Pennsylvania. 
 
 CHARLES W. TOWNSEND, M. D., 
 
 Physician to Out-Patients at Massachusetts General, Children's, and Boston Lying-in 
 Hospitals. 
 
 JAMES TYSON, M. D., 
 
 Professor of Clinical Medicine, University of Pennsylvania. 
 
 W. S. THAYER, M.D., 
 
 Associate Professor of Medicine, Johns Hopkins University ; Kesident Physician to the 
 Johns Hopkins Hospital, Baltimore. 
 
 VICTOR C. VAUGHAN, M. D., 
 
 Professor of Hygiene and Physiological Chemistry, University of Michigan. 
 
 THOMPSON S. WESTCOTT, M.D., 
 
 Instructor in Diseases of Children, University of Pennsylvania ; Assistant Physician to 
 the Children's Hospital, Philadelphia. 
 
 HENRY R. WHARTON, A.M., M. D., 
 
 Lecturer on Surgical Diseases of Children and Demonstrator of Surgery, University of 
 Pennsylvania ; Surgeon to the Children's Hospital, Philadelphia. 
 
 J. WILLIAM W T HITE, M. D., 
 
 Professor of Clinical Surgery, University of Pennsylvania. 
 
 JAMES C. WILSON, M. D., 
 
 Professor of the Practice of Medicine and of Clinical Medicine, Jefferson Medical 
 College, Philadelphia. 
 
CONTENTS 
 
 INTRODUCTION. 
 
 Page 
 THE CLINICAL INVESTIGATION OF DISEASE AND THE GENERAL 
 
 MANAGEMENT OF CHILDREN. By Louis Starr, M. D 1 
 
 Feeding. — Bathing. — Clothing. — Sleep. 
 
 THE CHEMISTRY OF MILK AND OF ARTIFICIAL FOODS FOR CHIL- 
 DREN. By Albert R. Leeds, Ph. D 37 
 
 MODIFIED MILK AND PERCENTAGE MILK-MIXTURES. By Thompson S. 
 
 Westcott, M. D 53 
 
 SEA-AIR AND SEA-BATHING IN CONVALESCENCE. By W. M. Powell, 
 
 M.D 60 
 
 PART I. 
 
 INJURIES INCIDENT TO BIRTH AND DISEASES OF THE NEW-BORN. 
 
 By Edward P. Davis, A. M., M. D 68 
 
 Caput Succedaneum. — Cephalhematoma. — Hematoma of the Sterno-cleido-mastoid Mus- 
 cle. — Haemorrhage in the New-born. — Asphyxia. — Haemorrhages from Mucous Sur- 
 faces. — Obstetric Paralysis and Injuries to the Nervous System. — Fractures and Dislo- 
 cations of the Trunk and Extremities. — Umbilical Haemorrhage. — Umbilical Polypi. 
 — Umbilical Hernia. — Gastro-intestinal Haemorrhage. — Icterus Neonatorum. — The 
 Infections attacking the New-born. — General Septic Infection. — Erysipelas, — Acute 
 Peritonitis in the New-born. — Tubercular and Typhoid Infections. — Inspiration 
 Pneumonia. — Tetanus. — Mastitis. — Infections of the Blood. — Meleena Neonatorum. 
 
 PART II. 
 THE DIATHETIC DISEASES, 
 
 LITHiEMIA. By B. K. Rachfobd, M. D H 
 
 HEREDITARY SYPHILIS. By Henry Dwight Chapin, M.D 108 
 
xii CONTENTS. 
 
 PART III. 
 THE INFECTIOUS DISEASES. 
 
 Page 
 MEASLES. By Louis Starr, M. D = 117 
 
 SCAELET FEVER. By Marcus P. Hatfield, M. D. - 131 
 
 RUBELLA. By Wm. T. Plant, M. D 152 
 
 CHICKEN-POX. By Wm. T. Plant, M. D. 156 
 
 VARIOLA AND VARIOLOID. By C.G.Jennings, M. D 163 
 
 VACCINIA. By Thompson S. Westcott, M. D 171 
 
 PAROTITIS. By Andrew F. Currier, M. D 177 
 
 WHOOPING-COUGH. By J. P. Crozer Griffith, M. D 182 
 
 TYPHOID FEVER. By F. Gordon Morrill, M. D 194 
 
 EPIDEMIC CEREBROSPINAL MENINGITIS. By Roland G. Curtin, M. D, . . 208 
 
 EPIDEMIC INFLUENZA. By Chas. Warrington Earle, M. D 214 
 
 ERYSIPELAS. By Frederick A. Packard, M. D 221 
 
 CHOLERA. By E. O. Shakespeare, M. D 231 
 
 DIPHTHERIA. By Dillon Brown, M. D 250 
 
 TUBERCULOSIS. By Wm. Osler, M. D, M. R. C. P 270 
 
 MALARIAL FEVER. By W. S. Thayer, M. D 303 
 
 PAET IV. 
 
 GENERAL DISEASES NOT INFECTIOUS. 
 
 RACHITIS. By J. Lewis Smith, M. D 319 
 
 RHEUMATISM. By J. M. DaCosta, M. D., LL.D 351 
 
 PART V. 
 
 DISEASES OF THE BLOOD. 
 
 ANEMIA, SPLENIC AKZEMIA, LYMPHATIC AN.EMIA, AND LEUKAEMIA. 
 
 By Frederick A. Packard, M. D 359 
 
 HAEMOPHILIA. By Wm. Perry Northrup, M. D 377 
 
 PURPURA HEMORRHAGICA. By Geo. Roe Lockwood, M. D 379 
 
 SCORBUTUS. By Wm. P. Northrup, M. D., and David Bovaird, M. D 389 
 
CONTENTS. xiii 
 
 PART VI. 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Page 
 I. DISEASES OF THE MOUTH; II. DENTITION. By F. Forchheimer, M. D. 396 
 
 Stomatitis Catarrhalis. — Stomatitis Aphthosa. — Stomatitis Mycosa. — Stomatitis Ulcerosa. 
 — Stomatitis Gangrenosa. — Stomatitis Crouposa and Diphtheritica. — Stomatitis 
 Syphilitica. — Dentition. 
 
 DISEASES OF THE PHAEYNX AND NASO-PHAKYNX. By W. E. Cassel- 
 
 BERRY, M. D 415 
 
 Acute Pharyngitis and Naso-pharyngitis. — Simple Chronic Pharyngitis and Elongation 
 of Uvula. — Chronic Folliculous Pharyngitis. — Acute Folliculous Tonsillitis. — Peri- 
 tonsillar Abscess or Suppurative Tonsillitis. — Hypertrophy of the Tonsils. 
 
 GASTKIC CATAEKH (ACUTE AND CHEONIC) ; GASTEIC ULCEE. By A. D. 
 
 Blackader, M. D. . . . • 441 
 
 MUCOUS DISEASE (CHEONIC GASTEO-INTESTINAL CATAEEH). By W. A. 
 
 Edwards, M. D 454 
 
 DIAEEHOSAL DISEASES. By Victor C. Vattghan, M. D 463 
 
 Acute Intestinal Indigestion. — Chronic Intestinal Indigestion. — Milk Infection, Acute, 
 Subacute. 
 
 INFLAMMATION OF COLON AND EECTUM (DYSENTEEY). By S. S. 
 
 Adams, M. D 485 
 
 CHEONIC CONSTIPATION. By J. Henry Fruitnight, A. M., M. D 496 
 
 SIMPLE ATEOPHY. By Louis Starr, M. D 503 
 
 DISEASES OF THE CECUM AND APPENDIX. By John Ashhurst, Jr., M. D. 509 
 
 INTUSSUSCEPTION. By John Ashhurst, Jr., M. D. . . 517 
 
 INTESTINAL PAEASITES. By Chas. W. Townsend, M. D 524 
 
 DISEASES OF THE LIVEE. By John H. Musser, M. D 53S 
 
 Jaundice. — Congestion of the Liver. — Fatty Liver. — Amyloid Disease of the Liver. 
 
 — Syphilitic Inflammation of the Liver. — Suppurative Hepatitis. — Hydatid Disease. 
 
 — Cirrhosis of the Liver. 
 
 PEEITONITIS, TUMOES OF THE PEEITONEUM AND OMENTUM, AND 
 
 ASCITES. By J. Henry Fruitnight, A. M., M. D 563 
 
 CONGENITAL INTESTINAL MALFOEMATIONS, AND DISEASES OF THE 
 
 ANUS AND EECTUM. By Henry E. Wharton, M. D 575 
 
 Pruritus Ani. — Syphilitic Affections of the Anus. — Vegetations and Warts. — Fistula in 
 Ano. — Fissure of the Anus. — Stricture of the Anus. — Marginal Abscess. — Diph- 
 theria of the Anus. — Proctitis and Periproctitis. — Ischiorectal Abscess. — Ulceration, 
 Stricture, and Syphilis of the Eectum. — Prolapsus of the Rectum. — Hemorrhoids. — 
 Polypus and Nrevus of the Eectum. — Malignant Diseases o( the Keetum. — Wounds 
 of, and Foreign Bodies in, the Eectum. 
 
 PART VII 
 
 DISEASES OF THE NERVOUS SYSTEM* 
 
 SIMPLE CEEEBEAL MENINGITIS. By Thos, S. Latimer, M. P. 
 SIMPLE CEEEBEO-SPINAL MENINGITIS. l>v Thos. & UlTMER, M. P. 
 
xiv CONTENTS. 
 
 Page 
 TUBERCULOUS MENINGITIS. By James Hendrie Lloyd, M. D 610 
 
 HYDROCEPHALUS. By James Hendrie Lloyd, M. D 624 
 
 ABSCESS OF THE BRAIN. By Frederick Peterson, M. D 630 
 
 TUMORS OF THE BRAIN AND MENINGES. By Frederick Peterson, M. D. 634 
 
 THE AFFECTIONS OF THE NERVOUS SYSTEM DUE TO INHERITED 
 
 SYPHILIS. By Chas. W. Burr, M. D 645 
 
 INFANTILE CEREBRAL PALSIES. By Frederick Peterson, M. D 649 
 
 SPEECH DEFECTS AND ANOMALIES. By Chas. K. Mills, M. D 658 
 
 IDIOCY AND IMBECILITY. By Chas. K. Mills, M. D 667 
 
 CRETINISM. By Chas. K. Mills, M. D 680 
 
 MYOTONIA, OR THOMSEN'S DISEASE. By Chas. K. Mills, M. D 687 
 
 ACROMEGALY. By Chas. K. Mills, M. D 690 
 
 ATHETOSIS AND ATHETOID AFFECTIONS. By Chas. K. Mills, M. D. . . 694 
 
 INSANITY IN CHILDREN. By Chas. K. Mills, M. D 697 
 
 IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. By Chas. K. Mills, 
 
 M. D 712 
 
 HEADACHE. By Chas. K. Mills, M. D 718 
 
 HYSTERIA. By James Hendrie Lloyd, M. D 727 
 
 CONVULSIONS. By Frederick Peterson, M. D 741 
 
 EPILEPSY. By James Hendrie Lloyd, M. D 747 
 
 CHOREA. By M. Allen Starr, M. D., Ph. D 754 
 
 TETANY. By Henry M. Lyman, M. D 764 
 
 PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. By F. T. Miles, M.D. 768 
 
 FACIAL PARALYSIS, AND FACIAL HEMIATROPHY. By Chas. W. Burr, M.D. 774 
 
 INFLAMMATORY DISEASES OF THE SPINAL MENINGES AND SPINAL 
 
 CORD. By Archibald Church, M. D 777 
 
 ACUTE ANTERIOR POLIOMYELITIS. By Archibald Church, M. D. . . . 789 
 
 LANDRY'S PARALYSIS. By Archibald Church, M. D 798 
 
 TUMORS OF THE SPINAL CORD. By James Hendrie Lloyd, M. D 801 
 
 SYRINGOMYELIA AND HYDROMYELIA. By James Hendrie Lloyd, M. D. 809 
 
 HEREDITARY ATAXIA. By Archibald Church, M. D. . 815 
 
 RAYNAUD'S DISEASE. By Thompson S. Westcott, M. D 820 
 
 PART VIII. 
 
 DISEASES OF THE RESPIRATORY SYSTEM. 
 
 DISEASES OF THE NOSE. By W. E. Casselberry, M. D 826 
 
 Acute Rhinitis.— Simple Chronic Rhinitis and Purulent Rhinitis.— Hypertrophic 
 Rhinitis.— Atrophic Rhinitis.— Nasal Myxomata .— Hereditary Syphilis of the Nose 
 and Throat. 
 
 CATARRHAL LARYNGITIS (SPASMODIC CROUP). By H. Illoway, M. D. . 844 
 
 LARYNGISMUS STRIDULUS. By H. Illoway, M. D 857 
 
 FOREIGN BODIES IN LARYNX AND TRACHEA. By John B. Deaver, M.D. 865 
 
CONTENTS. xv 
 
 L'AGE 
 
 TKACHEOTOMY. By Henry K. Wharton. M. D 870 
 
 INTUBATION OF LAEYNX. By Henry R. Wharton, M. D 891 
 
 POST-NATAL ATELECTASIS. By S. S. Adams, M. D 898 
 
 BRONCHO-PNEUMONIA. By William Pepper, M. D 004 
 
 CROUPOUS PNEUMONIA. By William Pepper, M. D 013 
 
 GANGRENE AND ABSCESS OF THE LUNG. By Henry Jackson, M. D. . . 010 
 
 BRONCHITIS. By W. S. Christopher, M. D 924 
 
 PLEURISY AND EMPYEMA. By Henry Koplik, M. D 035 
 
 PULMONARY EMPHYSEMA. By John Dorning, M. D 950 
 
 BRONCHIAL ASTHMA. By John Dorning, M. D 056 
 
 FIBROID PHTHISIS. By Frederick C. Shattuck, M. D 963 
 
 PART IX. 
 
 DISEASES OF THE HEART. 
 
 CONGENITAL AFFECTIONS OF THE HEART. By Barton Cooke Hirst, 
 
 M. D 968 
 
 ORGANIC DISEASE OF THE HEART. By Floyd M. Crandall, M. D. . . . 974 
 Pericarditis. — Acute Endocarditis. — Chronic Heart Disease. 
 
 FUNCTIONAL AFFECTIONS OF THE HEART (THE CARDIAC NEUROSES). 
 
 By J. C. Wilson, M. D 986 
 
 PAET X. 
 
 DISEASES OF THE GENITO- URINARY SYSTEM. 
 HEMATURIA, PYURIA, ENURESIS, Etc. By E. M. Buckingham, M. D. . 991 
 
 DIABETES MELLITUS, DIABETES INSIPIDUS, AND LITHIASIS. By James 
 
 Tyson, M. D 999 
 
 ACUTE AND CHRONIC NEPHRITIS, AND AMYLOID DISEASE OF THE 
 
 KIDNEY. By I. N. Danforth, M. D 1011 
 
 TUMORS AND OTHER ENLARGEMENTS OF THE KIDNEY. By Thomas 
 
 R. Neilson, M. D 1027 
 
 Renal Cysts.— Hydronephrosis. — Pyonephrosis.— Perinephritie Abscess.— Tumors of the 
 Kidney. 
 
 VESICAL CALCULUS. By J. William White, M. 11 1038 
 
 GONORRHOEA AND VULVO-VAGINITIS. By J. William Whitk, M. D. 
 
 PHIMOSIS, ADHERENT PREPUCE, PARAPHIMOSIS. By Henry K. Whar- 
 ton, M. D 1057 
 
 PAET XI. 
 
 ORTHOPAEDICS. By James E. Moore, M. D 
 
xvi CONTEXTS. 
 
 PART XII. 
 
 Page 
 DISEASES OF THE SKIN. By W. A. Haedaway, M. D 1090 
 
 I. Disorders of the Glands : Sebaceous Glands : Seborrhea, Comedo, Acne, Milium. 
 
 Sweat- Glands: Hyperidrosis, Miliaria. 
 II. Inflammations : Erythema Simplex, Erythema Multiforme, Herpes Iris, Erythema 
 Nodosum, Eelapsing Scarlatiniform Erythema, Eczema, Lichen Planus, Psoriasis, 
 Pemphigus, Herpes Simplex, Herpes Zoster, Impetigo Contagiosa, Dermatitis 
 Exfoliativa Neonatorum, Dermatitis Gangrenosa Infantum (Crocker), Urticaria 
 Pigmentosa, Pityriasis Eosea, Prurigo, Furunculus. 
 
 III. Hemorrhages: Purpura. 
 
 IV. Hypertrophies: Lentigo, Ichthyosis, Molluscum Epitheliale, Verruca, Nsevus 
 
 Pigmentosus, Sclerema Neonatorum, Scleroderma, Morphoea. 
 V. Atrophies : Albinism, Leucoderma, Alopecia Areata. 
 VI. New Growths: Kaposi's Disease, Nsevus Vascularis, Lupus Vulgaris, Scrofulo- 
 derma, Syphiloderma. 
 VII. Parasitic Affections: Tinea Favosa, Tinea Trichophytina, Scabies, Pediculosis. 
 
 PART XIII. 
 
 DISEASES OF THE EAE. By B. Alexander Eandall, A. M., M. D 1158 
 
 I. Affections of the External Ear : Eczematous Inflammations, Furuncle, Ceru- 
 men Impaction, Foreign Bodies, Caries of the Wall of the Auditory Canal, Congeni- 
 tal Atresia. 
 II. Affections of the Middle Ear : Acute Simple Inflammation of Middle Ear, 
 Acute Suppurative Inflammation of Middle Ear. Chronic Suppuration of Middle 
 Ear. 
 III. Affections of the Internal Ear. 
 
 PART XIV. 
 
 DISEASES OF THE EYE. By G. E. de Schweinitz, M. D 1178 
 
 I. Diseases of the Lids : Abscess and Furuncle, Hordeolum, Exanthematous Erup- 
 tions, Blepharitis, Phthiriasis, Syphilis of the Eyelids, Tumors and Hypertrophies, 
 Tarsitis, Blepharospasm, Ptosis, Lagophthalmos, Symblepharon, Trichiasis and Dis- 
 tichiasis, Entropion, Ectropion, Milium, Molluscum Contagiosum, Sebaceous and 
 Dermoid Cysts, Injuries of the Eyelids, Emphysema of the Eyelids. 
 II. Diseases of the Conjunctiva: Simple Conjunctivitis, Purulent Conjunctivitis, 
 Diphtheritic Conjunctivitis, Spring Catarrh, Follicular Conjunctivitis, Granular Con- 
 junctivitis. Ecchymosis of Conjunctiva, Chemosis, Tumors and Cysts, Tubercle, 
 Injuries, Phlyctenular Keratoconjunctivitis. 
 
 III. Diseases of the Cornea : Ulcer, Kerato-malacia, Interstitial Keratitis, Injuries, 
 
 Foreign Bodies. 
 
 IV. Diseases of the Iris and Ciliary Body : Iritis, Gumma of Iris, Injuries to 
 
 the Iris and Ciliary Eegion, Sympathetic Irritation and Sympathetic Inflammation. 
 V. Diseases of the Lachrymal Apparatus : Dacryoadenitis, Dacryocystitis, Lach- 
 rymal Abscess. 
 VI. Diseases of the Orbit : Periostitis, Cellulitis, New Growths. 
 VII. Congenital Cataract. 
 
 VIII. The Eefraction of the Eye in Childhood. 
 IX. Strabismus, or Squint. 
 
AN AMERICAN TEXT-BOOK 
 
 OF THE 
 
 DISEASES OF CHILDREN. 
 
 INTRODUCTION. 
 
 THE CLINICAL INVESTIGATION OF DISEASE AND THE 
 GENERAL MANAGEMENT OF CHILDREN. 
 
 By LOUIS STARR, M. D., 
 
 Philadelphia. 
 
 I. THE CLINICAL INVESTIGATION OP DISEASE. 
 
 Early life may be divided into two periods — namely, infancy and child- 
 hood. Infancy is the time elapsing between birth and the complete eruption 
 of the milk teeth, an event that transpires about the end of the second year of 
 life; childhood extends from this age to the development of puberty, about the 
 age of thirteen or fifteen years. 
 
 Of the diseases that may occur during these periods a few are peculiar to 
 the time of life, or are "children's diseases" proper; others, while identical 
 in class with the ordinary affections of adult and mature years, are variously 
 modified in symptoms and course by conditions inherent to early age : but in 
 all the clinical investigation is beset with difficulties which the student must 
 be prepared to overcome. Thus, the absence of speech in the infant deprives 
 us of the important assistance afforded by correctly described subjective symp- 
 toms, and renders it necessary to look to the mother or nurse for the history 
 of an illness. In older children the case is little better, since with them words 
 are not prompted by sufficient knowledge to be of great service. Further, the 
 wilfulness, dislikes, fear, and agitation of the child are impediments which 
 must be overcome before a satisfactory examination can be made, and which 
 will often tax the skill and patience of the physician to the utmost in the over- 
 coming. Another source of difficulty lies in the activity of growth and devel- 
 opment in infants, which renders them liable to be affected by slight causes, 
 and makes disease sudden in its attack, short in its course, and intense in its 
 symptoms. The rapid development of the nervous system especially leads to 
 confusion. The nerves bind every portion oi' the frame in a sympathy so close 
 that an affection of a single part may cause marked genera] disturbance, and 
 local symptoms are often reflected, directing attention to organs very distant 
 from those really diseased. Finally, the extreme excitability o( the nervous 
 system of healthy children often causes a trifling illness to assume an asp< 
 the greatest gravity ; while, on the contrary, the depression of nen 
 
2 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bility that attends chronic wasting diseases so obscures the symptoms that a 
 dangerous intercurrent affection may appear trifling or remain altogether 
 latent. 
 
 On the other hand, to offset these difficulties, disease in the child is usually 
 uncomplicated, rarely has its course and symptoms modified by tissue lesions 
 the result of previous affections, and never by vicious habits, such as the abuse 
 of stimulants and narcotics, or by mental overwork and nerve-strain. The 
 confusing element of misstated subjective symptoms is also absent, while cor- 
 rect diagnosis is greatly aided by the facility with which physical examination 
 of the whole body may be practised. 
 
 In conducting the investigation it is well to proceed in three regular stages, 
 as follows : 1st. Questioning the attendants ; 2d. Inspecting the child ; 3d. 
 Physical examination. 
 
 1. Questioning the Attendants. 
 
 When the patient is under eight or ten years of age, the only way of 
 obtaining a knowledge of the previous history and of what may occur between 
 visits is carefully to question the mother or nurse. The account must be 
 patiently elicited, and credited with due reference to the narrator's intelligence. 
 It is well never entirely to discredit a statement without good reason, for many 
 women, though weak and foolish in other respects, are excellent observers when 
 their powers are guided by affection. Besides, being thoroughly acquainted 
 with their children's habits and dispositions, they will often detect deviations 
 from health that the physician might overlook entirely. This part of the 
 examination, particularly when the acquaintance and good-will of the child 
 have not previously been obtained, should, if possible, be made before entering 
 the sick-room. 
 
 As there are certain points about which it is always necessary to be 
 informed, the adoption of a definite order of questioning is advisable. 
 
 The family history as far back as the parents should first be ascertained, 
 inquiry being chiefly directed to the detection of chronic maladies and trans- 
 missible diseases, as tuberculosis and syphilis. If any deaths have occurred, 
 their causation should be investigated ; and an inquiry into the occurrence, or 
 the reverse, of previous stillbirths is often important. Then an outline of the 
 child's life from birth up to the date of the illness in question must be obtained. 
 This should include the following items : The manner of feeding during 
 infancy — whether at the breast or from a bottle, and if the latter, the com- 
 position of the food employed ; the date of commencement and the regularity 
 of dentition ; the general state of health in regard to strength or weakness and 
 liability to illness ; the time of occurrence and the nature of any prominent 
 attack of illness, especially of the eruptive fevers ; whether vaccination has 
 been performed or no ; the hygienic surroundings — for instance, the healthful- 
 ness of the locality of residence, the sort of house and room occupied, and the 
 character of the clothing and food. In older children, if at school, the time 
 devoted to study, and if at labor, the nature and the hours of work. 
 
 After this it is necessary to fix the time the attack in hand began. The 
 occurrence of some striking symptom, as convulsions or violent vomiting, often 
 establishes this point beyond a doubt ; but when there is any uncertainty the 
 best plan is to question back, day by day, until a time is reached at which the 
 child was perfectly well, and to date the onset from this period. The most 
 common of the general indications of commencing illness are disturbed sleep 
 and irritability of temper. 
 
CLINICAL INVESTIGATION OF DISEASE. 3 
 
 The next step is to learn the mode of attack and the symptoms and course 
 of the disease prior to the first visit. The questions now must he general, 
 never leading. They must be sufficiently exhaustive to touch upon all the 
 functions of the body, and when a trail is started it must be patiently followed 
 to the end. Alterations in sleep, bodily strength, surface temperature, appe- 
 tite, digestion, urine elimination, respiration, and so on, must be sought for, 
 and the account of such deviations from the normal state as vomiting, diarrhoea, 
 or cough will suggest further questions, as well as point out the path to be 
 followed in the future examination. 
 
 This portion of the investigation is closed by an inquiry into the treatment 
 that may have been already adopted. 
 
 2. Inspecting the Child. 
 
 When the eye and ear of the physician are trained to their work, valuable 
 information can be obtained by simply looking at an ill child and listening to 
 its cry or spoken words. Even while the child is lying asleep or sitting quietly 
 in the nurse's lap many facts may be learned ; but this portion of the exami- 
 nation is never complete without an inspection of the naked body. The points 
 thus ascertained consist in alterations in the expression of the face, in decubitus, 
 in the appearances of the body, and so on, and may be designated the features 
 of disease. The relative position of the observer and patient during inspection 
 is of importance. If possible, the former should stand with his back to, and 
 the latter be so placed that his face is toward, a window or lamp. The light 
 must never be strong enough to dazzle when the countenance is the object of 
 inspection, as this causes distortion of the features. 
 
 For convenience, the features of disease will be studied under different 
 headings; and since to appreciate them it is necessary to have a knowledge of 
 the healthy aspect, both the normal and abnormal appearances will be described. 
 
 Face. — The face of a healthy sleeping child wears an expression of perfect 
 repose. The eyelids are completely closed, the lips slightly parted, and while 
 a faint sound of regular breathing may be heard, there is no perceptible move- 
 ment of the nostrils. Incomplete closure of the lids, with more or less exposure 
 of the whites of the eyes, is noted when sleep is rendered unsound by moderate 
 pain and during the course of all acute and chronic diseases, particularly when 
 they assume a grave type. Twitching of the lids heralds the approach of a 
 convulsion, and at such times, too, there is often oscillation of the eyeballs or 
 squinting. A marked smile, due to contraction of the muscles about the 
 mouth, signifies abdominal pain or colic, and pursing out of the lips and chew- 
 ing motions of the jaw, gastro-intestinal irritation. Dilatation of the alse nasi. 
 with or without noisy breathing, points to embarrassed respiration, the result 
 of extensive bronchial catarrh, pneumonia, or pleurisy with effusion. 
 
 When awake and passive the healthy infant's face has a look of wondering 
 observation of whatever is going on about it. As age advances the expression 
 of intelligence increases, and every one is familiar with the bright, round. 
 happy face of perfect childhood, so indicative of careless contentment and so 
 mobile in response to emotions. 
 
 The picture is altered by the onset o\' anv illness, the change being in pro- 
 portion to the severity of the attack. An expression of anxiety or of 8uff 
 appears, or the features become pinched and lines are seen about the eyes and 
 mouth. Pain most of all sets its mark upon the countenance, and by n 
 the feature affected it is often possible to fix the seat of serious disease. 
 contraction of the brows denotes pain in the head : sharpness of the nostrils, 
 
4 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 pain in the chest ; and a drawing of the upper lip, pain in the abdomen. As 
 a rule, the upper third of the face is modified in expression in affections of the 
 brain, the middle third in diseases of the chest, and the lower third in lesions 
 of the abdominal viscera. Puffiness of the eyelids and a fulness of the bridge 
 of the nose indicate dropsy, and should direct attention to the kidneys. When 
 there is a tuberculous tendency the face is often oval, the features delicate, and 
 the expression intelligent ; the hair fine and silky ; the skin smooth and trans- 
 parent ; the temporal veins visible ; the eyelashes long and curving, the irides 
 large and deep-colored, and the sclerotics pearly white or bluish ; finally, a 
 growth of fine hair is often noticeable on the temples and in front of the ears. 
 On the contrary, the face may be round and heavy ; the complexion doughy ; 
 the upper lip swollen ; the nostrils wide and the alae of the nose thick ; the 
 eyelids swollen and reddened at their edges ; the hair coarse ; and the 
 lymphatic glands of the neck enlarged. 
 
 A marked disfigurement of the face may indicate one of several diseases, 
 according to its character. For example, broadness or complete flatness of 
 the bridge of the nose is significant of constitutional syphilis. A large, square 
 head and projecting forehead, with a face of natural size or smaller, show that 
 the child has suffered from rickets. An immense globular head, overhanging 
 forehead, and diminutive face, with eyeballs projected downward and irides 
 almost concealed by the lower lids, are pathognomonic signs of chronic 
 hydrocephalus. 
 
 Decubitus. — The complete repose depicted on the countenance of a healthy 
 sleeping child is shown also by the posture of the body. The head lies easy 
 on the pillow ; the trunk rests on the side, slightly inclined backward ; the 
 limbs assume various but always most graceful attitudes, and no movement is 
 observable but the gentle rise and fall of the abdomen in respiration. In the 
 waking state the child, after early infancy, is rarely still. The movements of 
 the arms, at first awkward, soon become full of purpose as he reaches to handle 
 and examine various objects about him. The legs are idle longer, though 
 these, too, soon begin to be moved about with method, feeling the ground in 
 preparation for creeping and walking. 
 
 With the onset of disease the scene changes. In acute attacks attended 
 with pain sleep is no longer restful. The infant is content only when rocked, 
 fondled, or "walked" in the nurse's arms. The older child tosses about 
 uneasily in bed, or demands a constant change from the bed to the lap. 
 During the waking hours the movements are purposeless, quick, and impatient, 
 the position is constantly shifted, and frequent whining complaints are made. 
 As a contrast to this condition of jactitation, at the beginning of the specific 
 fevers children often lie quiet and drowsy for hours. In chronic affections 
 attended with debility the movements become slow and languid, and in stupor 
 and coma there are perfect stillness and immobility. 
 
 There are certain positions and gestures which have especial significance. 
 Sleeping with the head thrown back and the mouth open is a frequent accom- 
 paniment of chronic enlargement of the tonsils. A tendency to "sleep high " — 
 that is, with the head and shoulders elevated by the pillow — indicates impaired 
 pulmonary or cardiac function. So, too, does an upright position in the nurse's 
 arms, with the chest against her breast and the head hanging over her shoul- 
 der — a posture assumed by young children. " Sleeping cool " — namely, rest- 
 ing only after all the bed-clothing has been kicked off — is an early symptom 
 of rickets. The position termed en ehien de fusil is a symptom of the advanced 
 stages of cerebral disease, especially tubercular meningitis. The child lies 
 upon one side, with the head stretched far back, the arms pressed close to the 
 
CLINICAL INVESTIGATION OF DISEASE. 5 
 
 sides and folded across the chest, the thighs drawn up toward the abdomen, the 
 legs flexed on the thighs, and the feet crossed. Restless movements of the 
 head or boring of the head into the pillow also point to cerebral disease. A 
 retained position, as on the back or one side, together with short, quick breath- 
 ing, points to some inflammatory change in the respiratory or abdominal organs. 
 Persistent lying on the face is an evidence of photophobia. 
 
 Of gestures, the frequent carrying of the hand to the head, ear, or mouth 
 indicates headache, earache, or the pain of dentition respectively, and constant 
 rubbing of the nose is a feature of gastro-intestinal irritation. 
 
 If the thumbs be drawn into the palms of the hands and the fingers tightly 
 clasped over them, or if the toes be strongly flexed or extended, a convulsion 
 may be expected. The presence of clonic contractions of the muscles, with 
 unconsciousness, indicates, of course, a convulsion ; while irregular, badly 
 co-ordinated, jerky movements — consciousness being retained — attend chorea. 
 In infants the existence of colic is shown by repeated extension and retrac- 
 tion of the legs, clenching of the hands into fists, flexion and extension of 
 the forearms, and a writhing movement of the trunk. The fact of one limb 
 remaining passive while the others are actively moved about naturally sug- 
 gests motor paralysis. 
 
 The Skin. — In the new-born infant the color of the skin varies from a 
 deep to a light shade of red. After the lapse of a week this redness fades 
 away, leaving the surface yellowish-white, and in a fortnight the skin assumes 
 its typical appearance. Allowing for natural variations in complexion, the 
 skin of a healthy child is beautifully white, transparent, and velvety. The 
 cheeks, palms of the hands, and soles of the feet have a delicate pink color, 
 and the general surface is rosy in a warm atmosphere, marbled with faint blue 
 spots or lines in a cool one. As age advances the coloring becomes more pro- 
 nounced, and until the completion of childhood the complexion is much fresher 
 than in adult life. 
 
 Lividity of the eyelids and lips is a sign of imperfect aeration of the blood 
 and points to pulmonary or cardiac disease. Marked blueness of the whole 
 face is a symptom of morbus cceruleus, and indicates a congenital malforma- 
 tion of the heart. On the other hand, a faint purple tint of the eyelids and 
 around the mouth shows weak circulation merely, or, more frequently, deranged 
 digestion. A decided yellow hue of the, skin and conjunctivae is seen in jaun- 
 dice; an earthy tinge of the face in chronic intestinal diseases ; a waxy pal- 
 lor in renal diseases; and paleness in any affection attended with exhaustion. 
 Brownish-yellow discoloration of the forehead is significant of inherited syphi- 
 lis ; a bright, circumscribed flush on one or both cheeks, of inflammation of 
 the lungs or pleura or of gastro-intestinal catarrh, according to its occurrence 
 with or without an elevated temperature. 
 
 In addition to the cutaneous lesions of the eruptive fevers, each haying its 
 special characteristics, an eruption of herpetic vesicles on the lips may be men- 
 tioned as present both in pneumonia and in malarial fevers. 
 
 Slight want of proper aeration of the blood is shown by blueness of the 
 finger-nails; a greater degree, bv cyanosis of the whole hand. Deformity of 
 the nails is a symptom of syphilis: clubbing of the finger-tips, of chronic lung 
 disease; and redness, swelling, and suppuration about the nails, of struma. 
 The dropsy of scarlatinal nephritis causes a puffiness ami cushiony appear- 
 ance of the dorsum of the hands. Often, too. in tins condition, the finger-ends 
 are glossy as if smeared with oil, and there is an exfoliation o( the epidermis 
 about the nails. The last two symptoms frequently serve to confirm a r 
 spective diagnosis of scarlet fever. 
 
6 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Mode of Drinking. — By watching an infant taking the breast or bottle 
 some knowledge can be obtained of the condition both of the mouth and 
 throat and of the respiratory organs. 
 
 If there be any soreness of the mouth, the nipple is held only for a 
 moment, and then dropped with a cry of pain. When the throat is affected, 
 deglutition is performed in a gulping manner, an expression of pain passes 
 over the face, and no more efforts are made than required to satisfy the first 
 pangs of hunger. Under similar circumstances older children drink little and 
 refuse solid food entirely. An infant suffering from the oppression of pneu- 
 monia or severe bronchitis seizes the nipple with avidity, swallows quickly 
 several times, and then pauses for breath. In older patients the act of drink- 
 ing, which should be continuous, is interrupted in the same way. 
 
 If the finger be put into the mouth of a healthy baby, it will be vigor- 
 ously sucked for some little time. The diminution of the act of suction dur- 
 ing a severe illness is a sign of danger ; its re-establishment a good omen. 
 In conditions of stupor and coma it is noticeably absent. 
 
 The Cry. — Crying is the chief, if not the only, means that the young 
 infant possesses of indicating his displeasure, discomfort, or suffering. Even 
 long after the powers of speech have been developed, the cry continues to be 
 the main channel of complaint. It may be accepted as a rule that a healthy 
 child rarely cries. Of course, some acute pain, as from a fall or accident or 
 blow, will cause crying in the most healthy child, but the storm is quickly 
 over. Incessant, unappeasable crying is due to one of two causes — namely, 
 earache or hunger — and the distinction may readily be made by putting the 
 child to the breast or offering a properly-prepared bottle. The hydr encephalic 
 cry, denoting pain in the head, is a sudden, sharp, very loud, and paroxysmal 
 shriek. Crying during an attack of coughing or for a brief time afterward, 
 and attended with distortion of the features, indicates pneumonia. In acute 
 pleuritis the cry also accompanies the cough, but it is produced too by move- 
 ments of the body and by pressure on the affected side. It is louder, indica- 
 tive of greater suffering, and sometimes most difficult to check. Intestinal 
 pain causes crying just before or after an evacuation of the bowels, and is 
 associated with wriggling movements of the body and pelvis and with eruc- 
 tation or the passage of flatus. Conditions of general distress or malaise 
 predispose to fits of fretful crying, the paroxysms being excited by any dis- 
 turbing influence, or even by merely looking at the little sufferer. 
 
 When the cry has a nasal tone, it indicates swelling of the mucous mem- 
 brane of the nares or other obstructing condition. Thickening and indistinct- 
 ness occur with pharyngeal affections. A loud, brazen cry is a precursor of 
 spasmodic croup. Hoarseness points to a lesion of the laryngeal mucous 
 membrane, either catarrhal or syphilitic in nature. In membranous croup 
 and in some cases of extreme exhaustion the cry is faint and inaudible. 
 Finally, in severe croupous pneumonia, in extensive pleural effusion, and in 
 rickets ordinary disturbing causes are inoperative for the production of fits 
 of crying, and there is a seeming unwillingness to cry, on account of the 
 action interfering with the respiratory function. 
 
 The conditions of altered tone apply equally to the articulate voice in 
 children who are old enough to speak. 
 
 The cough, too, must not be disregarded. Many of its characters corre- 
 spond with the voice and cry. It is brazen in spasmodic croup, suppressed 
 in true croup, hoarse in laryngeal catarrh, and so on. But it has certain fea- 
 tures of its own. In bronchitis it is more or less paroxysmal, evidently dry 
 in the early stages, loose and rattling as the catarrh "breaks up." In the 
 
CLINICAL INVESTIGATION OF DISEASE. 7 
 
 painful pulmonary affections, pneumonia and pleurisy, it is choked back, and 
 whenever it occurs an expression of pain passes like a cloud over the face. 
 In pertussis the peculiar spasmodic cough is the pathognomonic symptom. 
 Cough is always unproductive — that is, unattended by expectoration — in 
 children under seven years of age. 
 
 The formation of tears rarely begins before the third or fourth month 
 of life. Subsequently, an alteration in this secretion may be of aid in fore- 
 casting the result of disease. The prognosis is bad when the tears become 
 suppressed ; good when the secretion continues during an illness or when it 
 reappears after being suppressed. 
 
 There are several other sources of information which should be investi- 
 gated before proceeding to the physical examination, although, strictly speak- 
 ing, they do not come under the head of inspection of the child. These are 
 the alterations in the odor of the breath, and the characters of the faecal evacu- 
 ations, of the urine, and of material ejected by vomiting. • 
 
 The Breath. — The breath of a healthy child is odorless, or, as the nurse 
 will say, "sweet," except perhaps immediately after taking nourishment, when 
 it may, for a short time, have the smell of milk or other food. Any persist- 
 ent odor is abnormal. 
 
 Any morbid condition of the system that prevents the elimination of meta- 
 morphosed nitrogenous tissue through the mucous membrane of the intestines 
 or retards the passage of decomposing detritus along the bowels will cause an 
 offensive breath. Under this head are conditions characterized by high tem- 
 perature, catarrhal inflammation of the gastro-intestinal tract, chronic debili- 
 tating diseases, etc. The same result also frequently attends structural lesions 
 of the kidneys. The reason for this is, that the system, in order to get rid 
 of poisonous matter — for accumulated waste is poison — and to maintain the 
 balance between the constant construction and destruction of tissue, must 
 throw off elsewhere what the intestinal glands and the kidneys fail to excrete ; 
 so the lungs take on vicarious activity and the expired air becomes tainted. 
 Purely local causes of halitosis also exist. These are decayed teeth, caries 
 of the nasal and maxillary bones, ulceration of the mucous membrane of the 
 mouth, nose, larynx, trachea, and bronchial tubes, and gangrene of the cheeks. 
 Chronic poisoning by lead, arsenic, or mercury, though not very common 
 in childhood, is another cause of ill-smelling breath. 
 
 To speak in general terms, the breath may become sour, catarrhal, foetid, 
 gangrenous, ammoniacal, and stercoraceous. Sour breath is present, in infants 
 more especially, when there is gastric fermentation. Catarrhal breath has 
 numerous shades of difference. In chronic catarrh of the pharynx there is a 
 "heavy" odor, not noticeable far from the patient's face. It is always most 
 marked during and after sleep. Should there be associated follicular tonsilli- 
 tis, the breath, while still heavy, becomes extremely offensive, with a scout 
 somewhat like that of decaying cheese, and is very penetrating. This odor. 
 too, is worse after sleeping. At the onset of acute catarrh of the stomach 
 the breath sometimes has a vinous odor, at others it is sweetish, and again it 
 has the same quality as after an inhalation of other. Later in the attack it 
 becomes sour or has the odor of sulphuretted hydrogen. What is known as a 
 "feverish breath " has a heavy, sweetish smell. It is mot with in diseases of high 
 temperature; thus, it is very marked and rapid in appearance ill scarlatina. 
 
 Foetor of the breath is observed in its mildest form in such affections as 
 aphthoe and ulcerative stomatitis. It is bettor developed in ossena and necrosis 
 of the maxillary bones. Decaying teeth give much the same odor, though it 
 is less strong and penetrating. 
 
8 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Noma gives rise to a gangrenous odor, and a patient so affected will fill 
 the room in which he lies, or even a whole dwelling, with the most sickening 
 stench. Cases of empyema, with ulceration of the lung and discharge of pus 
 through the bronchial tubes, have an almost equally offensive breath, but here 
 there is often a superadded flavor of garlic. 
 
 Ammoniacal breath is observed only . in patients suffering with uraemic 
 poisoning. A purely stercoraceous breath is rare, and when met with is an 
 accompaniment of faecal tumor or of intussusception. 
 
 The different metallic poisons give rise to no characteristic odor, and it is 
 necessary to look to the clinical history to determine the special poison. 
 
 The F^ical Evacuations. — The daily number of evacuations natural 
 for a child varies greatly with its age. For the first six weeks there should 
 be three or four stools every twenty-four hours. After this time, up to the 
 end of the second year, two movements a day is the normal average. Sub- 
 sequently, the frequency*of defecation is usually the same as in adults — once 
 per diem. During the firs^period the stools have the consistence of thick 
 soup, are yellowish-white or orange-yellow in color, with sometimes a tinge of 
 green, have a faint faecal, slightly sour odor, and are acid in reaction. In the 
 second they are mushy or imperfectly formed, of uniform consistence through- 
 out,1%*ownish-yellow in color, and have a more faecal odor. The last two charac- 
 ters become, more marked as additions are made to the diet. After the comple- 
 tion of the first dentition the motions have the same appearance as in adult 
 life ; they are forpied, and brownish in color, with a decided faecal odor. 
 
 Many alterations occur in disease. The frequency of the movements may 
 be increased, constituting diarrhoea, or lessened, constituting constipation. In 
 the former condition the consistency is diminished, in the latter increased. 
 Instead of being uniform throughout, the stool may be mixed, partly liquid, 
 partly solid, indicating imperfect digestion, and curds of milk and pieces of 
 undigested solid food may be mingled with the mass. Flaky, yellowish, or 
 yellowish-green evacuations, containing whitish, cheesy lumps, are also met 
 in cases of indigestion. Scanty, scybalous stools, dark-brown or black in 
 color, and mixed with mucus, are characteristic of intestinal catarrh. Doughy, 
 grayish, or clay-colored motions show a deficiency of bile. An intermixture 
 of blood, altered blood-clots, and shreds of mucous membrane indicate some 
 breach of continuity in the intestinal lining, such as occurs in follicular ente- 
 ritis, typhoid fever, dysentery, and tubercular disease. Watery, almost odor- 
 less stools occur in the latter stages of entero-colitis, most offensive, carrion- 
 like motions in both catarrhal and tuberculous ulceration of the intestines, 
 and sour-smelling evacuations in the diarrhoea of sucklings. The discovery 
 of worms or their ova in the stools is the certain evidence of the existence 
 of intestinal parasites. 
 
 This outline of the changes that may take place will serve to show how 
 much may be learned from the stools, and the importance of making a per- 
 sonal examination of them. 
 
 The Ueine. — It is impossible to make a definite statement as to the num- 
 ber of times the urine is voided by a healthy infant in each twenty-four hours. 
 In any given case the frequency will differ very much from day to day, depend- 
 ing upon the temperature of the surrounding air, the amount of moisture that 
 it contains, and so on. Sometimes it will be necessary to change the diaper 
 every hour during the day and three or four times at night. Again, it may 
 remain dry for six, eight, or even ten hours. Neither condition indicates dis- 
 ease, and between the two extremes there is a wide range of variation. Should 
 the urine not be passed for twelve hours or more, a careful examination should 
 
CLINICAL INVESTIGATION OF DISEASE. 9 
 
 be made to discover and remedy retention. As the child grows older the fre- 
 quency diminishes, and at the age of three years the number of voidings will 
 be reduced to six or eight during the waking hours, and perhaps one at night. 
 When the desire does arise during sleep, the child, if in a normal state, wakes 
 up and demands the chamber, and never passes urine unconsciously. Wetting 
 the bed, therefore, or the involuntary passage of the urine during sleep, is indic- 
 ative of an abnormal condition and requires investigation. Painful micturition 
 points to inflammation of the urethra, a narrow preputial orifice, a highly acid 
 condition of the excretion, or stone in the bladder. 
 
 The urine of a healthy infant, while it wets, should- not stain the diaper, 
 the fluid being clear and almost colorless. It has a low specific gravity — 
 1.003 to 1.006 — and an acid reaction. As age advances the adult characters 
 are more and more nearly approached, though during the whole of childhood 
 the urine is paler and of lower specific gravity than in adult life. The normal 
 daily amount excreted cannot be stated absolutely, but the following figures 
 are approximate : Between two and five years, 15-25 oz. ; five and nine 
 years, 25-35 oz. ; nine and fourteen years, 35-40 oz. Other characters of 
 the urine in childhood will be considered under appropriate headings in subse- 
 quent sections. 
 
 Vomiting. — Both vomiting and regurgitation are of ready production and 
 frequent occurrence in infancy, on account of the vertical position and cylin- 
 drical outline of the stomach at this period of life. Babies suckled at an abun- 
 dant breast, and who are in perfect health, often vomit habitually. In these 
 cases, the supply of food being large, the infant as it lies at the breast is apt 
 to draw more than it can digest. The stomach rids itself of this over-supply 
 by an act which more nearly resembles regurgitation than vomiting, and which 
 must be regarded as an evidence of health rather than the reverse. There is 
 no violent effort or retching ; the material ejected is the breast-milk alone, either 
 entirely unaltered or slightly curdled ; and there are no symptoms of nausea, 
 such as paleness, languor, and faintness. In older children vomiting may also 
 occur after the stomach has been overladen. If the act be followed by relief 
 from the general distress, headache, and epigastric pain, it must not be regarded 
 as a symptom of disease. 
 
 Vomiting attended with the train of symptoms embraced under the term 
 nausea is not a pathognomonic symptom. It may indicate disease of the 
 stomach, of the intestines, of the lungs and pleura, and of the brain, or it 
 may be a prodrome of one of the eruptive fevers. Which condition is pres- 
 ent can only be determined by watching the case. The character of the ejecta 
 is more definite. For instance, the expulsion of mucus is a symptom of gas- 
 tric catarrh. The regurgitation of mouthfuls of curdled milk, partially digested 
 food, and liquid so sour that it causes a grimace to pass over the face, is an 
 indication of dyspepsia, with fermentation and the formation of aeid. The 
 appearance of lumbricoid worms in the vomit — a not infrequent occurrence — 
 of course shows conclusively the existence of these parasites in the alimen- 
 tary canal. 
 
 3. Physical Examination. 
 
 The methods of physical exploration in children are identical with those 
 employed in adults, and the results do not differ in kind. Since, however, the 
 object of exploration is to elicit the greatest amount o'l information with the 
 least possible disturbance of the child, and as this very disturbance alters the 
 character of some of the information obtained, it is well to adopt a somewhat 
 different order of examination, and one which at first sight may seem irregular. 
 
10 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Thus it is best first to ascertain the character of the respiration and the pulse, 
 then to strip the body to determine the degree of muscular development and 
 the condition of the skin, next to investigate the physical condition of the lungs, 
 heart, and abdominal organs, and last of all to examine the mouth and throat. 
 In this order, then, the normal, as well as the more prominent abnormal, fea- 
 tures connected with the different organs will be considered. 
 
 The Respiration. — In children the respiration is chiefly abdominal in 
 type, irrespective, of sex, and it is not until just before the age of puberty that 
 the movements in the female change, becoming superior costal. Consequently, 
 in estimating the number of movements per minute, it is best to place the fingers 
 lightly on the epigastrium. The count should always be made by the watch, 
 and the most convenient time for the observation is while the child sleeps. 
 
 Soon after birth the number of movements per minute is 44, between the 
 ages of two months and two years, 35, and between two and twelve years, 23. 
 During sleep the frequency is reduced about 20 per cent. 
 
 Children under two years, while awake, breathe unevenly and irregularly. 
 In sleep there is greater regularity. After the second year the movements 
 become steady and even. All children, however, but particularly the very 
 young, are subj ect to a great increase in the rapidity of respiration under excite- 
 ment, either muscular or mental. 
 
 Accelerated breathing may be caused by an elevation in the body temper- 
 ature, by an interference with the blood aeration, and by thoracic or abdominal 
 pain. As the increase in frequency may be unattended by any apparent effort 
 or true dyspnoea, it is well to make a rule of counting the respirations in every 
 case in which the diagnosis is doubtful. 
 
 Diminished frequency is noted in certain brain affections, as in chronic 
 hydrocephalus, and in the later stages of tubercular meningitis. In such 
 cases the rhythm may be greatly altered — a tidal form being assumed ; this 
 is termed " Cheyne-Stokes respiration." Another form of breathing, in which 
 the alteration is mainly in the rhythm, is termed expiratory respiration. It is 
 characterized by the pause coming between inspiration and expiration, instead 
 of between expiration and inspiration, as is the normal rule. This alteration 
 occurs most frequently in young children, and is an evidence of dangerous 
 pulmonary embarrassment. 
 
 Perfectly healthy children breathe through the nose, and so softly that it 
 is difficult to hear the breezy sound of the ingoing and outgoing air. A dry, 
 hissing sound or a moist sound of snuffling indicates partial obstruction of the 
 nasal passages ; oral respiration, complete occlusion. Difficult breathing with 
 prolonged inspiration — inspiratory dyspnoea — shows an impediment to the 
 entrance of air into the lungs and indicates laryngeal obstruction, due, most 
 commonly, to spasm or to the formation of false membrane. In such cases the 
 inspiratory act is also attended by a loud, piping, or rasping sound. Labored 
 breathing with prolonged wheezing respiration — expiratory dyspnoea — occurs 
 when the escape of air is impeded. The causative lesion is to be found, not 
 in the larynx, but in the lungs. It may be a bronchial catarrh with excessive 
 secretion, emphysema, or asthma. In both forms of dyspnoea the movements 
 are slow as well as difficult, and a combination of the two forms is met with 
 in cases of marked laryngeal stenosis. 
 
 Yawning, if it recur frequently, denotes great failure of the vital powers. 
 
 The Pulse. — To obtain any reliable data from the pulse it must be felt 
 while the patient is perfectly quiet. The best time is during sleep, but if the 
 child cannot be caught in this condition, advantage may be taken of its pla- 
 cidity while nursing at the breast, feeding from a bottle, or amused by a toy. 
 
CLINICAL INVESTIGATION OF DISEASE. 11 
 
 With very young infants it is sometimes impossible to feel the beat of the radial 
 artery, and it is necessary to ascertain the frequency of the pulse by directly 
 auscultating the heart. After the second month palpation of the pulse at the 
 wrist in the ordinary way presents no difficulties. 
 
 The child's pulse differs from the adult's by being much more frequent, 
 more irregular, and more irritable, and necessarily of smaller volume. 
 
 The frequency, or the number of beats per minute, varies with the age. 
 The following is the average rate: 
 
 From birth to the second month 160 to 130 
 
 From the 2d to the 6th month 130 to 120 
 
 " 6th " 12th " 120 to 110 
 
 " 1st " 3d year 110 to 100 
 
 « 3d " 5th " 100 to 90 
 
 " 5th " 10th " 90 to 80 
 
 " 10th " 12th " 80 to 70 
 
 These figures represent the pulse in a waking but passive state. During sleep 
 the frequency is less. Thus, between the second and ninth years there are 
 about sixteen beats less per minute while asleep than when awake ; between 
 the ninth and twelfth years, eight less ; and between the twelfth and fifteenth 
 years, only two less. Below the age of two years the disparity is even greater. 
 The irregularity of the pulse in childhood is confined to an alteration of the 
 rhythm. It is most marked in infants, and is greatest during sleep, when the 
 pulse is slowest. The feature of irritability — that is, the facility with which its 
 frequency is increased by muscular activity and mental excitement — is greater 
 in proportion to the youth of the child. A rise of 20, 30, or even 40 beats a 
 minute is not uncommon in early infancy under the excitement of the slightest 
 effort or disturbance. On account of these wide variations in health little 
 symptomatic meaning need be attached to alterations of the rhythm and fre- 
 quency while unassociated with other abnormal features. When so associated 
 they become important in diagnosis. 
 
 Increased frequency is a constant attendant of the febrile state. The extent 
 of the increase corresponds with the degree of elevation of the temperature, 
 though the pulse curve always runs higher than the temperature curve. The 
 more frequent the pulse the higher the fever is the rule, but in estimating the 
 prognostic value of the increase the law of the fever in question must be taken 
 into consideration. For example, in scarlatina a pulse of 160 is usual and not 
 indicative of special gravity, whereas in measles the same degree of accelera- 
 tion would be abnormal and show great danger. Jaundice and parenchymatous 
 nephritis are accompanied by a diminution in the rate. Irregularity is met 
 with in diseases of the brain and heart, and sometimes in nervous and anaemic 
 children. 
 
 The Temperature must be estimated before removing the clothing, and a 
 clinical thermometer must always be used. The instrument is usually placed in 
 the rectum or groin 1 of the infant and young child; in the axilla or mouth 
 of an older and more controllable child. It should remain in position from 
 one to five minutes, according to the delicacy of the instrument. 
 
 During the first week of life the temperature fluctuates considerably. After 
 that the puerile norm — 98.5° to 99° F. — is established, but until the fourth or 
 fifth month it is greatly influenced by healthy causes of variation, the fluctua- 
 tions ranging; between 0.9° and 3.6°. By the fifth month regular morning and 
 evening oscillations begin and certain definite laws are followed. There is a 
 
 1 The rectal temperature is normally 1° higher than the axillary ; that of the groin about 
 
 1° lower. 
 
12 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 fall in the evening of 1° or 2°. The greatest fall occurs between 7 and 9 p. M., 
 and the minimum is reached at or before 2 A. M. After 2 A. M. there is a grad- 
 ual rise, the maximum being reached between 8 and 10 A. M. Throughout the 
 day the oscillation is trifling. These variations are independent of eating and 
 sleeping. 
 
 In disease there may be either a rise above or a fall below the normal 
 standard. Fever is always associated with an elevation of the temperature. 
 Rapid and transient rises attend slight catarrhs and passing indigestions ; pro- 
 longed rises, inflammatory and essential fevers. The degree of elevation marks 
 the type of the pyrexia. This is moderate when the mercury stands at 102°, 
 severe at 104° or 105°, and very grave above 107°. The duration of the ele- 
 vation and the peculiar range of the oscillations — for there are oscillations in 
 disease as well as in health — determine the nature of the fever. The febrile 
 oscillations differ from the healthy in that the lowest marking is noticed in 
 the morning, the highest in the evening. Variations in the typical range of 
 any given fever are important prognostic omens : a sudden fall of temperature, 
 together with improvement in the general symptoms, indicates the beginning 
 of convalescence ; a similar fall, with an increase of the general symptoms, 
 is a precursor of death. When the morning temperature is equal to that 
 of the preceding evening, there is great danger ; if higher, greater danger 
 still. Marked remission in continued fevers is generally a forerunner of con- 
 valescence. 
 
 Abnormal depression of temperature is occasioned by haemorrhage and by 
 the loss of fluids in profuse watery diarrhoea. It is also met with in anaemia, 
 in atrophy from insufficient nourishment, in diseases of the heart and lungs 
 attended by imperfect blood-aeration, and it constantly attends collapse and 
 the death agony. A maintained temperature of 97° F. is dangerous in chil- 
 dren, and for every degree of reduction below this point the risk to life is 
 more than proportionately increased. 
 
 The Gexeeal Development. — The healthy child under two years of 
 age is plump of body and round of limb, with well-developed fat cushions 
 and firm flesh, and with the head and abdomen large in proportion to the rest 
 of the frame. As age advances the figure gradually assumes the characteris- 
 tics of adolescence. 
 
 To be robust, the newly-born child must have a certain average size and 
 weight. Subsequently, under normal circumstances, there is a regular rate 
 of increase in both of these respects. At birth the length is about 19 inches. 
 Growth is quickest in the first weeks of life. In the first year there is an 
 increase of from 5 to 6J inches ; in the second, from 2f to 3-J- inches ; in the 
 third, from 2J to 2f inches ; in the fourth, about 2 inches ; and from the fifth 
 to the sixteenth year the annual growth amounts to from If to 2 inches. The 
 average weight at birth is from 6 to 8 pounds. The daily increase in weight 
 should range from \ to f of an ounce. With these data it is quite possible 
 to estimate what should be the normal size and weight of a child at any age. 
 Consequently, if, on being measured and weighed, he be found to fall short of 
 the normal standard, it is proper to infer the existence of some fault in the 
 nutritive processes — a conclusion still further borne out by a want of rotund- 
 ity of outline and by flabbiness of the muscles. 
 
 The age at which the child sits erect, at which it walks, and at which the 
 anterior fontanelle becomes ossified are points closely connected with the sub- 
 ject of development and nutrition. For some time after birth the child, if 
 noticed while sitting upon the lap, will be observed to hold the head and 
 shoulders forward or to "stoop" a little, the spine from the cervical region 
 
CLINICAL INVESTIGATION OF DISEASE. 13 
 
 to the sacrum forming a continuous curve, with the convexity directed back- 
 ward. Toward the end of the eighth month the position begins to become 
 more erect, and in a few weeks is perfectly so, the spine assuming an almost 
 perpendicular line. Any marked delay in this change indicates general 
 debility. At the end of the fourteenth month the child should be able to 
 walk alone. The spine then assumes the S-like curve seen in healthy adults. 
 A delay in walking may be due to systemic weakness or infantile paralysis 
 affecting one or both legs. If the walking be done on the toes chiefly, if the 
 gait be limping, and especially if knee-pain be complained of and manipulation 
 of the limbs causes suffering, the chances are that hip-joint disease is com- 
 mencing. The anterior fontanelle should be ossified or completely closed at 
 some period between the fifteenth and twentieth months. The closure is much 
 retarded in rickets, which is pre-eminently a disease of malnutrition. Hydro- 
 cephalus has a like effect. In a state of health the opening, while still mem- 
 branous, is level with the cranial bones or very slightly depressed. Conditions 
 of systemic exhaustion cause marked sinking, and this depression is one of the 
 best indications of the necessity of stimulation. Bulging of the fontanelle is 
 a symptom of chronic hydrocephalus. 
 
 Conditions of the Skin. — In addition to the characters already described, 
 the skin of a healthy child has a velvety smoothness and softness, a scarcely 
 perceptible moisture, and a great degree of elasticity. 
 
 "Mucous disease" is attended with a dry, harsh skin, which is muddy in 
 color, and covered, especially on the extensor surfaces of the arms and legs, 
 by a more or less thick layer of exfoliating epidermis. Chronic abdominal 
 affections, particularly tuberculosis of the intestines and mesenteric glands, 
 lead to harshness, acridity, scurfiness, and a wrinkled appearance of the skin 
 covering the abdomen and thorax, with enlargement of the superficial abdom- 
 inal veins. Protracted diarrhoea, and, still more, vomiting combined with 
 diarrhoea, cause absorption of the subcutaneous fat and wasting of the mus- 
 cles. The skin becomes too large for the body, is dry, harsh, discolored, and 
 so inelastic that it falls into wrinkles over the joints when the limbs are moved, 
 and if pinched up retains the fold for a long time. The condition of general 
 atrophy popularly known as "marasmus" presents these features most strik- 
 ingly. Dryness is a concom'itant of the febrile state ; excessive moisture, of 
 prostration and collapse. Eruptions appear upon the integument in the skin 
 diseases proper, in the exanthemata, in constitutional syphilis, and in certain 
 digestive disorders. (Edema of the subcutaneous connective tissue may be 
 due to affections of the heart, liver, or kidneys. The cardiac variety usually 
 shows itself first in the feet ; the renal, in the eyelids ; the hepatic, in the feet 
 and legs, secondarily to ascites. 
 
 While examining the surface it is well to look for enlargement of the super- 
 ficial lymphatic glands and swelling of the joints. The former occurs in tuber- 
 culosis and syphilis ; the latter, in rheumatism. 
 
 Examination of the Abdomen. — To examine this portion of the body. 
 the child, still stripped, must be placed on its back and kept as quiet as possi- 
 ble. Palpation or percussion should never be made with cold hands. 
 
 The abdomen of a healthy child is prominent, uniformly soft, yielding, and 
 painless to the touch, and to percussion gives a tympanitic sound, varying in 
 tone according to the region percussed. The tympanitic note is lowest in pitch 
 over the epigastric and left hypochondriac regions, the seat oi' the stomach : 
 highest over the umbilical region, the position of the small intestine. 
 
 In disease inspection reveals any disproportion in the size or form of the 
 abdomen, the state of the integuments, of the superficial veins, and of the 
 
14 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 umbilicus. Palpation shows the temperature, pliability, moisture, and tension 
 of the walls, and the presence or absence of tenderness, of fluctuation, and of 
 enlargement of the mesenteric glands and other solid viscera. Percussion serves 
 to demonstrate the nature of enlargements, whether due to accumulation of gas 
 or liquid or to solid growths. By it, also, the outline and size of the liver 
 and spleen may be determined. 
 
 Distention of the abdomen is, in the vast majority of instances, due to 
 flatulence. In this condition the skin feels tense, the umbilicus is level or 
 slightly prominent, there is no tenderness on pressure, and percussion is 
 markedly tympanitic. Drum-like distention, with great tenderness, and muffled 
 tympanitic percussion-note occur in general peritonitis. Uniform distention, 
 again, may be due to ascites. The abdomen is barrel-shaped, painless to the 
 touch, and there is extended fluctuation. Percussion is dull over the position 
 of the fluid, but in nearly every instance there is an area of tympany which 
 changes its position. Localized distention may be traced to gaseous accu- 
 mulation, to enlargement of the liver and spleen, to faecal accumulation, to 
 circumscribed peritonitis, and to distention of the bladder. Collections of 
 gas are always tympanitic on percussion. The extent of liver dulness is to 
 be estimated by percussion, or palpation with the tvarmed hand. An enlarged 
 spleen may be felt by placing the fingers of the right hand on the back, directly 
 below the twelfth rib and outside of the lumbar muscles, the fingers of the 
 left on the abdomen, directly opposite, then bringing the hands toward one 
 another. The fact that both the liver and spleen, though still unenlarged, 
 may be more readily felt than natural when pressed downward by the dia- 
 phragm, must not be overlooked. A faecal accumulation is distinguished by 
 the absence of tenderness, by the oblong shape of the tumor, by the situation 
 in the region of the transverse or descending colon, to which its long axis cor- 
 responds, and by its shape being capable of some modification by pressure. 
 Percussion over such a mass is dull. Distention of the bladder gives rise to 
 a bulging tumor in the hypogastric region, which is elastic to the touch and 
 dull on percussion. 
 
 A shrunken or scaphoid condition of the abdomen is met with in serious 
 brain affections, notably tubercular meningitis, also in entero-colitis, follicu- 
 lar enteritis, and dysentery. 
 
 Tenderness to pressure indicates inflammatory lesion of the intestines. The 
 presence or absence of this sign in an infant can be determined by forcing the 
 attention, by bringing it before a strong light, for instance, and then making 
 pressure on the abdomen. If crying be produced, there is tenderness ; if not, 
 the reverse. 
 
 Examination of the Chest. — The stethoscope and pleximeter are unne- 
 cessary in examining the lungs. In the case of the heart the former may be 
 occasionally required to localize murmurs. When used, it is better to give the 
 instrument to the child to handle and become familiar with before application. 
 The thoracic end must never be adjusted without being warmed. The quieter 
 the patient, the more complete and satisfactory will be the results of the explo- 
 ration. Unfortunately, though, it is too often necessary for one to do the best 
 possible in the midst of cries and struggling. However, by skilfully seizing 
 opportune moments much reliable information may be gained. 
 
 The steps of the examination are — first, inspection ; second, auscultation ; 
 third, palpation ; and fourth, percussion. The reason for making the order 
 different from that practised in adults is to place the most disturbing element 
 last. Mensuration and succussion are infrequently resorted to in children. If 
 required, they are best postponed until the end of the examination. 
 
CLINICAL INVESTIGATION OF DISEASE. 15 
 
 Inspection. — The sitting posture, the child being stripped and in a good 
 light, is the best for this process. Note is to be taken of the shape of the 
 chest, the character of the breathing, and the position of the apex- beat of 
 the heart. 
 
 In the new-born baby the chest is nearly circular in shape ; later, the 
 lateral diameter considerably exceeds the antero-posterior. The intercostal 
 spaces are poorly marked, and the scapulae lie so close that their outline is 
 scarcely perceptible. The circular shape of the chest allows of little lateral 
 expansion, and for this reason the respiration is chiefly abdominal in type. 
 Together -with the movement of the abdominal walls, every act of inspiration 
 is attended by a certain amount of recession of the lower part of the chest- 
 walls, the yielding ribs being forced inward by the pressure of the external 
 air before they can be sufficiently supported by the expanding lung. The 
 rise and fall of the cardiac apex can be seen — except when there is a great 
 accumulation of fat — a short distance below and to the right of the left 
 nipple. 
 
 Disease may alter all of these conditions. The tuberculous diathesis is 
 characterized by a small chest, and one which has either the alar or the flat 
 shape. In rickets the thorax becomes irregularly triangular in outline. Em- 
 physema causes a barrel-shaped chest, with stooping shoulders and round back. 
 Pleuritis with large effusion produces bulging of the affected side, and some- 
 times prominence of the intercostal spaces. After absorption has taken place 
 there may be marked retraction, sinking of the interspaces, falling of the 
 shoulders, and curvature of the spine toward the healthy side. Cessation of 
 the costal respiratory movements indicates inflammation of the lung or pleura 
 or a large pleuritic effusion ; cessation of the abdominal play, inflammation 
 of the peritoneum or of the intestines : excessive ascites and gaseous accu- 
 mulations produce the same effect. Rachitic softening of the ribs, and those 
 diseases of the lungs which offer a direct obstacle to the entrance of air, are 
 associated with a great increase in the normal recession of the lower portion 
 of the chest on inspiration. The position of the apex-beat is altered by car- 
 diac diseases, by pleuritis, and occasionally by gaseous distention of the stom- 
 ach. "When the left ventricle is enlarged, it is shifted downward and to the left. 
 Transmitted epigastric pulsation shows enlargement of the right ventricle. An 
 extended impulse is not necessarily a sign of disease, since the chest-walls are 
 so elastic in childhood that the normal impact of the apex is apt to affect a wide 
 area. The effusion of pleurisy pushes the heart to the right or left, while the 
 retraction, after absorption or evacuation, draws it in one or other direction. 
 The apex is pushed upward and to the left in gastric flatulence. Emphysema, 
 by pushing the heart away from the thoracic wall, diminishes or hides the 
 impulse. 
 
 Auscultation. — With infants the back of the chest is most conveniently 
 ausculted when the child is held in the nurse's left arm, with his breast against 
 hers, his chin resting upon her left shoulder, his left arm around her neck, and 
 his head kept in position by her disengaged hand ; the front, when reclining 
 on the back on a pillow ; the sides, when sitting upright on the lap, first one 
 arm and then the other being lifted up to allow the observer's ear to be applied. 
 Older children may be made to take the same position as adults. It is not suf- 
 ficient to auscult the posterior aspect of the thorax alone, as is stated by some 
 authors. The whole chest should be examined, particularly in doubtful cases. 
 The signs of croupous pneumonia are most frequently discoverable at one or 
 other base, posteriorly ; the friction-sound of pleuritis at the junction of the 
 middle and lower third of the chest, laterally ; and the signs of emphysema at 
 
16 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the apices, anteriorly. Therefore, unless the exploration be thorough, import- 
 ant lesions may be overlooked. 
 
 In healthy infants the inspiratory act in ordinary breathing is superficial, 
 and the respiratory murmur, as a consequence, feeble. If, however, a deep 
 inspiration be taken, a frequent occurrence under excitement and during cry- 
 ing, the murmur becomes loud, or puerile. After the age of two years puerile 
 respiration is habitual. The breathing is loudest over the anterior, lateral, and 
 posterior inferior regions of the thorax ; faintest over the scapulae and the pre- 
 cordial area. Sometimes the expiratory element is wanting in young children 
 over the lower posterior portions of the lungs. In the interscapular region 
 there is often an approach to the bronchial type of breathing. If the child 
 speaks, cries, or coughs while the ear is applied to the chest, a muffled rumbling 
 sound, the normal vocal resonance, will be heard. At the same time vibra- 
 tion of the walls, the vocal fremitus, can be felt. 
 
 The cardiac sounds are readily heard when the ear is placed on the prsecor- 
 dia. In young infants the examination is somewhat difficult, but after the first 
 year, the circulation becoming slower and more regular, there is little trouble 
 in distinguishing the sounds, and even slight alterations in them. The first 
 sound is longer and graver than the second, the rhythm is ordinarily quite 
 regular, and the area of distribution is extended. 
 
 Palpation. — In practising palpation the palmar surface of the well-warmed 
 hand must be applied to the naked chest. This method of exploration is use- 
 ful as a means of determining the number of respiratory movements, the degree 
 of expansion of the thoracic walls, the position of the cardiac apex-beat, the 
 presence or absence of painful regions and of pleural or bronchial fremitus, the 
 existence of fluctuation in the intercostal spaces, and the character of vocal 
 fremitus. 
 
 Percussion. — In percussing the different surfaces of the chest the child 
 must be placed in the same position as for auscultation. When contrasting 
 the two sides, percussion should be made in identical regions and during the 
 same period of the respiratory movement. Babies when constrained or when 
 disturbed hold their breath in the intervals of crying, and as they always do 
 so at the end of an inspiration, this is a favorable time to seize for the compar- 
 ative examination. The percussion strokes must be lighter than in the adult, 
 but in other respects the operation in no wise differs. 
 
 In health the resonance will be found to correspond closely with the res- 
 piratory murmur. Thus in infants under one year, the respiratory murmur 
 being feeble, percussion is rather insonorous, but so soon as puerile respiration 
 becomes established the resonance is uniformly intense. With the exception 
 of this greater intensity the sound is exactly similar to that obtainable in adults. 
 It is always attended, too, by a sensation of elasticity, appreciated by the finger 
 used as the pleximeter. 
 
 Different portions of the thorax possess, normally, different degrees of sonor- 
 ousness. In front, the right side is markedly resonant from the clavicle down 
 to the fifth interspace or the upper border of the sixth rib in the mammary 
 line, where the liver dulness begins. On the left side the resonance is equally 
 intense, but it is encroached upon by the gastric tympany, which extends 
 upward as high as the seventh or sixth rib, as well as by the area of car- 
 diac dulness. The latter is never so decidedly marked as in adults. Later- 
 ally, both axillary regions are very resonant. The upper portions of the infra- 
 axillary regions are a degree less resonant, and the lower portions are dull on 
 account of the presence of the liver on the right and the spleen on the left side. 
 The superior border of the liver dulness is found in the seventh interspace, or 
 
CLINICAL INVESTIGATION OF DISEASE. 17 
 
 at the eighth rib : that of the spleen, at the upper edge of the ninth rib. Gas- 
 tric tympany may supplant the pulmonary resonance over the left infra-axillary 
 region. Posteriorly, there is little resonance in the scapular region, partic- 
 ularly the supraspinous portions. Over the interscapular space the sound 
 improves, but it is less resonant than anteriorly or laterally. Over the infra- 
 scapular regions the resonance is but little less pure than in front, until the 
 tenth rib is reached on the right side and the liver dulness is again met with. 
 On the left side the resonance extends to the very base, the posterior splenic 
 dulness being detected with difficulty. The right base is, therefore, naturally 
 less resonant than the left, and this difference is especially marked during expi- 
 ration, the liver rising higher at that time. 
 
 Affections of the lungs produce various alterations in the percussion sound. 
 The chief of these are the substitution of tympany, of dulness, and of flatness 
 for the normal resonance, and of increased resistance to the finger for elasticity. 
 Cardiac diseases cause changes in both the extent and the shape of the area of 
 precordial dulness. 
 
 Examination of the Mouth and Fauces. — This portion of the exami- 
 nation is most apt to cause crying, but it must never be omitted. In infants 
 gentle pressure of the fingers upon the chin is sufficient to cause wide opening 
 of the mouth. An older child will frequently open the mouth when requested, 
 but if he refuse, some smooth, flat instrument may be inserted in the mouth, 
 and downward pressure made upon the tongue, when the jaws will be widely 
 separated. The fauces can sometimes be seen by directing the mouth to be 
 opened wide and the tongue to be alternately protruded and retracted, or a pro- 
 longed sound of " Ah " to be made. With the refractory, and always with 
 infants, the tongue has to be held down by a spoon-handle or tongue-depressor. 
 
 The healthy oral mucous membrane has a deep pink color and is smooth, 
 moist, and warm to the touch. The color is deeper on the lips and cheeks, 
 lighter on the gums. The latter, up to the sixth month, as a rule, have a mod- 
 erately sharp edge. Subsequently, the edge begins to broaden and soften, and 
 the color of the investing mucous membrane deepens to a vivid red, and becomes 
 hot as the teeth begin to force their way through. The first, or milk teeth — so 
 called from their color — are twenty in number, all told, ten to each jaw; the 
 two lower central incisors, the first of the set, make their appearance at some 
 time between the fourth and seventh months, the others following at stated 
 intervals. 1 The permanent teeth, thirty-two in number, begin to appear 
 about the sixth year. 
 
 The tongue should be freely movable. It is pink in color, and the dorsum, 
 or upper surface, marked in the centre by a slight longitudinal depression, has 
 a velvety appearance, and is soft, moist, and warm to the finger. The hard pal- 
 ate is roughened anteriorly by transverse ridges. The soft palate is smooth, and 
 its mucous membane is paler than that of the rest of the mouth. The fauces, 
 on the contrary, are redder. In the triangular recess between the half-arches 
 of the palate the tonsils can always be seen. They should be about the size 
 and shape of almond-kernels, and they present a number of circular open- 
 ings, the orifices of pouches into which the follicles open. The uvula is short 
 and tongue-shaped. The posterior wall of the pharynx should be red, smooth, 
 and moist. 
 
 Disease produces a great variety of changes in the mouth, tongue, and 
 fauces. Fever makes the mouth hot and dry and causes the tongue to be 
 frosted or coated. Affections of the gastro-intestinal tract are always attended 
 by coating of the tongue, and the various appearances of this coating are of 
 
 1 See article on Dentition. 
 
18 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 important diagnostic and therapeutic significance. Inflammation of the mouth 
 itself reddens the mucous membrane, makes it hot and tender to the touch, 
 increases its moisture, alters the surface of the tongue, and leads to the forma- 
 tion of aphthae, to ulceration, and even to gangrene. The eruptions of scar- 
 let fever, measles, varicella, and varioloid make their appearance first on the 
 mucous membrane of the palate and fauces. Finally, the conclusive evidences 
 of diphtheria and of the various tonsillar affections are found in the fauces. 
 
 Irregular dentition indicates faulty nutrition ; delayed dentition, rickets ; 
 and certain peculiarities in the formation of the permanent teeth, constitu- 
 tional syphilis. 
 
 II. THE GENERAL MANAGEMENT OP CHILDREN. 
 1. Feeding. 
 
 The whole question of feeding bears so close a relation to age that it is 
 necessary to study it from the standpoint of the two stages of a child's life 
 already mentioned. 
 
 An infant may be fed in one of three ways : 1st, from the mother's breast; 
 2d, from the breast of a wet-nurse ; and 3d, from a bottle by the method known 
 as artificial or hand-feeding. 
 
 1st. Feeding from the Maternal Breast. — This, being the natural, is the 
 proper method of nourishing the human infant ; and every mother who is 
 able should nourish her child solely from her breast up to the age of eight 
 months, and partially to the end of the first year, or, failing in either limit, so 
 long as possible. 
 
 The infant should be put to the breast as soon as the mother has recovered 
 somewhat from the fatigue of labor — some four or eight hours after birth. Of 
 course no milk can be drawn at this early date, but the babe gets a small 
 quantity of colostrum, which affords sufficient nourishment, and from its laxa- 
 tive properties clears out the infant's intestinal canal. This, too, is of great 
 advantage to the mother, for it ensures proper uterine contraction, draws out 
 the nipples, and encourages the formation of milk. Put the child to the 
 breast every two hours while the mother is awake, and up to the fourth day 
 there need be no fear of starvation. Usually on the fourth day milk is 
 secreted and regular lactation commences. Before this time the administra- 
 tion of gruel or any form of artificial food is more than useless, as it lessens 
 the activity of sucking and frequently deranges the stomach. 
 
 Many untrained mothers make a failure of nursing because they know 
 nothing of the manner of giving suck ; of the length of time the child 
 should be kept at the breast; of the proper time for, and interval between, 
 feedings ; and of the importance of regularity. 
 
 While nursing the infant must be held partly on its side, on the right or 
 left arm according to the gland about to be drawn, while the mother must 
 bend her body forward, so that the nipple may fall easily into the child's 
 mouth, and steady the breast and regulate the flow of milk with the first and 
 second finger of the disengaged hand placed above and below the nipple. 
 Each of the breasts should be drawn alternately, and a healthy child may be 
 allowed to nurse until satisfied. Usually during the first six weeks the breast 
 is required every second hour from 5 A. M. until 11 p. M., and in some cases 
 once during the night ; but this night-nursing should be given up as soon as 
 possible, that the mother may secure essential repose. Regularity in meal 
 hours is most important, and a little perseverance will form the habit of 
 waking to suck the breast with almost the precision of the clock. This rule, 
 

 GENERAL MANAGEMENT OF CHILDREN. 19 
 
 however, is not rigid, some infants requiring food less, others more, frequently. 
 These exceptions can only be determined by observation of individual charac- 
 teristics, and every mother must early learn to distinguish the cry of hunger from 
 that due to the pain of indigestion, and avoid the dangerous practice of resort- 
 ing to constant feeding as a means of pacifying crying. 
 
 After the sixth week the interval between nursings may be slowly increased 
 until, by the fourth month, it reaches three hours. During this period, also, 
 the time of lying at the breast may be gradually lengthened, for the quantity 
 of milk secreted and the child's appetite and capacity for food are all aug- 
 mented as the days pass by. At the 'end of the sixth month feeding every 
 fourth hour suits some children well, but as a rule the three-hour interval must 
 be adhered to from the fourth month to the end of lactation. 
 
 After the sixth or eighth month "mixed feeding" — breast- and bottle- 
 feeding alternating — is advisable if the babe ceases to thrive on the breast 
 alone. Otherwise, the maxim of not interfering w T ith any course that is 
 doing well is as applicable here as elsewhere, and the breast may be relied upon 
 entirely until the time comes for weaning. Should additional nutriment be 
 required, the food must be selected with due reference to age and prepared in 
 the same manner as in regular hand-feeding. 
 
 The date of weaning cannot be fixed for all cases, since it depends upon 
 the health of the mother and the development of the child. When the former 
 continues to be robust and the child steadily grows and gains flesh, lactation 
 can be prolonged until the tenth or twelfth month. If persevered in longer, 
 the mother's strength usually begins to fail, her milk is lessened in quantity 
 or becomes poor in quality, the child's nutrition suffers, and it grows pale, 
 thin, and flabby, and may develop the disease known as rickets. 
 
 Weaning may be accomplished gradually or suddenly. In gradual wean- 
 ing about four weeks are required to prepare for the absolute withdrawal of 
 the breast. For instance, if suck be given every three hours from 5 a.m. 
 until 11 P. M., or seven times a day, there should be, during the first week 
 of preparation, one artificial feeding and six nursings daily ; during the sec- 
 ond, two and five, and so on until the breast is entirely withheld. Carefully 
 prepared milk food, administered from a bottle, is the best substitute. At the 
 age of ten months a mixture that ordinarily agrees well is — 
 
 Cream f|ss. 
 
 Milk fiiv. 
 
 Sugar of milk 3j. 
 
 Water fgiss. 
 
 Should fever or disordered digestion occur during the period of prepara- 
 tion, the number of artificial feedings must be reduced or the breast resumed 
 until the disturbance be passed ; then the course may be begun again and car- 
 ried to its completion. 
 
 Sudden w r eaning is more difficult to accomplish, and is not advisable unless, 
 while the breast is being presented, there is an absolute refusal to take artificial 
 food, or unless the mother's health becomes so affected as to render any further 
 sucking a positive peril to the child's life : attacks of erysipelas or of small- 
 pox are instances in point. 
 
 The physician is often forced to decide upon the advisability of premature 
 weaning. His decision must be made cautiously and after thorough investi- 
 gation of two propositions — namely (a) the effect of further lactation upon the 
 health of the mother ; and (b) the requirements of the child. 
 
 (a) Lactation, being a physiological process, is not a drain upon the sys- 
 
20 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 temic strength so long as the functions of nutrition are actively performed, but 
 under other circumstances it very frequently becomes so. Premature weaning 
 is necessary when the mother is attacked by any acute disease threatening dan- 
 gerous temporary prostration, such as typhoid or typhus fever. A change must 
 also be made if pulmonary consumption be developed, or, being already pres- 
 ent, rapidly advances under the drain of milk-secretion. Usually, however, 
 the general condition that leads to withdrawal of the breast is one of simple 
 loss of strength and flesh on the part of the mother, and one which may often 
 be overcome by attention to her health. 
 
 If the trouble be merely diminished milk-secretion, it may often be reme- 
 died by the free use of animal broths, chocolate, gruel, or milk, and some- 
 times the moderate employment of stimulants, in the form of ale and porter, 
 may be necessary. Such tonics as malt extract, ferrated elixir of cinchona, 
 bitter wine of iron, and the preparation known as "beef, wine, and iron," are 
 useful when there is anaemia or when the general failure of strength cannot be 
 overcome by food and attention to hygienic rules. 
 
 The ordinary local conditions indicating the necessity of premature wean- 
 ing on the mother's account are fissures of the nipple and mammary abscess. 
 
 (b) On the part of the infant there are several indications for premature 
 weaning. It must be done if the occurrence of pregnancy or the recurrence 
 of menstruation renders the milk unwholesome ; if the mother contract a dan- 
 gerous contagious disease, as small-pox, scarlet fever, or erysipelas ; if the 
 mammary glands become inflamed ; if the breast does not afford sufficient 
 nourishment and artificial food be refused ; and, finally, if dentition be mark- 
 edly delayed and the premonitory symptoms of rickets appear. 
 
 Upon deciding to anticipate the time of weaning, the next point to con- 
 sider is whether the infant shall be brought up by hand or by a wet-nurse. 
 
 2d. Feeding by a Wet-nurse. — The advantage of this mode of feeding is 
 that the mother's milk is substituted by the milk of another woman ; in other 
 words, that natural feeding is continued — a matter of moment in all cases, and 
 of inestimable importance with delicate children. The disadvantage consists 
 in the difficulty of finding, in a woman belonging to the class from which wet- 
 nurses come, all the moral and physical characters essential to a good substitute, 
 and in the fact that a stranger is introduced into the household, often to deceive 
 and annoy the family, and on the slightest provocation to leave her charge to 
 fate or to the tender mercies of another of her kind. For these reasons it 
 is preferable, in the majority of instances, to trust to careful bottle-feeding. 
 Nevertheless, as some children must have human milk if their lives are to be 
 saved, the rules for selecting a wet-nurse must be understood. 
 
 The woman chosen must be strong and robust, but rather spare than fat. 
 Her bill of health must be perfectly free from hereditary tendency to mental 
 or physical disease and from taint of syphilis, consumption, or scrofula. She 
 must be cheerful, good-natured, active, careful, and temperate in habits. Her 
 age should be between twenty and thirty years ; she should understand the 
 care of an infant and the manner of giving suck ; her child ought to be nearly 
 of the same age as the infant to be adopted, and she must be able to afford an 
 abundant supply of good milk. The last quality can be estimated by inspect- 
 ing the breasts, by examining some of the milk drawn by a pump, and by ascer- 
 taining the condition of the woman's own child. The breasts of a good nurse 
 are not necessarily large, but are firm to the touch and pyriform in shape, with 
 well-developed, prominent nipples, and with the skin distinctly marbled with 
 large blue veins. The milk, which ought to flow readily on pressure or on 
 suction, should be opaque and dull white in color, have a specific gravity of 
 
GENERAL MANAGEMENT OF CHILDREN. 21 
 
 1.031, an alkaline reaction, and show, when placed under the microscope, a 
 number of minute, equal-sized fat-globules. Its quantity may be ascertained 
 by weighing the child before and after sucking, the normal gain being from 
 three to six ounces. There is, however, no better or more readily applied test 
 of the quality of a nurse than the size, weight, and general development of 
 her own child : and if it be weak and ill-nourished, no amount of fitness in 
 other respects can warrant her engagement. Even when a woman is found 
 fulfilling in her single person all the required conditions — a rare thing, indeed 
 — it does not necessarily follow that her milk will suit the babe to be suckled. 
 Then changes and new trials must be made until the desired end be attained. 
 
 3d. Artificial Feeding. — There are many women who, no matter how will- 
 ing, are completely unable to suckle their babies, and a vast number in whom 
 the secretion of milk fails after a few weeks or months of lactation. These 
 must resort to a wet-nurse or to artificial feeding. Usually, they select the 
 latter method. 
 
 To ensure success in hand-feeding — always a difficult task — it is important 
 to make a detailed study of the following questions : a, the selection of a 
 proper substitute for the natural food — the breast-milk ; b, the quantity to be 
 given ; c, the method of preparation ; d, the mode of administration ; and, e, 
 the means of preservation. 
 
 a. Healthy breast-milk must be taken as the type of infants' food, and the 
 nearer an artificial substance can be made to approach it in chemical composi- 
 tion and physical properties the more perfect it is. Normal breast-milk has a 
 specific gravity of 1.031. It is a persistently alkaline fluid, having a some- 
 what animal, usually disagreeable, and, very rarely, sweetish taste. It is 
 bluish-white in color and thin and watery in consistence. It contains nitro- 
 genous material (caseine), carbohydrates (milk-sugar and fat), salts, and water 
 — all the elements essential to repair tissue-waste, to supply new material for 
 growth, and to maintain body heat, or, in other words, to constitute a perfect 
 aliment ; and these, too, are so proportioned in the combination as to most 
 easily and completely meet the demands. 
 
 In seeking a substitute for human milk one naturally turns to the domestic 
 animals for the source of supply ; cows' milk is usually selected, because, being 
 plentiful, it is easily obtained and cheap. 
 
 Cows' milk (market milk) has a lower specific gravity than human milk — ■ 
 namely, 1.029 ; notwithstanding this, it is richer-looking — that is, whiter and 
 more opaque ; its reaction is slightly acid unless perfectly fresh from pasture- 
 fed animals, when it may be neutral or alkaline. Its component ingredients are 
 similar to those of human milk, but nitrogenous material exists in greater, the 
 fat in somewhat less, and the sugar in far less proportion. The nitrogenous 
 material also differs in quality, containing a much larger proportion of albumin 
 coagulable by acids. This difference is readily tested by adding rennet to the 
 two fluids. In the case of cows' milk the caseine is coagulated into large, firm 
 masses, while with human milk a light, loose curd is formed. In the stomach 
 the acid gastric juice has the same effect, producing in the first instance a coag- 
 ulum most difficult to digest ; in the other, one readily attacked and broken 
 down by the gastro-intestinal solvents. These chemical and physical proper- 
 ties of cows' milk can be altered by various methods of preparation, and 
 unless this be done there are few instances in which it will not prove a poor 
 substitute for the natural food. 
 
 Condensed milk is frequently recommended by physicians, and largely used 
 by the laity on their own responsibility. It keeps better than cows' milk, and 
 is supposed to be more readily digested by young infants. The latter suppo- 
 
22 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 sition is a mistaken one, and arises from the overlooked fact that condensed 
 milk is always given dissolved in a large proportion of water, while cows' milk 
 is too frequently used insufficiently diluted or otherwise improperly prepared. 
 Condensed milk contains a large proportion of sugar, forms fat quickly, and 
 thus makes large babies ; sugar also counteracts the tendency to constipation 
 — often a troublesome complaint in hand-feeding. These advantages are 
 unquestioned, and, together with the ease of preparation, are those which place 
 it so high in the esteem of monthly nurses. It is equally true, however, that 
 as a food it contains too much cane-sugar, and not enough nutrient material 
 to supply the wants of a growing baby. Infants fed upon it, though fat, are 
 pale, lethargic, and flabby ; although large, they are far from strong, have 
 little power to resist diseases, often cut their teeth late, and are very liable 
 to drift into rickets. It must be remembered also that condensed milk, when 
 long kept or when packed in imperfect cans, not unfrequently undergoes 
 decomposition, and thus becomes utterly unfit for use. For a temporary 
 change of diet, however, and as a substitute during travelling or under cir- 
 
 © 7 1 CD CD 
 
 cumstances in which sound cows' milk cannot be obtained, it may be resorted 
 to with advantage. 
 
 The farinaceous substances so often selected, especially by the poor, to replace 
 breast-milk, are not only bad foods, but have both directly and indirectly a delete- 
 rious effect upon the processes of nutrition. They are bad for two reasons : First, 
 they differ materially in chemical composition from human milk. For example, 
 in arrowroot, which is the favorite, the proportion of the tissue-building to the 
 heat-producing element is as one to twenty, while in human milk it is about 
 one to five. Secondly, the heat-producing principle, starch, must be converted 
 into sugar before it can be absorbed. This change is accomplished in the body 
 by the saliva and pancreatic juice — secretions that are not fully established 
 until the fourth month. While the starch lies undigested in the gastrointes- 
 tinal canal it is subject to fermentation, resulting in the formation of irritant 
 products that rapidly induce catarrh of the mucous membrane — a condition- 
 directly interfering with the digestion and absorption of food. Again, perfect 
 nutrition demands rapid waste and removal of effete tissues as well as repair 
 of the same. This is effected by oxidation. Now, sugars are known to have 
 a much greater affinity for oxygen than albuminates, and when the diet con- 
 sists of farinaceous material the small amount of sugar formed and absorbed 
 appropriates oxygen that otherwise would go toward the removal of waste, and 
 so retards the necessary changes. Farinaceous food, as such, is never permis- 
 sible before the fourth month ; earlier, it is only to be employed for its mechan- 
 ical action as an addition to milk preparations. This will be mentioned later. 
 
 The nutrient value of the cereals and their products as they exist in so-called 
 " infants' foods " has been imperfectly determined. They are undoubtedly use- 
 ful as mechanical attenuants, but it is very certain that none of them, 
 unless prepared with milk, can permanently meet the demands of nutrition. 
 At the same time, it is quite probable that the soluble albuminoid substances 
 obtained by Liebig's process have a food value of their own, making them more 
 serviceable than the starches. 
 
 b. The quantity of food to be allowed each day varies with the appetite 
 and age, and the question of the correct amount in a given case must be 
 answered by observation. Nevertheless, it is well to have some guide. (See 
 table, page 24 et seq.) 
 
 After the twelfth month the quantity depends upon whether additions be 
 made to the diet or milk food be used exclusively. When the daily amount 
 reaches three pints, the limit of the capacity of the stomach is usually attained, 
 
GENERAL MANAGEMENT OF CHILDREN. 23 
 
 and the greater demand for nutriment, as growth advances month by month, 
 must be met by adding to the strength of the food rather than by increasing 
 its bulk. These two factors, strength and quantity, are intimately associated 
 throughout the whole period of infancy, and in the earlier months a mere 
 increase in the latter is not always sufficient to maintain the balance of 
 nutrition. 
 
 c. The object to be accomplished in the preparation of cows' milk is to make 
 it resemble human milk as much as possible in chemical composition and phys- 
 ical properties. To do this it is necessary to reduce the proportion of caseine, 
 to increase the proportion of fat and sugar, and to overcome the tendency of 
 the caseine to coagulate into large, firm masses upon entering the stomach. 
 Dilution with water is all that need be done to reduce the amount of caseine 
 to the proper level ; but as this diminishes the already insufficient fat and 
 sugar, it is essential to add these materials to the mixture of milk and water. 
 Fat is best added in the form of cream, and of the sugars either pure white 
 loaf sugar or sugar of milk may be used. The latter is greatly preferable, as 
 it is little apt to ferment and contains some of the salts of milk, which are of 
 nutritive value. Firm clotting may be prevented by the addition of an alkali 
 or a small quantity of some thickening substance. Lime-water is the alkali 
 usually selected. It acts by partially neutralizing the acid of the gastric juice, 
 so that the caseine is coagulated gradually and in small masses, or passes, in 
 great part, unchanged into the intestine, to be there digested by the alkaline 
 secretions. As it contains only half a grain of lime to the fluidounce, the 
 desired result cannot be attained unless at least a third part of the milk mix- 
 ture be lime-water. Instead of lime-water, two to four grains of bicarbonate 
 of sodium may be added to each bottle, or, better still, from five to fifteen 
 drops of the saccharated solution of lime. 
 
 This solution is made in the following way : 
 
 Take of— 
 
 Slaked lime 1 ounce.^ 
 
 Refined sugar, in powder 2 ounces. 
 
 Distilled water 1 pint. 
 
 Mix the lime and sugar by trituration in a mortar. Transfer the mixture to 
 a bottle containing the water, and, having closed this with a cork, shake 
 it occasionally for a few hours. Finally, separate the clear solution with 
 a siphon and keep it in a stoppered bottle. 
 
 Thickening substances — attenuants, such as barley-water, gelatin, or one 
 of the digestible prepared foods — act purely mechanically by getting, as it 
 were, between the particles of caseine during coagulation, preventing their 
 running together and forming a large, compact mass. To prepare the former, 
 put two teaspoonfuls of washed pearl barley, with a pint of cold filtered water, 
 into a saucepan ; boil slowly down to two-thirds and strain. The liquid ob- 
 tained does not possess the disadvantages of farinaceous foods generally. To 
 be efficient, it must be used as a diluent instead of, and in the same proportion 
 as, water. Gelatin is prepared in the following way : Put a piece of plate gel- 
 atin, an inch square, into a half-tumblerful of cold water, and let it stand for 
 three hours ; then turn the whole into a teacup ; place this in a saucepan half 
 full of water and boil until the gelatin is dissolved. When cold this forms a 
 jelly; from one to two teaspoonfuls may be added to each bottle of milk food. 
 When an " infants' food " is used to act mechanically, care should be taken to 
 select one in which the starch has been converted into maltose and dextrin 
 by the process of manufacture. 
 
24 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The following table and schedule will aid in the practical understanding 
 of the method of preparing food : 
 
 Table of the Ingredients, Hours and Intervals of Feeding, and Total Quantity of Food from Birth to 
 
 the End of Seventh Month. 
 
 Age. 
 
 Cream. 
 
 Whey. 
 
 Milk. 
 
 f#j 
 
 fciij 
 
 
 f^ij 
 
 
 f^ss 
 
 fgss 
 
 
 f^x 
 
 f^ss 
 
 
 m 
 
 f|ss 
 
 
 f^iijss 
 
 Water 
 
 Hours for 
 Feeding. 
 
 Intervals Total 
 Feeding. Quantit ^ 
 
 During 1st week 
 
 From 2d to 6th 
 
 week 
 
 From 6th week to 
 
 end of 2d month 
 From 3d month to 
 
 6th month . . 
 During 6th and 7th 
 
 months .... 
 
 5 A. M. to 11 
 p. M. 
 
 Occasionally 
 once or 
 twice at 
 night. 
 
 5 A. m. to 11 
 p. M. 
 
 5 A. M. to 11 
 P. M. 
 
 5 A. M. tO 
 
 10.30 p. m. 
 
 7 A. M. tO 10 
 P. M. 
 
 2 hours. 
 
 2 hours. 
 
 2 hours. 
 2J hrs. 
 
 3 hours. 
 
 ^*ij- 
 
 f3xxx. 
 
 fjxxxij. 
 
 f^xxxvj. 
 
 Throughout the eighth and ninth months five meals a day will be sufficient. 
 First meal, at 7 A. M. — 
 
 Milk fgvi. 
 
 Cream f^ss. 
 
 Milk-sugar 3j. 
 
 Water f^jss. 
 
 Second meal at 10.30 a. m. — Milk, cream, and water in the same propor- 
 tion ; a reliable "infants' food," two teaspoonfuls. Third meal at 2 P. M. — 
 same as second. Fourth meal at 6 P. M. — same as second. Fifth meal at 10 
 p. M. — same as first. This gives forty fluidounces of food per diem. Instead 
 of "infants' food," a teaspoonful of "flour-ball" may be added. To make 
 flour-ball, take a pound of good wheat flour — unbolted, if possible ; tie it up 
 very tightly in a strong pudding-bag ; place it in a saucepan of water and boil 
 constantly for ten hours ; when cold, remove the cloth, cut away the soft, outer 
 covering of dough that has been formed, and reduce the hard-baked interior 
 by grating. In the yellowish-white powder obtained almost all the starch has 
 been converted into dextrin by the process of cooking, and the proportion of 
 the nitrogenous principle to the calorifacient is as one to five — nearly the same 
 as human milk. Two meals of flour-ball daily — the second and fourth — are 
 all that can be digested. To prepare these, rub one teaspoonful of the powder 
 with a tablespoonful of milk into a smooth paste, then add a second tablespoon- 
 ful of milk, constantly rubbing until a cream-like mixture is obtained. Pour 
 this into eight ounces of hot milk, stirring well, and it is then ready for use. 
 The other meals should be composed of milk, cream, sugar of milk, and water, 
 as already given. Flour-ball is best suited for infants having a tendency to 
 too frequent and liquid fecal evacuations, as it has a somewhat astringent 
 action, and is to be avoided in cases of sluggish bowels and constipation. 
 Under the latter conditions a more laxative food, such as oat-meal, crushed 
 wheat, or barley, should be employed, the quantity of each being determined 
 by the effect to be produced. 
 
 Diet from the tenth to fourteenth month — five meals daily : 
 First meal, 7 A. M. — 
 
GENERAL MANAGEMENT OF CHILDREN. 25 
 
 Milk f^viiiss. 
 
 Cream f £ss. 
 
 One of the Liebig foods 3ss. 
 
 (Or barley jelly 3ij.) 
 
 Water f^jss. 
 
 Occasionally, about the end of the first year a child may require a more 
 varied and substantial diet ; for example : First meal, 7 A. M. — milk mixture 
 as above. Second meal, 10.30 A. M. — a breakfast-cupful (f gviij) of warm 
 milk. Third meal, 2 p. M. — the yelk of an egg lightly boiled, with stale 
 bread-crumbs. Fourth meal, 6 P. M. — same as first. Fifth meal, 10 P. M. — 
 same as second. On alternate days the third meal may consist of a teacupful 
 (six fluidounces) of beef tea 1 containing a few stale bread-crumbs. A further 
 variation can be made by occasionally using mutton, chicken, or veal broth 
 instead of beef tea. 
 
 As much more difficulty is experienced in feeding infants during the first 
 twelve months than during the second, it would be well to pause here to con- 
 sider what had best be done in case the food described should disagree. 
 
 If, after feeding, vomiting occur, with the expulsion of large, firm clots of 
 caseine, the effect of adding lime-water or barley-water must be tried, both 
 being added in the same quantity as the ordinary diluent — water. 
 
 Sometimes, particularly if there be diarrhoea, boiling makes the milk more 
 tolerable ; condensed milk, too, can be employed temporarily, making, for an 
 infant of six weeks, each portion of — 
 
 Condensed milk 3J. 
 
 Cream fgss. 
 
 Hot water f ^iiss. 
 
 Should further alteration be necessary, goats' or asses' milk may be substi- 
 tuted for cows' milk, the strong odor of the former and the laxative properties 
 of the latter being removed by boiling. The milk should be used warm from 
 the udder. 
 
 " Strippings " is another good substitute for cows' milk. It is obtained 
 by remilking the cow after the ordinary daily supply has been drawn, and con- 
 tains much cream and but little curd. One part of strippings to two of water 
 or an equal measure of barley-water makes an easily digested mixture. 
 
 The process of predigestion or peptonization enables us to overcome many 
 of the difficulties encountered in bottle-feeding. Pancreatin is the agent to 
 be employed. That manufactured under the name of extractum pancreatis by 
 Fairchild Brothers & Foster of New York has proved most efficient in my hands. 
 To accomplish artificial digestion put into a clean quart bottle five grains of 
 extractum pancreatis, fifteen grains of bicarbonate of sodium, and four fluid- 
 ounces of cool filtered water ; shake thoroughly together, and add a pint of 
 fresh, cool milk. Place the bottle in water, not so hot but that the' whole 
 hand can be held in it for a minute without discomfort, and keep the bottle 
 there for exactly thirty minutes. At the end of that time put the bottle on 
 ice to check further digestion and to keep the milk from spoiling. The fluid 
 obtained, while somewhat less white in color than milk, does not differ from it 
 in taste : if, however, an acid be added, the caseine, instead of being coagu- 
 
 1 Beef tea for an infant is made in the following way : Half a pound of fresh rump-steak, 
 free from fat, is cut into small pieces and put, with one pint of cold water, into a covered tin 
 saucepan. This must stand by the side of the fire for four hours, then be allowed to simmer 
 gently (never boil) for two hours, and, finally, be thoroughly skimmed to remove all grease. 
 
26 AMERICAN TEXT-BOOK OF DISEASES OF CHIIDBEN. 
 
 lated into large, firm curds, takes the form of minute soft flakes or readily 
 broken-down, feathery masses of small size. When the process is carried just 
 to the point described, the caseine is only partly converted into peptone, but 
 every succeeding moment of continued warmth lessens the amount of caseine 
 until peptonization is complete. Then the liquid is grayish-yellow in color, 
 has a distinctly bitter taste, and shows no coagulation whatever on the addition 
 of an acid. 
 
 " Peptogenic milk powder," prepared by the same chemists, has given me 
 even better results than the pancreatin and soda. This powder contains a 
 digestive ferment, pancreatin ; an alkali, bicarbonate of sodium ; and a due 
 proportion of milk-sugar. The mode of employment is as follows : 
 
 Take of— 
 
 Milk fgij. 
 
 Water f^ij. 
 
 Cream f^ss. 
 
 Peptogenic milk powder 3J. 1 
 
 This mixture is to be heated slowly to boiling, ten minutes being occupied, 
 and then quickly cooled. When properly prepared the resultant, so-called 
 "humanized milk," presents the albuminoids in a minutely coagulable and 
 digestible form ; has an alkaline reaction ; contains the proper porportion of 
 salts, milk-sugar, and fat ; is not bitter in taste, being but partially peptonized, 
 and in appearance as well as chemical composition resembles human milk. 
 
 The great advantages of partial peptonization are that the necessity for 
 lime-water, barley-water, and thickening substances to keep apart the curd is 
 done away with, and that, when the digestive disturbance requiring a careful 
 preparation of food is removed, an ordinary milk diet can be gradually resumed 
 by regularly diminishing the time artificial digestion is allowed to progress. 
 This changes the caseine in a less and less degree, until, finally, it is taken in 
 its natural form. 
 
 " Sterilization" is another process of importance. As milk exists in the 
 healthy cow's udder it is aseptic — i. e. free from any poisonous or dangerous 
 ingredient — but during milking and subsequent handling and transportation 
 various foreign materials get into it and are apt to set up some injurious change. 
 To deprive these accidentally introduced organic impurities of their activity — 
 or, in other wwds, to sterilize — it is necessary to su bj ect the fluid to high heat 
 under pressure. 
 
 Several admirable implements have been devised for conducting the process; 
 one of the most simple, made after a design of my own, is shown in Fig. 1. 
 
 This apparatus is made of tin, and consists of an oblong case provided with 
 a well-fitting cover, and having a movable perforated false bottom (d), which 
 stands a short distance above the true one and has attached a framework capa- 
 ble of holding ten six-ounce nursing-bottles. On the outside of the case is a 
 row of supports (b) for holding inverted bottles while drying, and at the proper 
 distance below these a gradually inclining gutter (c) for carrying off the drip. 
 A movable water-bath (a) is hung to the side ; in this each bottle of food may 
 be warmed at the time of administration. Ten graduated nursing-bottles are 
 used, so that the whole supply of milk intended for a day's consumption can 
 be prepared at once. Each bottle is provided with a perforated rubber cork, 
 which in turn is closed by a well-fitting glass stopper. 
 
 Sterilization should be performed in the morning as soon as possible after 
 
 1 Measure provided with jar only to be used when preparing, at once, the whole quantity 
 of food to be given in a day. 
 
GENERAL MANAGEMENT OF CHILDREN. 27 
 
 the milk has been served" The process is as follows : First, see that the ten 
 bottles are perfectly clean and dry ; pour into each six fluidounces of milk ; 
 insert the perforated rubber corks, without the glass stoppers, however; 
 remove the false bottom and place the bottles in the frame ; pour into the 
 
 Fig. 1. 
 
 Author's Sterilizer. 
 
 case enough water to fill it to the height of about two inches ; replace the false 
 bottom carrying the bottles ; adjust lid and put the whole on the kitchen range. 
 Allow the water to boil, and, by occasionally removing the lid, ascertain that 
 the expansion that immediately precedes boiling has taken place in the milk ; 
 then press the glass stoppers into the perforated corks, and thus hermetically 
 close each bottle. After this keep the apparatus on the fire and the water 
 boiling for twenty minutes. Finally, remove the false bottom with the bot- 
 tles ; pour out the water, replace and carry the whole, covered with the lid, 
 to the nursery. 
 
 Milk sterilized by this process will remain sound for many days : it is espe- 
 cially useful in travelling, when fresh milk cannot be obtained ; for use in 
 cities during the heat of summer, when milk is most apt to undergo injurious 
 changes ; for a temporary change of food in delicate children or for those suffer- 
 ing from disease of the stomach or intestinal canal. It must be remembered, 
 however, that the prolonged heating produces certain changes in the compo- 
 sition of the milk which make it more difficult to digest, and that on this 
 account many children do not thrive upon it. 
 
 Another process of sterilization, suggested by Leeds, is free from this dis- 
 advantage, and has proved most useful in my practice. It consists in heating 
 the milk, rendered feebly alkaline with lime-water or sodium bicarbonate, to 
 155° F. for six minutes, or, better still, of applying the same amount of heat 
 to milk with pancreatin and bicarbonate of sodium or with peptogenic milk 
 powder. By the latter method the milk is both predigested and sterilized ; if 
 not used at once, it must be momentarily heated to the boiling-point to check 
 peptonization before the development of a bitter taste. 
 
 According to Rowland Gr. Freeman, the problem that presents itself in the 
 sterilization of milk for food is to devise a method which shall destroy by 
 efficient means the contained germs, and yet in the least possible degree 
 interfere with its nutritive qualities. The experiments of Leeds show that 
 
28 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 sterilization at the boiling-point of water causes the following modifications : 
 the starch-liquefying ferment is destroyed and coagulated ; caseine is rendered 
 less coagulable by rennet, and is acted on slowly and imperfectly by pepsin 
 and pancreatin ; proteid matters attach themselves to fat-globules, and prob- 
 ably bring about a less perfect assimilation of fat ; while milk-sugar, by pro- 
 longed heating, is completely destroyed. Koplik states that "from the temper- 
 ature of 75° C. upward there is a separation of the serum-albumin of the milk ; 
 the caseine loses its coagulability to rennet, and at 85° C. amounts of rennet 
 which for the raw condition of milk are found sufficient to act cease to be effec- 
 tive." Hueppe considers that from a physiological standpoint milk is best 
 sterilized under a temperature of 75° C, while other experimenters have shown 
 that temperatures lower than 100° C, if continued for a short time, will destroy 
 a very large proportion of the germs, and w T ill destroy with certainty many 
 pathogenic germs which find their way into milk either from the cow or as 
 external contaminations. 
 
 Dr. Freeman, therefore, feels satisfied that Pasteurization offers the most 
 rational solution of the question under consideration. The elaborate and 
 recent experiments of Yersin, Granchier, Lidoux-Libard, and Bitter show 
 that the bacillus tuberculosis in milk will be destroyed in ten minutes by an 
 exposure to 75° C, in fifteen minutes to 70°, and in thirty minutes to 68°. 
 Concerning other bacteria, Van Geuns found that a few seconds' exposure to 
 60° would kill the cholera spirilla, the Finkler-Prior bacillus, the typhoid 
 bacillus, and the pneumococcus of Friedlander. 
 
 It may, therefore, be concluded that a temperature of not less than 158° F. 
 will render milk sufficiently germ-free for infant food, and that a temperature 
 of less than 176° F. will not injure milk materially. Methods of Pasteurizing 
 milk in bulk have been brought forward both in Germany and in this coun- 
 try ; and now the procedure has been brought down to an easily-managed 
 system for household use. This depends upon the theory that the tempera- 
 ture of the milk to be treated may be raised to about the desired point 
 (167° F.) by immersing a certain definite quantity of milk in a properly pro- 
 portioned bulk of boiling water, the source of heat having been removed. 
 The apparatus consists of two parts, a graduated pail for the water and a 
 receptacle for the bottles of milk. This receptacle consists of a series of 
 seven or ten hollow zinc cylinders fastened together, which fits into the pail 
 containing the boiling water. Each of these cylinders is large enough to hold 
 one of the bottles of milk, the series of seven cylinders accommodating seven 
 eight-ounce bottles, and the series of ten cylinders being intended for ten six- 
 ounce bottles. When the bottles are in place water is poured around them 
 to secure perfect conduction of the heat. After the water in the pail is thor- 
 oughly boiling, it is removed from the stove and placed on a non-conducting 
 surface. The cylinders are now introduced, and the pail covered and left 
 standing for thirty minutes, after which the milk is rapidly cooled in a refrig- 
 erator or by cold water or ice and water. Milk thus treated and put imme- 
 diately into a refrigerator usually shows no change for several days. 
 
 Sometimes milk, in every form and however carefully prepared, ferments 
 soon after being swallowed and excites vomiting, or causes great flatulence and 
 discomfort, while it affords little nourishment. With these cases the best plan 
 is to withhold milk entirely for a time and try some other form of food. The 
 following are good substitutes : 
 
 Veal broth (J lb. of meat to the pint) f iiss. 
 
 Barley-water f^iss. 
 
GENERAL MANAGEMENT OF CHILDREN. 29 
 
 Or, Whey f^iss. 
 
 Barley-water f^iss. 
 
 Milk-sugar 3ss. 
 
 For one portion : to be given every two hours at the age of two months. 
 
 A teaspoonful of the juice of raw beef every two hours will usually be 
 retained when everything else is rejected. Such foods are only to be used 
 temporarily until the tendency to fermentation within the alimentary canal 
 ceases ; then milk may be gradually and cautiously resumed. 
 
 When infants approaching the end of the first year become affected with 
 indigestion, it is often sufficient to reduce the strength and quantity of the food 
 to a point compatible with digestive powers. For instance, at eight months 
 the food may be reduced to that proper for a healthy child of six months or 
 even less. Here, too, predigestion of the food is very serviceable. If a few 
 grains of extractum pancreatis be added to a gobletful of thick, well-boiled 
 starch gruel at a temperature of 100° F., the gelatinous mucilage quickly grows 
 thinner, and soon is transformed into a fluid, the starch having been rendered 
 soluble by the action of the pancreatin ; by still longer contact the hydrated 
 starch is converted into dextrin and sugar. Advantage may be taken of this 
 property to render the foods containing starch assimilable. Thus, to a mixture 
 of barley jelly and milk — e. g. 
 
 Barley jelly 3jj, 
 
 Milk sugar 3j, 
 
 Warm milk f^viij, 
 
 add three grains of extractum pancreatis and five grains of bicarbonate of 
 sodium, and keep warm for half an hour before administering. 
 
 The same process may be employed with food containing oatmeal, arrow- 
 root, or wheaten flour, or in the case of meat broths, with a view of converting 
 the starchy and albuminoid ingredients into digestible elements without mate- 
 rially altering the taste. 
 
 Returning to the regimen of the healthy infant, it will be found that after 
 the fourteenth month far less change is required in the food. 
 
 Diet from the fourteenth to the eighteenth month, five meals per day : 
 First meal, 7 A. M. — a slice of stale bread, broken and soaked in a breakfast- 
 cup (eight fluidounces) of new T milk. Second meal, 10 a. m. — a teacup of 
 milk (six fluidounces), with a soda biscuit or thin slice of buttered bread. 
 Third meal, 2 p. M. — a teacup of meat broth (six fluidounces), with a slice of 
 bread ; one good tablespoonful of rice-and-milk pudding. Fourth meal, 
 6 p. M. — same as first. Fifth meal, 10 p. M. — one tablespoonful of Mellin's 
 Food, with a breakfast-cupful of milk. 
 
 To alternate with this : First meal, 7 A. m. — the yelk of an egg lightly 
 boiled, with bread-crumbs ; a teacupful of new milk. Second meal, 10 a. m. — 
 a teacupful of milk, with a thin slice of buttered bread. Third meal, 2 p. M. — 
 a mashed baked potato, moistened with four tablespoonfuls of beef tea ; two 
 good tablespoonfuls of junket. Fourth meal, 6 p. M. — a breakfast-cupful of 
 milk, with a slice of bread broken up and soaked in it. Fifth meal, 10 p. m. 
 — same as second. 
 
 The fifth meal is often unnecessary, and sleep should never be disturbed 
 for it ; at the same time, should the child awake an hour or more before the 
 first meal, he must break his fast upon a cup of warm milk, and not be allowed 
 to go hungry until the set breakfast hour. 
 
 Diet from eighteen months to the end of two and a half years, four meals 
 
30 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 a day : First meal, 7 A. M. — a breakfast-cupful of new milk ; the yelk of an 
 egg lightly boiled : two thin slices of bread and butter. Second meal, 11 A. M. 
 — a teacupful of milk, with a soda biscuit. Third meal, 2 p. M. — a breakfast- 
 cupful of beef tea, mutton or chicken broth ; a thin slice of stale bread ; a 
 saucer of rice-and-milk pudding. Fourth meal, 6.30 p. M. — a breakfast-cupful 
 of milk, with bread and butter. 
 
 On alternate days : First meal, 7 A. M. — two tablespoonfuls of thoroughly 
 cooked oatmeal or wheaten grits, with sugar and cream ; a teacupful of new 
 milk. Second meal, 11 A. M. — a teacupful of milk, with a slice of bread and 
 butter. Third meal, 2 P. M. — one tablespoonful of underdone mutton pounded 
 to a paste ; bread and butter, or mashed baked potato moistened with good 
 plain dish gravy; a saucer of junket. Fourth meal, 6.30 p. M. — a breakfast- 
 cupful of milk, a slice of soft milk toast or a slice or two of bread and butter. 
 
 AVhen sickness supervenes, all that is ordinarily necessary is a reduction of 
 the diet to plain milk or some easily digestible milk mixture. 
 
 An important point, often neglected, is the matter of drink. Even the 
 youngest infant requires water several times daily, and the demand increases 
 with age. The water must be as pure as possible, and should not be too cold. 
 In the heat of summer, however, bits of ice and water moderately cooled by 
 ice can be allowed without harm. 
 
 The foregoing schedule must, of course, be regarded only as an average. 
 Many children can bear nothing but milk food up to the age of two or even 
 three years, and, provided enough be taken, no fear for their nutrition need 
 be entertained. If a child be thriving on milk, he is never to be forced to take 
 additional food merely because a certain age has been reached ; let the healthy 
 appetite be the guide. 
 
 d. Success in hand-feeding depends quite as much on the administration 
 as upon the preparation of the food. 
 
 From birth up to such time as broth, bread, and eggs are added to the diet 
 all the food should be taken from a bottle. Even after this, as the bottle is a 
 comfort and ensures slow feeding, it may be allowed for milk preparations until 
 the child, of his own accord, tires of it. The only feeding apparatus to be 
 admitted to tne nursery is the simple bottle and tip. The bottle made after 
 my suggestion, and known as the "graduated nursing-bottle," has an interior 
 surface free from angles, so that it is readily kept clean, and is provided with 
 a scale for the measurement of ounces and half-ounces. It is made of trans- 
 parent flint glass, so that the slightest foulness can be detected at a glance, 
 and may vary in capacity from six to twelve fluidounces according to the age 
 of the child. Two should be on hand at a time, to be used alternately. Im- 
 mediately after a meal the bottle must be thoroughly washed out with scalding 
 water, filled with a solution of bicarbonate or salicylate of sodium — one tea- 
 spoonful of either to a pint of water — and thus allowed to stand until next 
 required ; then, the soda solution being emptied, it must be thoroughly rinsed 
 with cold water before receiving the food. The tips or nipples, of which there 
 should also be two, must be composed of soft, flexible India-rubber, and a con- 
 ical shape is to be preferred, as being more readily everted and cleaned ; the 
 opening at the point must be free, but not large enough to permit the milk to 
 flow in a stream without suction. At the end of each" feeding the nipple must 
 be removed at once from the bottle, cleansed externally by rubbing with a stiff 
 brush wet with cold water, everted and treated in the same*way, and then placed 
 in cold water and allowed to stand in a cool place until again wanted. 
 
 Next to cleanliness of the feeding apparatus it is important to insist upon 
 the separate preparation of each meal immediately before it is to be given. The 
 
GENERAL MANAGEMENT OF CHILDREN. 31 
 
 practice of making, in the morning, the whole day's supply of food, though it 
 saves trouble, is a most dangerous one. Changes almost invariably take place 
 in the mixture, and by the close of the day it becomes unfit for consumption. 
 
 The food must be administered at a temperature of about 95° F. It may be 
 heated by steeping the bottle containing the food in hot water or by placing 
 it in a water-bath over an alcohol lamp or gas-jet. 
 
 When feeding, the child must occupy a half-reclining position in the nurse's 
 lap. The bottle should be held by the nurse, at first horizontally, but gradu- 
 ally more and more tilted up as it is emptied, the object being to keep the 
 neck always full and prevent the drawing in and swallowing of air. Ample 
 time — say five, ten, or fifteen minutes, according to the quantity of food — should 
 be allowed for the meal. It is best to withdraw the bottle occasionally for a 
 brief rest, and after the meal is over sucking from the empty bottle must not 
 be allowed, even for a moment. 
 
 e. For children residing in cities an honest dairyman must be found who 
 will serve sound milk and cream from country cows once every day in winter, 
 and twice during the day in the heat of summer. The milk of ordinary stock 
 cows is more suitable than that from Alderney or Durham breed, as the latter 
 is too rich, and therefore more difficult to digest. The mixed milk of a good 
 herd is to be preferred to that from a single animal : it is less likely to be 
 affected by peculiarities of feeding, and less liable to variation from alterations 
 in health or different stages of lactation. 
 
 The care of the herd and of the milk is of great consequence. The cows 
 should be healthy, and the milk of any animal that seems indisposed should 
 be excluded. The cows must not be fed upon swill or the refuse of breweries, 
 glucose-factories, or any other fermented food. They must not be allowed to 
 drink stagnant water, and must not be heated or worried before being milked. 
 The pasture must be free from noxious weeds, and the barn and yard must be 
 kept clean. The udder should be washed, if dirty, before the milking. The 
 milk must be at once thoroughly cooled. This is best accomplished by placing 
 the can in a tank of cold spring-water or in ice- water, the water being the same 
 depth as the milk in the can. It is well to keep the water in the tank flowing; 
 indeed, this is necessary unless ice-water be used. The can should remain 
 uncovered during the cooling, and the milk should be gently stirred. The 
 temperature should be reduced to 60° F. within an hour, and the can must 
 remain in the cold water until the time for delivering. In summer, when ready 
 for delivery, the top should be placed in position and a cloth wet in cold water 
 spread over the can, or refrigerator cans may be used. At no season should 
 the milk be frozen, and at the same time no buyer should receive milk having 
 a temperature over 65° F. 
 
 For transportation from the dairy it is safer for the family to provide two 
 sets of small cans — one set to be thoroughly cleansed and aired, while the other 
 is taken away by the milkman to bring back the next supply. So soon as this 
 arrives in the morning, or in the morning and evening in hot weather, the milk 
 should be emptied into separate and absolutely clean earthenware or glass pitch- 
 ers, and these put at once into a refrigerator reserved exclusively for them. 
 This may stand in some convenient spot near the nursery, but not in it, and 
 especially not in an adjoining bath-room. With a good refrigerator there is 
 no difficulty in keeping milk perfectly sweet for twenty-four hours in winter 
 and for twelve hours in summer, except on intensely hot days ; then it may 
 be necessary to scald, slightly boil, or sterilize the whole of the supply when 
 received, in order to prevent change. 
 
 Childhood. — Children who have cut their milk teeth may be fed for ;? 
 
32 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 twelvemonth — namely, up to the age of three and a half years — in the follow- 
 ing way : First meal, 7 A. M. — one or two tumblerfuls of milk, a saucer of 
 thoroughly cooked oatmeal or wheaten grits, and a slice of bread and butter. 
 Second meal, 11 a. m. (if hungry) — a tumblerful of milk or a teacupful of beef 
 tea with a biscuit. Third meal, 2 p. M. — a slice of underdone roast beef or 
 mutton or a bit of roast chicken or turkey, minced as fine as possible ; a baked 
 potato thoroughly mashed with a fork and moistened with gravy ; a slice of 
 bread and butter ; a saucer of junket or rice-and-milk pudding. Fourth 
 meal, 7 p. m. — a tumblerful of milk and one or two slices of well-moistened 
 milk toast. 
 
 From three and a half years up the child must take his meals at the table 
 with his parents, or with some reliable attendant who will see that he eats 
 leisurely. The diet, while plain, must be varied. The following list will 
 give an idea of the food to be selected : 
 
 BREAKFAST. 
 
 Every Day. One Dish only Each Day. 
 
 Milk. Fresh fish. Eggs, plain omelette. 
 
 Porridge and cream. Eggs, lightly boiled. Chicken hash. 
 
 Bread and butter. " poached. Stewed kidney. 
 
 " scrambled. " liver. 
 
 Sound fruits may be allowed before and after the meal, according to taste, as oranges, grapes 
 (seeds not to be swallowed), peaches, thoroughly ripe pears, and cantaloupes. 
 
 DINNER. 
 
 Every Day. Two Dishes Each Day. 
 
 Clear soup. Potatoes, baked. Hominy. 
 
 Meat, roasted or broiled, " mashed. Macaroni, plain. 
 
 and cut into small Spinach. Peas. 
 
 pieces. Stewed celery. String-beans, young. 
 
 Bread and butter. Cauliflower. Green corn, grated. 
 
 Junket, rice-and-milk, or other light pudding, and occasionally ice cream, may be allowed 
 for dessert. 
 
 SUPPER. 
 
 Every Day. 
 Milk. 
 
 Milk toast or bread and butter. 
 Stewed fruit. 
 
 Fried food, highly seasoned or made-up dishes are to be excluded, and no 
 condiment but salt is to be used. Eating, however little, between meals must 
 be absolutely avoided. Keep a young child from knowing the taste of cakes 
 or bonbons, or, having learned it, let him feel that they are as unattainable 
 as the thousand other things beyond his reach, and he soon ceases to ask for 
 them. Even a piece of bread between meals should be forbidden. His 
 appetite then remains natural, and he will eat proper food at his regular meal 
 hours. As to the quantity, a healthy child may be permitted to satisfy his 
 appetite at each meal, under the one condition that he eats slowly and masti- 
 cates thoroughly. Filtered or spring water should be the only drink, tea, 
 coffee, wine, or beer being entirely forbidden. 
 
 In case of illness the diet must be reduced in quantity and quality, accord- 
 ing to the rules that are applicable to adults. 
 
 2. Bathing. 
 During the first two and a half years of life a child ought to be bathed 
 once every day. The bath should be given at a regular time, and it is best to 
 
GENERAL MANAGEMENT OF CHILDREN 33 
 
 select some hour in the early morning, midway between two meals — ten o'clock, 
 for instance. The tub should be placed near the fire or in a warm room in 
 winter, and away from currents of air in summer. It should contain enough 
 water to cover the child up to the neck when in a reclining posture, and the 
 temperature must be about 95° F. Upon undressing the child the first step is 
 to wet his head; then he is to be plunged into the water and thoroughly washed 
 with a soft rag or sponge and pure, unscented castile soap. After remaining 
 in the water from three to five minutes the surface must be well dried and rubbed 
 with a flannel cloth or soft towel ; then the body must be enveloped in a light 
 blanket and the infant either returned to his crib to sleep or kept in the lap 
 for ten or fifteen minutes until thoroughly warm and rested, and finally dressed. 
 If there be repugnance to the bath, the tub may be covered over with a blanket, 
 and the child, being placed upon it, may be slowly lowered into the water with- 
 out seeing anything to excite his fears. In very hot weather, in addition to 
 the morning full bath, the body may be sponged twice daily with water at a 
 temperature of 90° F. ; this, contrary to what might be expected, has a 
 greater and more permanent cooling effect than bathing with cold water. 
 
 After the third year three baths a week are quite sufficient. An evening 
 hour is now to be preferred, but the water must still be heated to 90°. About 
 the tenth year cooler baths can be begun, from 72° to 75° being the proper 
 temperature. The cold sponge or cold plunge is not admissible as a daily 
 routine until youth is well advanced. 
 
 The hot bath — 95° to 100° F. — is employed for various purposes, notably 
 for a derivative action, to cause diaphoresis, to relieve nervous irritability, and 
 to promote sleep. Whether a full bath or merely a foot-bath be required, five 
 minutes is a sufficient time for immersion ; then, with or without drying, 
 according to the degree of sweating desirable, the whole body, or only the 
 feet and legs in case of a foot-bath, must be enveloped in a blanket, and the 
 child put to bed. To render these baths more stimulating, from a teaspoonful 
 to a tablespoonful of mustard flour may be added, and the child held in the 
 water until the arms of the nurse begin to tingle. It is important not to con- 
 tinue a hot bath too long, lest the primary stimulating effect be followed by 
 depression. 
 
 Cold baths, by shocking the system, first produce depression ; but this is 
 temporary and is followed by reaction, during which the skin grows red and 
 the pulse becomes fuller and stronger. They have, therefore, a general stimu- 
 lant and tonic action, promoting nutrition and giving tone to the body. On 
 account of the shock, the extent of which depends directly upon the coldness of 
 the water, these baths must be used with caution, and are not to be employed in 
 very young or feeble subjects. When giving a cold bath, the child must be 
 stripped in a warm room, and thoroughly rubbed with the palm of the hand 
 until the whole body, especially the spinal region, is reddened ; he must then 
 stand in a tub containing enough hot water to cover the feet, and be rapidly 
 sponged with the cold water. The temperature of the latter must never be 
 below 60°, and the addition of half an ounce of sea-salt or a tablespoonful of 
 concentrated sea-water to the gallon renders it more stimulating and ensures a 
 complete reaction. After the sponging the surface must be thoroughly and 
 quickly dried with a soft towel and shampooed with the open hand until 
 aglow. 
 
 The cooled bath may be employed with advantage in extreme conditions 
 of hyperpyrexia. The child is first immersed in water at 95°, and this is 
 gradually lowered to 70° by the addition of cold water, the process occupying 
 from fifteen to thirty minutes. 
 
34 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 3. Clothing. 
 
 Infants and young children have little power of resisting cold, and on this 
 account require warm clothing. The condemnation of the fashion of allowing 
 children to go, even while in the house, with bare legs and knees must be 
 absolute. Occasionally during the most oppresive heat of a summer midday 
 the legs may be left uncovered ; but with this exception the rule is to keep the 
 whole body encased in woollen underclothing. The thickness of this must 
 vary, of course, with the season. Providing this be done, the outer clothing 
 may be left to the taste of the mother ; but all garments should fit loosely, 
 that the functions of the different viscera may not be impeded by pressure. 
 
 The best pattern of a winter night-dress is a long, plain slip, with a draw- 
 ing-string at the bottom, to prevent exposure of the feet and limbs should the 
 child kick off the bed-covering. This should be made of flannel or the more 
 easily washed canton flannel. In summer a loose muslin one may be put on, 
 without the drawing-string. A flannel under-vest should always be worn at 
 night, light gauze in summer and heavier wool in winter ; care must be taken, 
 however, to have one for night alone, discarding that worn in the daytime. 
 
 In infants under a year old a broad flannel abdominal bandage, extending 
 from the hips well up to the thorax, or, better still, a knitted worsted band 
 shaped to fit the form, is very useful in keeping the abdominal organs warm, 
 aiding digestion and preventing pain. 
 
 All clothing should be changed sufficiently frequently to ensure cleanliness. 
 
 Shoes must be large, well shaped, and made of soft leather with pliable 
 soles, so as to allow the feet to grow freely. 
 
 When dressing a child for exercise in the open air in cold weather, the 
 outer clothing must not be put on until just before leaving the house, and 
 removed immediately on return. It is important to protect the head from cold 
 in winter by a close-fitting, thick cap, and from the direct rays of the sun in 
 summer by a broad-brimmed, light straw hat. Rubber shoes are necessary in 
 wet weather to keep the feet warm and dry while walking out of doors. 
 
 4. Sleep. 
 
 For some time after birth infants spend the intervals between being fed, 
 washed, and dressed, in sleep, and thus pass fully eighteen out of the twenty- 
 four hours. As age advances the amount of sleep required becomes less, until 
 at two years thirteen hours, and at three years eleven hours, are enough. This 
 matter, though, is perhaps more a question of training than any other item 
 of nursery regimen, and one cannot too soon begin to form the good habit of 
 regularity in sleeping hours. So far as circumstances will admit, the follow- 
 ing rules may be enforced : 
 
 From birth to the end of the sixth or eighth month the infant must sleep 
 from 11 P. M. to 5 A. M., and as many hours during the day as nature demands 
 and the exigencies of feeding, washing, and dressing will permit. From eight 
 months to the end of two and a half years a morning nap should be taken from 
 12 M. to 1.30 or 2 p. m., the child being undressed and put to bed. The night's 
 rest must begin at 7 P. M. If a late meal be required, the child can be taken 
 up at about ten o'clock ; but if past the age for this, he may sleep undisturbed 
 until he wakes of his own accord some time between 6 and 8 A. m. From two 
 and a half to four years, an hour's sleep may or may not be taken in the morn- 
 ing, according to the disposition of the subject; but in every case the bed 
 must be occupied from 7.30 p. M. to 6 or 7 o'clock on the following morning. 
 After the fourth year few children will sleep in the daytime ; they are ready for 
 
GENERAL REMARKS ON TREATMENT. 35 
 
 bed by 8 f. m.. and should be allowed to sleep for ten hours or more. A later 
 retiring hour than 9 p. M. ought not to be encouraged until after the twelfth 
 or fifteenth year. 
 
 When feasible, different rooms should be used for the day nursery and the 
 sleeping apartment. If an apartment has to be occupied during both the day 
 and night, it must be vacated for half an hour or more in the evening and 
 well aired before the child is put to bed. The temperature of the room must 
 be as uniform as possible, the proper degree of heat being from 64° to 68° F. 
 
 5. Exercise. 
 
 A certain amount of muscular exercise is necessary for development and for 
 the proper performance of the digestive functions. Infants before they are 
 able to stand will use their muscles sufficiently if, when loosely clad, they are 
 placed upon their backs in a bed and allowed to kick and turn about at pleas- 
 ure. After the age of nine or ten months a healthy child will begin to creep ; 
 at the end of a year he will make efforts at standing, and from four to eight 
 months later will be able to walk by himself; children, however, present great 
 differences in this respect, and a delay of a few months must not be considered 
 as abnormal. So soon as efforts at creeping are made there need be no fear 
 that insufficient exercise will be taken ; the care should be rather to prevent 
 over-fatigue. Fresh air and sunlight are as necessary as muscular exercise. 
 The child must be taken out of doors every day, weather permitting, after 
 arriving at the proper age : this is four months for children born in the early 
 fall and winter, and one month for those born in summer. In cool weather 
 babies who are unable to walk should be taken out in a coach or in the nurse's 
 arms for an hour in the morning and half an hour in the afternoon, while the 
 sun is shining. In summer they may pass the greater part of the waking 
 hours in the open air, provided they be well protected from the direct rays of 
 the sun. Children old enough to walk may spend a longer time in the air in 
 winter, and may be out all day in summer. But until the fourth year it is 
 better to let them play about at will than take a long set walk. Until well 
 advanced in childhood the house is the safest place in damp and rainy weather, 
 when there is a strong east or north wind blowing, and when the thermom- 
 eter stands below 15° F. 
 
 III. GENERAL REMARKS ON TREATMENT. 
 
 It is difficult to formulate a precise, reliable, or handy posological table ; 
 in fact, the whole matter of dosage for children is one of experience, and with 
 practice every one makes his own dose-list in his mind, and the proper amount 
 of a given drug for a given age requires as little effort of memory as in the 
 case of adults. Nevertheless, as a guide to the student, Cowling's rule is 
 serviceable — namely, the proportionate dose for any age under adult life is 
 represented by the number of the following birthday divided by 24 — i. e. 
 for one year, -fa = Aj ; for two years, ^ = -J- ; and so on. 
 
 All powerful drugs must be given with caution to children, but opium re- 
 quires the greatest care. Infants bear it only in infinitesimal proportions, and 
 in these its use is to be avoided as much as possible ; still, combined with cas- 
 tor oil, it is a useful drug in bad cases of flatulent colic, the average commen- 
 cing dose in the first six weeks of life being not more than Hl-g 1 ^- of the tincture 
 (laudanum). After the second or third month the extreme susceptibility to 
 the drug disappears, and TTL^- of laudanum may be given for a dose. 
 
36 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Bromide of potassium, a most valuable remedy in many diseases, must be 
 given to infants with watchfulness, as it sometimes, even in small doses, pro- 
 duces severe local inflammations of the skin and localized patches of soft, 
 warty growths. 
 
 Belladonna and arsenic are illustrations of an opposite tendency, for chil- 
 dren are very tolerant of these drugs, particularly the first. A child of four 
 or five years can readily take from two to five minims of tincture of bella- 
 donna, and in cases in which it is necessary to administer arsenic to choreic 
 children of six years and upward a commencing dose of five minims of Fow- 
 ler's solution may often be given three times daily, and a considerable increase 
 in this be attained if required. Such initial doses are, however, occasionally 
 productive of the symptoms of mild arsenical poisoning, and therefore it is 
 well to begin with one- or two-minim doses and increase rapidly. This rule 
 applies especially to children belonging to the wealthier classes, for these, like 
 their parents, are much more sensitive to drugs than hospital patients — an 
 undoubted physiological fact of wide bearing. 
 
 Alcohol is frequently indicated and is of great value, but it must be used 
 with judgment. It is most useful in broncho-pneumonia, severe febrile condi- 
 tions ; in the prostration fallowing measles, diphtheria, and whooping cough ; and 
 in the collapse that frequently attends severe thoracic or abdominal disease. 
 
 All drugs should be made as palatable as possible. 
 
 In conclusion, it must be remembered that children do not often require 
 energetic treatment with drugs. Proper feeding and hygiene are of most 
 importance in the management of disease in early life. 
 
 Antipyretics. — Antipyrine especially, and phenacetin to a less degree 
 only, must be used with extreme caution in the febrile affections of early life, 
 on account of their marked tendency to produce cardiac depression. Spong- 
 ing the surface at proper intervals with tepid or cool water is a much safer 
 method of reducing temperature, but in every instance the law of the temper- 
 ature-curve of the disease under treatment must be taken into consideration ; 
 and it is a safe rule not to interfere unless the temperature excess be great 
 and maintained. For example, in pneumonia, a disease in which antipyretic 
 drugs are especially dangerous and most frequently abused, an evening 
 temperature of 105° is to be expected, and unless maintained is neither cause 
 for alarm nor for the use of a powerful drug that tends to sap the strength 
 of the cardiac muscle, the very keystone of the bridge leading to recovery. 
 
THE CHEMISTRY OF MILK AND OF ARTIFICIAL 
 FOODS FOR CHILDREN. 
 
 By ALBERT R. LEEDS, Ph. D., 
 
 HOBOKEN. 
 
 I. The Chemistry op Milk. 
 
 The peculiar adaptation of milk to the feeding of the young depends upon 
 its unique combination of chemical and physical properties. It contains in 
 well-balanced proportions the three essential elements of nutrition — the nitrog- 
 enous, or tissue-building ; the carbohydrate, or heat-giving ; and the fats. 
 Along with these are a sufficiency of saline substances to carry on the chemical 
 metamorphoses of cell-formation, of secretion and excretion, and an ample 
 supply of water as the universal solvent. These substances are held partly in 
 a state of solution, partly in a state of semi-solution, conferring upon milk its 
 slightly colloidal consistency, and partly in suspension, producing its appear- 
 ance of density and opacity. But it contains no waste material like the indi- 
 gestible fibre and cellulose of flesh, fruit, and vegetables. Neither does it 
 exhibit a development of one or two elements of nutrition at the expense of 
 the third, as is the case with all other foods, — even eggs, which most nearly 
 approach milk in this respect, not being excepted. Finally, almost no prepara- 
 tion before, during, or after swallowing is requisite for the absorption of milk 
 through the rudimentary digestive apparatus of the young. 
 
 The chemistry of woman's milk can be well and effectively studied for our 
 present purposes only in connection with that of cow's milk. For at the very 
 outset a peculiar difficulty is experienced in attempting to procure a sample of 
 the former, which does not exist in the case of the latter. Some sort of a 
 breast-pump or similar appliance must be used, and this unnatural process 
 yields at the best but a partial sample. This fact explains many of the great 
 and anomalous variations exhibited in the analyses. It also renders the con- 
 clusions drawn from an isolated analysis of little value; and in practice it is 
 wiser to base any conclusions as to the sufficiency and quality of the breast- 
 milk upon the condition and yield of the gland, upon the physical condition 
 and nutrition of the mother, and, most of all, upon the development of the 
 child and its deportment in nursing. 
 
 On the other hand, innumerable analyses of complete samples of cow's milk 
 exist, embracing every variety of breed, under every condition of climate, age, 
 culture, and feeding. 
 
 Cow's Milk. — On no other article of food has such elaborate care been 
 expended, both as to its production and chemical investigation. Most civilized 
 communities have enacted laws to protect its purity, and recognize no evidence 
 in courts of law except when substantiated by adequate chemical testimony. 
 
 37 
 
38 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Similar investigations are being constantly made with a view of so adjusting 
 the feeding and the breed as to obtain the largest quantity of milk or the 
 greatest richness, or both. Beginning with cattle of small, imperfectly- 
 developed udders, the cow has become through generations of culture the incom- 
 parable milk-secreting animal of modern nations, and has so far displaced the 
 ass, goat, mare, and others that it is useless to consider their milk as an avail- 
 able substitute. 
 
 For similar reasons, the cow's milk which must be considered from the 
 standpoint of general dietetics is such sound, whole country milk as is ordi- 
 narily supplied by reputable dealers. It is useless to quote the analyses of the 
 milk of Alderney, Jersey, and Guernsey cattle, obtainable only by the few ; 
 and when obtained, such milk, with its higher percentage of proteids and its 
 greater liability to variation from idiosyncrasy in condition or health of indi- 
 vidual cattle, is not to be preferred over that of the 'average milk of large 
 herds properly bottled before being sent to market. So likewise as to the com- 
 position of the "strippings" of the udder. They are not usually procurable, 
 and their greater richness in fat and deficiency in casein can be better arrived 
 at, even when ordinary whole milk is used, by appropriately modifying its 
 composition. 
 
 Limiting our consideration strictly to commercial bottled milk, it becomes 
 of the greatest importance to inquire into the present conditions regulating its 
 production and handling at the farm, during transit, and in delivery to the con- 
 sumer. Hitherto, these conditions have fallen far short of the requirements 
 which chemical and medical science should rightly impose upon milk as the 
 prime article of artificial infant nutrition. The State laws have checked the 
 adulteration of milk by addition of water and removal of cream, but as yet 
 have done little, and that only incidentally, in the way of guaranteeing its 
 wholesomeness and improving its quality. In fact, enlightened public senti- 
 ment, assisted and directed by the medical profession, will do more in this 
 direction than can be expected at present from the State. And the same 
 remark is true of the efforts of the dairyman. What is being done and should 
 be done is best exemplified by a recital of the provisions of a legal contract 
 drawn up between a committee of certain medical societies in the vicinity of 
 New York on the one hand and a competent dairyman on the other. The 
 latter undertakes that his herd of Holstein and Jersey cattle shall be regularly 
 and frequently inspected by a veterinarian selected by the committee and paid 
 by the dairyman. All cattle that are pronounced by the surgeon, for any cause 
 whatsoever, disqualified to produce pure sound milk are forthwith excluded 
 from the herd. Interbreeding more frequently than the fourth generation is 
 interdicted. The cattle must be kept in a large, well-ventilated, well-lighted 
 stable, with ample space and no overcrowding, with abundance of pure water 
 for drinking and cleansing ; with perfect drainage ; with dry cemented floors ; 
 with clean fresh bedding of hay ; and with arrangements for securing them in 
 the stall which shall give ample liberty to the movements of the head and for 
 lying down, but shall do away with the necessity of chains or other fastening. 
 Separate stalls and partitions, as interfering with ventilation and cleanliness, 
 are done away with. The cow-stables must be removed from those in which 
 horses, chickens, and other stock are kept by so great a distance that the 
 cattle can in no wise come in contact with the other animals. The cows must 
 be groomed daily, and the teats washed before each milking. The milkmen 
 must perform their own toilets before milking, being especially required to thor- 
 oughly cleanse their hands and to remove the dirt beneath the finger-nails, wear- 
 ing also unsoiled clothing. The feeding is to be regulated by the season in such 
 
CHFJIISTFY OF MILK AXD ARTIFICIAL FOODS. 39 
 
 wise that the milk produced shall conform to the highest feasible standard of 
 excellence. Abundance of wholesome pasture, hay, meal, fodder, and ensilage 
 is demanded, but the refuse of glucose-factories, brewers' grains, swill in any 
 form, etc. are interdicted. There are also provisions in the contract that the 
 cattle shall not be worried, heated, or driven, or milked except after proper 
 interval after calving. The milking must be done with scrupulously cleansed 
 vessels : the milk filtered through fine metallic gauze, then cooled in a dust- 
 free atmosphere in such wise as to lower the temperature as rapidly as possible, 
 and also to permit the escape of the gases along with the animal heat ; and, 
 finally, transferred to bottles rendered as nearly sterile by cleansing with boil- 
 ing water and steam as possible. These jars, which must be entirely full, are 
 closed by a metallic cover, sealed, transferred to boxes with a layer of ice on 
 top of them, and delivered at an early hour in the day, the temperature of the 
 milk never being allowed to rise in the interval above 50° F. The dairyman 
 further undertakes to pay for the services of a competent chemist and biologist, 
 who shall frequently test the milk, and whose analyses and certificates shall 
 accompany it. He also undertakes to have his stables, cattle, feed, bottling 
 arrangements, etc. open at all proper times to inspection, and to comply with 
 all other requirements of the committee which they in their judgment shall 
 deem essential to securing the highest attainable degree of quality and purity. 
 The only obligation which the committee assumes is that it permits the milk to 
 be sealed with a label bearing the name of the dairy and the dairyman, and 
 the legend " Certified Milk," and to be accompanied by the certificate of purity 
 bearing the name of the committee, the chemist, biologist, and veterinarian. 
 
 Milk in the human gland or cow's udder, when tuberculosis or kindred dis- 
 ease is absent, contains no bacteria. Indeed, by rejecting the first portions 
 and excluding floating particles in the air, sterile cow's milk can be obtained, 
 and contrivances to this end have been patented ; but they are quite imprac- 
 ticable. So likewise is the proposition to sterilize all the milk before it leaves 
 the farm by heating it at 230° F. for a sufficient length of time completely to 
 destroy every spore which might by any possibility be present. Consumers 
 would not pay for the skill, time, and apparatus required, and the process itself 
 produces unfavorable changes in the milk. The first portion of this objection 
 applies also to the proposition that the milking should be done directly into 
 sterilized bottles, and the milk then Pasteurized by heating to a temperature 
 of 160°-170° for twenty minutes. 
 
 Any of the bacteria present in the air, water, ground, or derived from the 
 diseased or filthy condition of those who handle the milk at any time, or arising 
 from the animals themselves, may possibly find their way into milk. And, inas- 
 much as this fluid is an excellent culture-medium, they multiply with great 
 rapidity. But these things demand suitable care for their prevention, and not 
 a care involving the compulsory sterilization of all milk. The author believes 
 that no more should be required of the dairyman than the reasonable precau- 
 tions above detailed, which self-interest also demands. Then a false security 
 will not be placed in legal requirements sure to be evaded or neglected, and 
 necessitating an army of skilled inspectors, veterinarians, and chemists to 
 enforce. The few ounces of milk needed for artificial nursing are best sterilized 
 immediately before use, and this is best done in the course of the preparation 
 essential to adapt it for infant feeding, either just before transfer to the bottle 
 or in the bottle itself. By so doing, the fact, usually lost sight of, will be kept 
 constantly in mind — that the same precautions as to the bottle, nipple, the 
 waier used, the exclusion of floating particles from the milk, and the keeping 
 of it in a refrigerator are as essential to preserving the sterility of the milk as 
 
40 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 its sterilization in the first instance. Washing in boiling water cannot be 
 trusted to remove the adherent skin of fat and casein on the milk-vessels ; some 
 soda must be used ; the rubber nipple should be turned inside out over the 
 finger and scrubbed with a brush and precipitated chalk. 
 
 Supposing that the present enlightened public sentiment has secured such 
 a legalized system of sanitary cattle-inspection and milk-control as to make 
 the reasonable precautions now exercised voluntarily by honorable dairymen 
 obligatory upon all, bottled milk, which I shall term "sound dairy milk," 
 presents the following characteristics : In color it varies from white to yellow. 
 Even when allowed to fall in drops from the end of a rod it exhibits a dense 
 white opacity and consistency, the fluidity and bluish-white color of watered or 
 inferior milk being absent. It is almost neutral, reddening litmus-paper very 
 feebly. On standing, the cream rises in the neck of the quart bottle com- 
 monly used until it forms a layer about two and a half inches in depth. These 
 physical characters are all that need be noted. If they are absent, if the milk 
 is thin and watery, if it has a bluish, blue, strong yellow, or red color, if it is 
 stringy, lumpy, or glutinous, if it has a flat, stale, sour, or any abnormal taste 
 or odor, — it is simply to be rejected, and its investigation left to the milk 
 inspector and chemist. 
 
 Many analyses of such bottled milk afford me the following average results, 
 which are given as preliminary to the still better figures that will come with 
 "certified milk:" 
 
 Fats 3.75 per cent. 
 
 Lactose (milk-sugar) 4f£2 " 
 
 Albuminoids 3.76 " 
 
 Ash . 0.68 " 
 
 Total solids. 12.61 per cent. 
 
 In some of the States the legal standard calls for 12.5 per cent, of total 
 solids and 3 per cent, of fat. It is much to be deplored that in other States, 
 as in New Jersey, the standard demands only 12 per cent., and unless the fat 
 falls below 2 J the milk is assumed to be unskimmed. It was made thus low 
 in order that no lack of care in housing and cleanliness, no inadequacy of feed- 
 ing, no abstraction of cream from the evening milk (half-skimming), and no 
 accidental or judicious watering should bring the owner or vendor under con- 
 demnation of law. For the same reasons it is assumed that any milk which 
 has a higher specific gravity than 1.029 at 60° F. (100° on the lactometer scale) 
 is pure, whereas the average of sound dairy milk should be 1.0297. 
 
 Human Milk. — Having given the above general characteristics of cow's 
 milk, it is necessary to do the same for human milk, and then proceed to a 
 more specific comparison of their resemblances and differences. And in the 
 first place, while all the conditions and environment are arranged to develop 
 the milk-secreting function of milch cattle, in the human family, on the other 
 hand, they are more and more ignored as women become burdened with the 
 increasing duties and dissipations of modern society. The regular life with 
 moderate enjoyments, exercise, and occupation, the simple nourishing diet, 
 with abundance of fresh air and rest, which are most favorable to the milk- 
 secretion, are sacrificed, with the result of arresting or diminishing the flow and 
 deteriorating the quality of the milk. Stimulants, narcotics, improper or 
 highly-seasoned food, functional disorders with their attendant medicines, 
 violent emotions and paroxysms of grief, anger, and pain, render the milk 
 unwholesome and sometimes dangerous. As a contribution to the chemistry 
 
CHF3IISTFY OF MILK AND ARTIFICIAL FOODS. 41 
 
 of this subject I give in an accompanying table the results of 80 analyses of 
 samples of milk obtained from women of different nationalities, age, stage of 
 lactation, and physical constitution, but all living in a lying-in hospital under 
 the same conditions and eating the same food. (See pp. 42 and 43.) 
 
 The analyses are arranged according to the period of lactation, except in 
 cases where several samples were taken, these following consecutively. Many 
 hundred analyses would be required to determine what differences, if any, are 
 due to nationality or to the physical characteristics of the mother — whether 
 black, blonde, or brunette, or, more minutely, the color of the eyes, hair, com- 
 plexion, etc. But the influence of the physical condition was pronounced, the 
 best milk not coming from women of robust habit (Column I.), but from those 
 whose nourishment appeared rather in the milk-secretion than in the fattening 
 of the mother (Column II.) : 
 
 I. (6 cases). II. (6 cases.) 
 
 Fats 3.71 .... 3.96 
 
 Lactose 6.94 .... 6.74 
 
 Albuminoids 1.44 .... 2.12 
 
 Ash 0.25 .... 0.22 
 
 Total solids 12.34 .... 13.04 
 
 The reaction of every sample was alkaline, the alkaline reaction persisting 
 during one or more days. The color varied from bluish-white through chalky- 
 white to strong yellow, but the color was not a necessary index of the compo- 
 sition : the milk of a German (No. 34), which was the richest in fats (6.89 per 
 cent.), lactose, and total solids, was chalky-white in color, while that of another 
 German (No. 8), which was yellow, was very low in fats, having only 2.31 per 
 cent. Though the amount of lactose is more than a third greater than in cow's 
 milk, yet the taste can hardly be called sweet, and while the total solids 
 (13.27) and the specific gravity (1.0313) are both higher than in cow's milk, 
 yet the consistency is much thinner. This is due to its much smaller content 
 of albuminous matters, more especially of the caseinous or cheesy material. 
 
 The average amount of nitrogenous matters (albuminoids) is somewhat 
 greater at beginning of lactation, but the difference is not very marked. In 
 truth, the feature brought out by this long series of analyses, which over- 
 shadows every other in significance, is the fact that there is no progressive 
 change in the composition of milk during lactation, but after the function has 
 been normally established the milk remains substantially the same during the 
 entire period. This is what might be anticipated from what much larger expe- 
 rience teaches in regard to cow's milk, but it is at variance with notions com- 
 monly entertained, and which have led to elaborate and utterly useless dieta- 
 ries for infant nutrition. The child obtains more nutriment day by day, but 
 it is by spontaneously increasing the quantity according to the best rule, which 
 is that of normal appetite, and not by absorbing " stronger and stronger food." 
 
 Comparison of Cow's Milk and Human Milk. — Before proceeding 
 farther, the general characteristics may advantageously be summed up in the 
 following comparison : 
 
 Sound Dairy Milk. Woman's Milk. 
 
 Reaction ...... Feebly acid Persistently alkaline. 
 
 Specific gravity 1.0297 1.0313 
 
 Bacteria Always present Absent. 
 
 Fats 3 to 6 —average, 3.75 . . .2 to 7 — average, 4.13 
 
 Lactose . . . 3.5 to 5.5— " ' 4.42. . .5.4 to 7.9 — « 7.0 
 Albuminoids . 3 to 6 — " 3.76 . . . 0.85 to 4.86— " 2.0 
 Ash 0.6 to 0.9— ■ " 0.68 . . . 0.13 to 0.37— " 0.2 
 
42 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
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44 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 On an average, human milk has about J of 1 per cent, more fat than 
 average sound dairy milk, and 2J- per cent, more lactose. On the other hand, 
 it has \ of 1 per cent, less mineral matter, and, what is most important, 
 but 2 per cent, of albuminoids, or about half the quantity in cow's milk. The 
 fat is the most variable constituent, as is the case in cow's milk also. But 
 in both the sum of all the other constituents besides fat is a nearly constant 
 quantity, amounting in the vast majority of samples to about 9 per cent. 
 The significance of this physiological fact must not be lost sight of. It shows 
 that the final tendency and result of the complicated metabolic changes, which 
 take place in the protoplasmic cells of the mammary gland, is to secrete a nearly 
 constant total amount of nitrogenous, carbohydrate, and saline material, while 
 allowing the secreted fat to exhibit a wide and independent variability. An 
 increase in the amount of nitrogenous food does not increase the nitrogenous 
 element in the milk secreted by a nursing woman beyond the general limit 
 implied in the above rule, the metabolism in this case resulting in an increase 
 of the fat. An excess of fat, on the other hand, diminishes the metabolism. 
 And, as a practical deduction from the above, there results the necessity of 
 feeding a nursing woman on a diet which shall contain a sufficiency of pro- 
 teid matters, but not on a rich food, the former yielding by transformation not 
 only the albuminoids, but also the fats and lactose of the milk, whilst the 
 latter may not in this sense be nourishing, and may impair the metabolic 
 activity whereby the due proportion of the various constituents of the milk is 
 normally maintained. 
 
 It is necessary to the further understanding of the problem of infant nutri- 
 tion, and especially of artificial feeding, to study in detail the similarities and 
 differences of the individual constituents of woman's and cow's milk. 
 
 Lactose. — The lactose in the two secretions is chemically, physically, and 
 physiologically identical. The statements based on clinical results to the effect 
 that the lactose of cow's milk exerted a peculiar diuretic action and produced 
 glycosuria and set up abnormal digestive fermentations, etc. will have to be 
 reviewed. Until very recently all the samples of lactose coming into my lab- 
 oratory, even those supplied by manufacturers of highest repute as chemically 
 pure, were far from being so. They contained residues of the proteids of milk 
 and spores, the taste, appearance, and properties of the lactose being thereby 
 altered. So great is the present use of lactose in medicinal preparations that 
 correspondingly great improvements have been made in its manufacture, result- 
 ing in the production of a very pure, hard, white, transparent, crystalline 
 substance. 
 
 The carbohydrate element, which is made up of starches, the many varieties 
 of sugar, etc. in the food of adults, and which constitutes the largest part of 
 most vegetables and fruits, is represented in milk by lactose only. This body 
 is intermediate in its chemical properties between cane-sugar and starch, being, 
 like the former, soluble, but with a taste hardly perceptibly sweet. Its main 
 function is to supply by oxidation the animal heat, and, inasmuch as the human 
 infant cannot maintain its animal heat by locomotion, and yet at the same time 
 this heat must be preserved at even a higher temperature than that of the adult, 
 the lactose is relatively the largest constituent of human milk, forming more 
 than one-half its total solid matter. Being already in a soluble condition, it is 
 directly assimilable, and, unlike starch, requires little or no expenditure of 
 energy to effect its transformation prior to digestion. Under the influence of 
 certain bacteria, acting as ferments, the lactose is decomposed, with the forma- 
 tion of lactic acid. Up to the present time ten varieties of bacteria, including, 
 along with the bacillus acidi lactici, certain species of micrococci and sphgero- 
 
CHEMISTRY OF MILK AND ARTIFICIAL FOODS. 45 
 
 cocci, have been described as more especially concerned in the lactic fermen- 
 tation of milk. They all bring about the curdling of the milk, but some of 
 them at the same time give rise to the formation of gas and alcohol, and others 
 do not. The primary change is due to the simple splitting of the molecule of 
 lactose into four molecules of lactic acid by addition of a molecule of water : 
 
 C 12 H 22 11 + H 2 = 4(C 3 H 6 3 ) 
 
 Lactose. Lactic acid. 
 
 This change, which is the ordinary normal one, ensures the curdling and 
 the development of lactic acid initiative to milk digestion. Under the influence 
 of other ferments the molecule of lactic acid may break up into a molecule 
 of alcohol and carbonic acid (C 3 H 6 3 = C 2 H 6 -\- C0 2 ), but this decomposi- 
 tion is secondary and abnormal, and takes place less readily and more slowly 
 than the decomposition of grape-sugar, glucose, or dextrose into alcohol and 
 carbonic acid under like circumstances. 
 
 Besides this fermentation, which results in the separation of a curd by 
 means of lactic acid, there is another fermentation, which is accompanied by 
 the development of a neutral or alkaline reaction. In this case the curd first 
 formed may all eventually pass into solution, being converted into soluble pep- 
 tones. The bacteria giving rise to these changes originate two soluble sub- 
 stances acting as ferments, one acting like rennet to curdle the milk, the other 
 dissolving the curd and exerting a peptonizing action. There is also produced 
 leucin, tyrosin, ammonia, and, more especially, butyric acid, which last body 
 gives its name to this kind of fermentation. Artificially, it is induced by con- 
 tact with putrid cheese. In the digestive tract the butyric fermentation is 
 usually brought about by the prolonged stay in the bowels of the undigested 
 curds of milk or of a foreign irritant substance like starch, or by both. It 
 is essentially a process of putrefactive decomposition, not present in normal 
 digestion. In its simplest form the change may be represented by the formula 
 
 2C 3 H 6 3 = C 4 H 8 2 + 2C0 2 + 2H 2 
 
 Lactic acid. Butyric acid. Carbonic acid. Water. 
 
 While starch is the principal carbohydrate of adult food, it cannot properly 
 be used in infant feeding on account of the absence of the ferment essential to 
 its digestion. This starch-digesting ferment exists under the name of ptyalin 
 in the saliva, and also is present to some extent in the pancreatic juice, but 
 its amount in infants is very small, and its secretion is not established until 
 after the third month. By its action the starch is made to take up a molecule 
 of water and then decompose into maltose and dextrin, the latter body, by con- 
 tinuance of the same action, passing into dextrose ; thus : 
 
 3(C 6 H 10 O 5 ) + H 2 = C 12 H 22 O n + C s H I0 O 5 
 
 Starch. Maltose. Dextrin. 
 
 2(C 6 H 10 O 5 ) + 2H 2 O = 2(C 6 H 12 O 6 ) 
 
 Dextrin. Dextrose. 
 
 Liebig proposed to eifect this change by means of the diastase contained in 
 malt, and his suggestion has been extensively followed. But the objection still 
 remains that the saccharine substances thus produced, like the vegetable sugars 
 in general, are not the same carbohydrate which is normally present in milk, 
 and it has not as yet been satisfactorily established that they undergo in diges- 
 tion the same series of changes and oppose equal resistances to abnormal fer- 
 
46 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 mentation. Though cane-sugar or sucrose, malt-sugar or maltose, and milk- 
 sugar or lactose, all belong to the same general class of sugars known as sac- 
 charoses, with the formula C^H^O^ yet their physical and chemical properties 
 are essentially different, and so also their behavior when in presence of certain 
 ferments. 
 
 Pat.— So far as is known at present, the principal difference between the 
 fat-globules of woman's and cow's milk is in the relatively greater size of the 
 former, which vary between 0.001 — 0.02 mm., while the latter average 
 0.00014 — 0.0063 mm. in diameter. The assumption that each globule is 
 surrounded by a membranous envelope has been disproved, the finely-divided 
 fat existing as naked globules, on the surface of each of which a number of 
 albuminous molecules are condensed by molecular attraction, and the coalescence 
 of the fat particles thereby hindered. 
 
 Albuminoids. — While the lactose of human and cow's milk is identical, 
 and the fats are very similar, the nitrogenous portion presents so many and 
 important differences that the question of the successful substitution of cow's 
 milk for human principally depends upon whether or no these differences can 
 be compensated or overcome. In both secretions the nitrogenous portion con- 
 sists mainly of casein and lactalbumin. In addition, there are substances of 
 the nature of peptones, in small quantities, but to what extent they exist 
 naturally, and to what degree, in the case of cow's milk, they are formed by 
 the peptonizing action of bacteria, is not at present determined. Casein is an 
 acid body existing in milk in combination with alkali, forming principally 
 potassium casemate. But the reactions of this body are complicated by the 
 presence of other mineral bodies, and more especially of calcium phosphate. 
 When dilute acid is added the casein of cow's milk readily precipitates in coarse 
 coagula or clots, but that of woman's milk requires more acid for its precipita- 
 tion and separates not in lumps, but in a fine powder which dissolves in excess 
 of the acid. The lactalbumin remains in solution in the whey after separation 
 of the casein. By boiling it is rendered insoluble. It closely resembles 
 serum-albumin. While in cow's milk the total fraction of the albuminoids 
 precipitable by acid (casein) exceeds by about four times the non-coagulable 
 portion, in human milk these proportions are reversed, the non-coagulable part 
 being about twice the coagulable portion. Similar differences exist in the 
 coagulum formed by the acid gastric juice : in the one case an excess of insol- 
 uble cheesy masses, in the other a relatively small amount of finely divided 
 soluble flakes, being formed. Taking equal weights of the two secretions, the 
 coagulum of woman's milk is but one-fifth as much as that of cow's milk. 
 The comparative smallness of this quantity must be as carefully considered 
 as the difference in the compactness and solubility of the coagula themselves. 
 It explains the rapidity with which infant digestion is overtaxed even by small 
 amounts of undiluted cow's milk. 
 
 Inorganic Matter. — The mineral matter in cow's milk is more than three 
 times that in woman's milk, and especially great is the excess of calcium 
 phosphate, which is four times larger. This excess is due to the correspond- 
 ingly larger amount of casein in cow's milk, with which substance the calcium 
 phosphate and the potash are principally combined. The soda appears to exist 
 in solution along with the lactalbumin as common salt. It is noteworthy that 
 the lime is already relatively greater in the cow's than in human milk, and it 
 is open to serious question whether the practice of using cow's milk alkalized 
 by excess of lime is as desirable, in the case of normal digestion, as it was 
 thought to be before the composition and properties of the constituents of 
 milk were known. The following table presents the relative composition of 
 
CHEMISTRY OF MILK AXD ARTIFICIAL FOODS. 47 
 
 the ash of cow's milk (Fleischinann) and of woman's milk (Konig), and also the 
 percentages of each constituent (Bunge) : 
 
 Cow's Milk. Woman's Milk. 
 
 Potash 24.5 0.18 33.78 0.07 
 
 Soda . 11.0 0.11 9.16 0.03 
 
 Lime . . . 22.5 0.16 16.64 0.03 
 
 Magnesia 2.6 0.02 2.16 0.01 
 
 Oxide of iron 0.3 0.0004 0.25 0.0006 
 
 Phosphoric acid 26.0 0.2 22.74 0.05 
 
 Sulphuric acid 1.0 — 1.89 — 
 
 Chlorine 15.6 0.17 18.38 0.04 
 
 II. The Chemistry of Artificial Foods. 
 
 Two methods have been followed in the attempt to solve the problem of 
 artificial feeding. The easier, and that most generally adopted, which would 
 also appear to be the more natural method, is that of attempting to produce 
 a food which should resemble as closely as possible woman's milk. The 
 other method aims to produce a food or foods which should be especially 
 adapted to the demands of nutrition for each particular infant in health or 
 disease : it is open to great diversities of opinion, due to opposing clinical 
 experiences, and is adapted rather to the treatment of special cases of dis- 
 ordered digestive and other functions than to common use. By general con- 
 sent the advocates of the first method have selected cow's milk as the basis 
 upon which to build. The difficulty of obtaining cheaply, readily, and of 
 proper quality the milk of the ass, the goat, or of any other animal than the 
 cow, has rendered the discussion of the possible advantages of such milk quite 
 useless. 
 
 Dilution. — The first expedient in connection therewith was that of dilution 
 with water until the percentage of albuminoids and salts should approximate 
 to that in woman's milk. But no amount of dilution with water alone is 
 adequate to prevent the separation of the curd in coarse, indigestible lumps in 
 presence of the acid secretions of the stomach. The next device was the 
 addition of an excess of lime-water, so as to partly neutralize the gastric juice 
 and allow much of the milk to pass unchanged from the stomach and undergo 
 digestion in the bowels. As the chemistry of the milk salts indicates, the 
 excess of lime is abnormal, and its addition is an expedient to meet a thera- 
 peutic condition connected with an over-development of acidity, and not to 
 change the nature of the difficultly digestible casein itself. 
 
 Predigestion. — To effect this latter change previous digestion with dilute 
 acid and pepsin was resorted to, and latterly this gave place to the more suc- 
 cessful digestion with pancreatin in alkaline solution. Both methods were 
 confined to cases of greatly impaired digestion, and the predigestion was carried 
 as far as possible. But inasmuch as in woman's milk there naturally remains 
 about one-fifth of the albuminoids in a caseinous condition, the most recent 
 practice is that of using a limited amount of pancreatin, acting for so short a 
 period that the process shall initiate the peptonization, and then be arrested by 
 the destruction of the ferment. The casein is thereby left in such a condition 
 that it separates on acidifying as a fine white powder, while the biuret reaction 
 for the albuminates becomes strongly developed. 
 
 Sterilization. — Recently the fact that woman's milk contains no bacteria, 
 while cow's milk usually contains large numbers and many kinds, patho- 
 genic species possibly included, has been strongly insisted upon. To overcome 
 this objection the practice of sterilizing the milk by repeated heating to a 
 temperature above the boiling-point of water has been extensively followed. 
 
48 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 So far as the destruction of all bacteria and their spores is concerned, the pro- 
 cess is successful, but the clinical results which have attended the use of such 
 sterilized milk have revealed serious drawbacks. It prevents the spread of 
 zymotic diseases through the medium of milk ; it is efficacious in checking 
 many gastro-intestinal disorders ; but its continued use is accompanied by a 
 failure to afford adequate nutrition. Besides the destruction of the bacteria, 
 the prolonged heating to or above the boiling-point brings about other changes 
 which are in the nature of deteriorations. More especially the lactalbumin 
 loses its solubility, and the fat-globules are made to coalesce with one another 
 and some of the insoluble albuminous matter. For these reasons the appli- 
 cation of continued heat in the process of sterilization is inadvisable, and is 
 now being discontinued. 
 
 Sterilization at a Low Temperature (Pasteurization). — In this process 
 of preparation the milk is kept for a brief interval, ten to twenty minutes, 
 at a temperature of 160°-170° F., or raised during heating continued for ten 
 minutes just to the boiling-point. While this process will not destroy all the 
 germs which are in the form of spores, it will destroy the spores of tubercu- 
 losis, scarlet fever, pneumonia, and typhoid, and almost completely inhibit the 
 existence of the developed spores, or bacteria, of every kind. 
 
 Pasteurization with Partial Predigestion (Humanized Milk). — The 
 adjustment of the lactose and the bringing about of a permanently alkaline 
 reaction are effected by the presence in the diluted sterilized milk of such an 
 amount of lactose and of the alkaline milk salts as will effect this result. In 
 order to raise the percentage of fat to that contained in woman's milk, cream 
 may be added, or some vegetable oil like olive or cocoa, or animal oil like that 
 of cod-liver. At present, by the aid of the Leval separator, cream has become 
 a commercial article easily obtained, and its use is more convenient and better 
 understood than that of the other fat substitutes, which require to be further 
 investigated. Inasmuch as it contains some casein and bacteria, due allowance 
 must be made for both in the process of modification heretofore explained. In 
 practice, by the use of a preparation of pancreatin, lactose, and alkaline milk 
 salts originated by Fairchild Brothers & Foster of New York, and known as 
 "Peptogenic Milk-powder," the author has found that with ordinary bottled 
 milk, cream, and water a modified sterilized milk is obtained which corresponds 
 so closely to woman's milk that he has given it the name of "humanized" 
 milk. The proportions recommended are — 
 
 Milk . J pint. 
 
 Water J pint. 
 
 Cream 4 tablespoonfuls. 
 
 Peptogenic Milk-powder 1 large measure. 
 
 The mixture is heated on a hot range or gas-stove with constant stirring, the 
 heating being so conducted that at the end of ten minutes it is brought to the 
 boiling-point. The temperature of 160° to 170° is high enough to destroy the 
 ferment, and this temperature, continued for twenty minutes, kills the bacteria 
 also. But it is so much easier to quickly raise the temperature for a moment 
 to the boiling-point, which also effects both objects, that the latter method is 
 to be preferred when by a process of partial peptonization, as in the process 
 described, the main portion of the albuminoids has been brought to a perma- 
 nently soluble form. 
 
 The milk thus prepared is slightly alkaline and sterile. It contains, accord- 
 ing to the author's analyses, bottled market milk being used in its preparation, 
 the following proportions of constituents : 
 
CHEMISTRY OF MILK AND ARTIFICIAL FOODS. 49 
 
 Fat 4.5 per cent. 
 
 Albuminoids 2.0 " 
 
 Lactose 7.0 " 
 
 Ash. . . JU " 
 
 Total solids 13.8 per cent. 
 
 When lime is used to counteract not only the slight acidity of market milk, 
 but also with the object of forming a soluble calcium caseinate which will not 
 be decomposed by the acid of the gastric juice and curds of casein thereby pre- 
 cipitated, the lime must be added in considerable quantities. A mixture of 
 2 ounces of milk, 2 ounces of lime-water, and 2 ounces of cream, to which a 
 teaspoonful of sugar of milk has been added, contains only a grain of lime, a 
 quantity too small to effect any notable chemical change of the casein. If this 
 mixture is sterilized, it should be done at a temperature between 160° and 170°, 
 since heating to the boiling-point causes some decomposition of the albuminoids 
 in presence of alkali. 
 
 "Condensed Milk." — When condensed milk is used the preceding remarks 
 require to be somewhat modified on account of the different modes of preparing 
 this substance. This will be readily understood by comparing the composition 
 of (I.) milk condensed with added cane-sugar, mean of forty-one analyses; 
 (II.) the same diluted with eight times its weight of water; (III.) Anglo-Swiss 
 milk, preserved without added sugar; (IV.) American-Swiss, preserved; (V.) 
 No. III. diluted with five times water. 
 
 i. 
 
 Fat 12.10 
 
 Albuminoids ....... 16.07 
 
 Lactose ....••.. 16.62 
 
 Sucrose 22.26 
 
 Ash 2.61 
 
 Total solids ...... 69.66 
 
 Water 30.34 
 
 When largely diluted with water, so that the percentage of albuminoids is 
 approximately the same as in human milk, the fat and lactose are brought far 
 below the quantity proper for infant nutrition. Nor is the deficiency adequately 
 supplied by the added sucrose of the milks condensed with this substance. 
 Referring to these points, Dr. Louis Starr justly remarks : " Condensed milk 
 is frequently recommended by physicians, and largely used by the laity on 
 their own responsibility. It keeps better than cow's milk, and is supposed to 
 be more readily digested by infants. The latter supposition is a mistaken one, 
 and arises from the overlooked fact that condensed milk is always given dis- 
 solved in a large proportion of water, while cow's milk is too frequently used 
 insufficiently diluted or otherwise improperly prepared. The author is con- 
 vinced of the accuracy of this statement from a number of years' close study 
 of the subject. Condensed milk contains a large proportion of sugar, forms 
 fat quickly, and thus makes large babies ; sugar also counteracts the tendency 
 to constipation — often a troublesome complaint in hand-feeding. These advan- 
 tages are unquestioned, and, together with the ease of preparation, are those 
 which place it so high in the esteem of monthly nurses. It is equally, true, how- 
 ever, that as a food it does not contain enough nutrient material to supply the 
 
 wants of a growing baby It must be remembered also that condensed 
 
 milk, when long kept or when packed in imperfect cans, not infrequently 
 undergoes decomposition, and thus becomes utterly unfit for use." 
 
 Attenuation. — An entirely different method of increasing the digestibility 
 
 II. 
 
 III. 
 
 IV. 
 
 V. 
 
 1.51 
 
 13.21 
 
 11.55 
 
 2.64 
 
 2.01 
 
 11.36 
 
 14.10 
 
 2.27 
 
 2.08 
 
 15.29 
 
 13.04 
 
 3.05 
 
 2.78 
 
 
 
 
 0.32 
 
 1.78 
 
 2.09 
 
 0.36 
 
 8.70 
 
 41.64 
 
 40.78 
 
 8.32 
 
 91.30 
 
 58.36 
 
 59.22 
 
 91.68 
 
50 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of the casein is that of adding farinaceous or gummy substances, the action of 
 which is not chemical, but mechanical, and depends upon the separation which 
 they effect of the otherwise cheesy masses into a multitude of fine particles. 
 Experiments in the laboratory of the author showed that when diluted cow's 
 milk, to which a solution of cane-sugar, grape-sugar, barley-water, starch-water, 
 or gelatin had been added, was treated with acid, the precipitated casein car- 
 ried down with it from one-third to more than twice its weight of the added 
 substance. Gelatin more especially must be used in very small quantity, since 
 otherwise it entirely arrests the precipitation of the casein. One of the simplest 
 and best of these attenuants is barley-water, added to one-third its volume of 
 milk. It may be prepared by boiling two teaspoonfuls of pearl barley in a 
 pint of water in an open saucepan until the bulk is reduced to two-thirds, and 
 then straining. Instead of barley, oatmeal may be used, or gelatin. To pre- 
 pare the latter put a piece of plate gelatin an inch square into a half-tumbler- 
 ful of cold water, and let it stand for three hours ; then turn the whole into a 
 teacup, place this in a saucepan half full of water, and boil until the gelatin is 
 dissolved. When cold this forms a jelly: two teaspoonfuls are sufficient to 
 thicken a mixture of three ounces of milk and five of water. 
 . Dextrinized Attenuants. — A gummy material like dextrin, or a gelat- 
 inous substance, or a saccharine body, or a finely-divided starch like that 
 occurring in barley- or oatmeal-water, along with more or less glutinous extrac- 
 tive matter, is far better adapted to serve mechanically as an attenuant of the 
 coagulated casein than farinaceous foods in their ordinary condition. Many 
 different preparations are sold in which, by prior heating (dextrinizing) or by 
 digestion with diastase, wheat and barley flours are modified to this end. By 
 the action of heat at 300° to 400° the principal substance which is formed is 
 dextrin, a body differing from starch by its being soluble and by having the 
 physical characters of a gum. Diastase produces principally maltose along with 
 dextrin. The flour selected for either treatment should be highly albuminous, 
 made of wheat grown at certain seasons and of certain grades, and should be 
 the best grade of that made by the roller process. Grouping together under 
 the head of soluble carbohydrates the sucrose, dextrose, maltose, and dextrin 
 originally present or made by treatment, the changes can be traced in the fol- 
 lowing table. The first column gives the composition of a wheat flour, the 
 second the same after baking. The remaining columns exhibit similar products 
 from other specimens of wheat flour, the process having been carried further in 
 some of the dextrinized foods than in others : 
 
 
 Wheat flour. 
 
 Same baked. 
 
 Blair's 
 Wheat Food. 
 
 Imperial 
 Granum. 
 
 Ridge's Food. 
 
 Schuma- 
 cher's Food. 
 
 Water 
 
 Fat 
 
 Starch 
 
 Soluble carbohy- 
 drates . . . < 
 Albuminoids . . . 
 Gum, cellulose, etc. 
 Ash 
 
 9.02 
 1.01 
 
 76.07 
 
 5.66 
 
 7.47 
 
 undetermi'd 
 « 
 
 7.78 
 
 0.41 
 
 67.60 
 
 14.29 
 
 9.85 
 1. 
 
 64.80 
 
 13.69 
 7.16 
 2.94 
 1.06 
 
 5.49 • 
 1.01 
 78.93 
 
 3.56 
 
 10.51 
 
 0.50 
 
 1.16 
 
 9.23 
 0.63 
 
 77.96 
 
 5.19 
 9.24 
 
 6.60 
 
 6.26 
 
 1.89 
 
 39.81 
 
 36.57 
 
 13.54 
 
 0.49 
 
 1.44 
 
 By heating, the albuminous substances also become considerably more 
 soluble in water. Wheat flour, which in its original condition yields a very 
 considerable amount of crude gluten on washing, after baking leaves a much 
 smaller quantity. For the same reason a baked wheat flour may be mistaken 
 
CHF3IISTHY OF 3IILK AXD ARTIFICIAL FOODS. 51 
 
 for barley flour, which has a non-glutinous dough. Along with these analyses 
 may be given that of Robinson's Patent Barley, which is flour prepared from 
 ground pearl barley, and "ABC" cereal milk, which is made from wheat and 
 barley meal : 
 
 Robinson's Patent Barley. " A. B. C." Cereal Milk. 
 
 Water -. . . . 10.10 9.33 
 
 Fat 0.97 1.01 
 
 Starch 77.76 58.42 
 
 Soluble carbohydrates 4.11 20.00 
 
 Albuminoids * 5.13 11.08 
 
 Gum, cellulose, etc 1.33 1.16 
 
 Ash 1.93 
 
 Flour-ball. — Much has been written on the use of "flour-ball" prepared 
 by long-continued boiling of superior wheat flour tied up tightly in a bag. A 
 sample thus prepared by Dr. J. Lewis Smith and analyzed at his request 
 afforded the following results. It was boiled for five days, fifteen hours a day, 
 or seventy-five hours in all, the bas; being taken out of the water over night. 
 The original flour was white ; the boiled flour, after thorough drying and 
 pulverizing, of a light-yellow color. Its taste was remarkably flat and insipid, 
 the long-continued boiling dissolving out the fat, some of the soluble albumi- 
 noids, and mineral matters. It is possible that very different results might have 
 been obtained from a flour of different character and boiled for a much shorter 
 interval (Dr. Eustace Smith recommends but ten hours) : 
 
 Original Flour. Same Boiled. 
 
 Water 9.546 10.55 
 
 Fat 0.766 noue. 
 
 Starch 71.924 72.362 
 
 Soluble carbohydrates 5.120 5.178 
 
 Albuminoids " 11.280 10.520 
 
 Gum, ceUulose, etc 0.835 1.028 
 
 Ash 0.506 0.42 
 
 Liebig's Foods. — In the preparation of the flour by means of diastase 
 (Liebig's foods) equal parts of wheat flour and barley malt, a certain amount of 
 wheat bran (added, it is said, for the sake of the adherent phosphates and 
 nitrogenous matter), together with 1 per cent, of potassium bicarbonate, are 
 mixed with sufficient water to make a thin paste. The mixture is allowed to 
 stand at ordinary temperatures for several hours, and then heated to 150° until 
 the conversion of the starch into maltose and dextrin is completed. It is then 
 strained and the residue pressed and exhausted with warm water. The extract 
 is evaporated in vacuum-pans at as low a temperature as consistent with rapid- 
 ity of working, and then dried with stirring at a higher temperature, so as to be 
 brought into pulverulent porous lumps. The author's latest examinations of 
 samples of foods belonging to this class are as follows : 
 
 Savory 
 Mellin's Food. Horlick's Food. and 
 
 Moore's. 
 
 Water 12.37 9.70 8.34 
 
 Fat 0.18 0.34 0.40 
 
 Albuminoids 10.07 10.43 9.63 
 
 Soluble carbohydrates 68.18 76.83 44.83 
 
 Starch . 36.36 
 
 Gum, cellulose, etc 5.45 0.50 0.44 
 
 Ash 3.75 2.20 0.89 
 
 The starch is absent when the process is complete, and such was the case 
 with some of the samples tested ; in other samples a considerable portion 
 remained. 
 
52 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 The preceding foods are ordinarily employed with milk, the mixture being 
 made at time of feeding. Still another class remains in which the dextrinized 
 or malted flour has already been evaporated with milk, and which is prepared 
 with the aid of water only. They are of very different composition, as will be 
 seen from the following table : 
 
 
 
 
 
 03 
 
 
 Orrt 
 
 1 
 
 
 
 
 02 
 
 
 
 
 Is 
 
 Oo 
 
 M 
 
 
 03 
 
 6 
 
 a 
 
 "f-t 
 
 
 m 
 
 6 
 o 
 
 a 
 
 si 
 
 "5 
 
 o3 3 
 
 3 
 
 
 fc 
 
 < 
 
 o 
 
 < 
 
 fc 
 
 £ 
 
 h3 
 
 s 
 
 
 5.00 
 4.25 
 
 11.00 
 
 6.50 
 4.91 
 
 10.26 
 
 6.78 
 2.21 
 9.56 
 
 5.68 
 
 5.81 
 
 10.54 
 
 4.43 
 
 3.70 
 
 13.00 
 
 7.76 
 
 1.64 
 
 11.85 
 
 24.32 
 15.32 
 
 8.23 
 
 2.18 
 
 jr a t . 
 
 5.30 
 
 Albuminoids • . 
 
 15.83 
 
 Soluble carbohydrates 
 
 40.91 
 
 46.43 
 
 44.76 
 
 45.35 
 
 46.09 
 
 39.00 
 
 49.43 
 
 66.99 
 
 Starch 
 
 36.86 
 
 29.48 
 
 35.00 
 
 30.00 
 
 30.86 
 
 36.43 
 
 Undet. 
 
 5.57 
 
 Cellulose, gum, etc 
 
 0.28 
 
 0.40 
 
 0.48 
 
 0.41 
 
 0.50 
 
 0.71 
 
 a 
 
 
 Ash 
 
 1.70 
 
 2.02 
 
 1.21 
 
 1.21 
 
 1.42 
 
 2.61 
 
 2.60 
 
 3.13 
 
 In the preparation of these foods the flour is first made into a dough and 
 baked. The resulting biscuit is then finely ground and mixed with various 
 amounts of condensed milk and dried by a slow heat at a moderate tempera- 
 ture. This leaves a mixture in which the starch has been partly changed into 
 dextrose, maltose, and dextrin; the albuminoids of the flour have undergone 
 the partial decomposition spoken of in the case of the farinaceous foods; the 
 casein has been dried into separate particles, and the lactalbumin has been 
 coagulated. On the addition of water the saccharine and a small portion of 
 the albuminoids dissolve ; the main portion of the albuminoids, the casein, and 
 the starch, are left undissolved. 
 
 In the actual preparation of farinaceous, Liebig's, and milk foods for use 
 in the feeding-bottle, the adjustment of the relative proportions should be such 
 as to afford a ratio between the fats, albuminoids, and saccharine materials as 
 nearly the same as that in human milk as possible. By making the cow's milk 
 the principal article of the mixture, and basing the approximation on such a 
 ratio as will render the albuminoids not very different in their gross amount 
 from that in woman's milk, foods of the following character may be obtained. 
 Of course the constituents other than the albuminoids differ widely in their 
 gross amounts, and what has been said before in relation to their relative values 
 in nutrition must here be borne in mind also. Selecting one food of each class, 
 Column I. represents a mixture of 3 parts of thoroughly dextrinized flour, 47 
 parts of cow's milk, and 50 parts of water; Column II. the same relative 
 amounts of Mellin's food, milk, and water; and Column III. a mixture of 1 
 part of Nestle's food and 6 of water: 
 
 i. 
 
 Fat 1.91 
 
 Soluble carbohydrates . . . 3.17 
 
 Starch 1.94 
 
 Albuminoids 2.27 
 
 Ash 0.36 
 
 Total solids 9.65 
 
 Water 90.35 
 
 II. 
 
 III. 
 
 1.86 
 
 0.71 
 
 4.11 
 
 6.82 
 
 
 6.14 
 
 1.89 
 
 1.83 
 
 0.43 
 
 0.28 
 
 8.29 
 
 15.78 
 
 91.71 
 
 84.22 
 
MODIFIED MILK AND PERCENTAGE MILK- 
 MIXTURES. 
 
 By THOMPSON S. WESTCOTT, M. D., 
 
 Philadelphia. 
 
 Modified Milk. — Modified milk is a term applied to the product of a 
 recently introduced method which aims to effect a recombination of the fats, 
 proteids, and lactose of cow's milk, so as to produce mixtures yielding 
 any desired percentage of each of these three essential ingredients. While 
 mother's milk is to he taken as the type of what such a mixture should 
 be. it is possible by this synthetic process to vary the percentage of any or 
 all of its three elements to meet any desired modification. The method 
 originated with Dr. Thomas M. Rotch of Boston, and was perfected with the 
 collaboration of Mr. Gr. E. Gordon, a dairyman of wide experience. The 
 result of their labors has been the establishment of milk-laboratories, the 
 first of which was opened in Boston in 1891 ; and since that time other 
 laboratories have been started in several of the principal cities of the Eastern 
 and Southern States, in Montreal, and, most recently, in London. Each 
 laboratory is supplied exclusively by a dairy under its absolute control, 
 situated within a short distance by rail, so that not more than three to six 
 hours shall intervene between milking and delivery at the laboratory. By 
 this means the laboratory has complete supervision of the handling of the 
 milk and the control of its herd of cows. No cow is accepted until proven 
 to be free from tuberculosis by the tuberculin test, and the health of each 
 animal of the herd is carefully watched. Moreover, the feeding is carried 
 out in a thoroughly scientific manner ; no silage or pasture-feeding is 
 allowed, and only measured quantities of wholesome fodder are given, for 
 the purpose of maintaining a constant analysis of the milk. Upon this 
 principle of feeding depends the uniformity of results, for it has been found 
 that the daily variation from the standard analysis of 4 per cent, fat, 4.5 
 per cent, sugar, and 4 per cent, proteids is so small as to be practically 
 unnoticeable in the laboratory modifications. 
 
 Not only is the health of the animals taken into consideration, but equal 
 attention is paid to the employes of the farm an(| the laboratory, looking to 
 personal cleanliness and the exclusion of any possibility of contamination 
 from infectious disease. More than this, sterilization of all bottles, imple- 
 ments, or utensils likely to contaminate the milk is carried out as a routine 
 procedure. In a word, every effort is made to secure a practical asepsis of 
 handling by attention to all the details now carried out in modern aseptic 
 surgery. The result of all these painstaking precautions is shown in the 
 production of a relatively sterile milk yielding a definite percentage of its 
 constituents. 
 
 53 
 
54 AMERICA X TEXT- BO OK OF DISEASES OF CHILD REX. 
 
 Briefly stated, the materials from which modified milk is produced are — 
 centrifugal cream of 16 per cent, fat-strength (rarely a 32 per cent, cream is 
 required for certain prescriptions) ; separated milk, from which practically 
 all fat has been removed by the centrifugation yielding the cream; a sugar- 
 of-milk solution of 20 per cent, strength ; and ordinary sterilized lime-water. 
 By combining these ingredients in varying proportions and making up to 
 the required total quantity with distilled water, almost any desired combina- 
 tion of percentages of fat, sugar, and proteids can be produced with great 
 accuracy. 
 
 The method at present does not include a modification of the inorganic 
 salts, nor does it attempt to vary the proportions of casein and lactalbumin, 
 but treats the total proteids as a unit. 
 
 After the materials have been combined in the total quantity required 
 for a day's feeding the mixture is divided up into as many portions as there 
 are to be feedings ; these are poured into sterilized nursing-bottles, which are 
 then stopped with cotton plugs. If so ordered, these bottles are subjected in 
 the sterilizing apparatus to any desired degree of heat for the purpose of 
 pasteurizing or sterilizing ; they are then packed in convenient baskets, and 
 are ready for delivery. By this means the infant receives the proper quan- 
 tity for a meal directly from a sterile bottle, without any chance of contami- 
 nation, after leaving the laboratory, from exposure to air or from unclean 
 vessels. 
 
 These laboratories are managed just like a reputable pharmacy, and 
 refuse to prescribe over the counter. Blanks are furnished in prescription 
 form, a copy of which, with a sample prescription, is as follows : 
 
 R 
 
 Per cent. 
 
 Remarks. 
 
 Fat 
 
 . 3 
 
 
 Number of feedings . 
 
 8 
 
 Milk-susar 
 
 . '6 
 
 
 Amount at each feeding 
 
 j 02. 
 
 Albuminoids . 
 
 . i 
 
 2i 
 
 Infant's age 
 
 j r/ios. 
 
 Mineral matter 
 
 
 
 Infant's weight 
 
 14 lbs. 
 
 Total solids . 
 
 . 
 
 
 Alkalinity 
 
 5 c /o 
 
 Water .... 
 
 . _ 
 
 
 Heat at 
 
 155° F. 
 
 
 100 00 
 
 
 Ordered for (Baby (Doe, 
 
 jogo (Blank Avenue. 
 
 Date, 
 
 : a,n. isi, 189c? 
 
 Signature, 
 
 (Dr. A. (B. C. 
 
 For sake of illustration it may be stated that a mixture conforming to 
 the above prescription will be made up of cream, ~i\ ounces ; separated milk, 
 of ounces ; sugar solution. 9} ounces ; lime-water, 2 ounces ; and distilled 
 water, 15^- ounces. A 3-6-2 mixture would contain cream ~\ ounces, sepa- 
 rated milk 13} ounces, sugar solution 7f- ounces, lime-water 2 ounces, and 
 distilled water 9^-J ounces. It will thus be seen that for the same percentage 
 of fat the quantity of cream remains constant for the same total quantity, 
 and that as the proteid percentage rises the quantity of separated milk 
 increases, the sugar solution undergoing a slight decrease because of the 
 greater proportion of milk-sugar present from the larger quantity of sep- 
 arated milk. 
 
MODIFIED MILK AXD PERCENTAGE MILK-MIXTURES. 55 
 
 The experience of a large number of physicians in feeding healthy infants 
 on modified milk has enabled the Walker- Gordon laboratories to tabulate the 
 average percentages and quantities of mixtures that have proven satisfactory 
 for varying ages, as follows : 
 
 Theoretical Basis for Feeding a Healthy Infant. 
 
 
 Age. 
 
 Gastric 
 
 
 Prescription. 
 
 
 
 Capacity. 
 
 
 
 
 
 
 
 Per ct. 
 
 Per ct. 
 
 Per ct. 
 
 
 
 
 Fat. 
 
 Milk-sugar. 
 
 Proteids 
 
 Premature infant, 
 
 
 Drachms. 
 2-6 
 
 fl.OO 
 \ 1.00 
 1 1.50 
 
 3.00 
 4.00 
 4.50 
 
 0.20 
 0.50 
 0.75 
 
 Birth at term, 
 
 Hours. 
 
 Oz. 
 
 
 
 
 
 24 to 36 
 
 1 
 
 
 
 5.00 
 
 
 
 1st 
 
 Week, 
 
 1 
 
 2.00 
 
 5.00 
 
 0.75 
 
 2d 
 
 IC 
 
 u 
 
 2.50 
 
 6.00 
 
 1.00 
 
 3d 
 
 « 
 
 2 
 
 3.00 
 
 6.00 
 
 1.00 
 
 4th to 6th 
 
 " 
 
 2M 
 
 3.50 
 
 6.50 
 
 1.00 
 
 6th to 8th 
 
 a 
 
 3 -3\ 
 
 3.50 
 
 6.50 
 
 1.50 
 
 8th to 16th 
 
 11 
 
 3i-4£ 
 
 4.00 
 
 7.00 
 
 1.50 
 
 16th to 24th 
 
 " 
 
 4J-5f 
 
 4.00 
 
 7.00 
 
 2.00 
 
 24th to 32d 
 
 a 
 
 5f-7 
 
 4.00 
 
 7.00 
 
 2.00 
 
 32d to 36th 
 
 K 
 
 7 
 
 4.00 
 
 7.00 
 
 2.25 
 
 36th to 40th 
 
 K 
 
 7 -8 
 
 4.00 
 
 6.50 
 
 2.50 
 
 40th to 44th 
 
 it 
 
 8 -8* 
 
 4.00 
 
 5.00 
 
 3.00 
 
 44th to 48th 
 
 it 
 
 8* 
 
 4.00 
 
 4.50 
 
 3.50 
 
 48th to 52d 
 
 It 
 
 9 
 
 4.00 
 
 4.50 
 
 4.00 
 
 These figures, it must be remembered, are to be taken simply as averages, 
 since the weight, as well as the age, of the child must be taken into account 
 as a guide of its digestive capacity. Each infant's needs must be studied 
 before a satisfactory modification may be secured. If anything, these aver- 
 ages are a little too high for any but infants in perfect health and with 
 unimpaired digestion. 
 
 Laboratory modification has given most satisfactory results in almost 
 all cases w T here artificial feeding was required, but more especially in cases 
 of chronic gastric or intestinal catarrh, w^here proteids are digested with 
 difficulty and variations in their proportions from day to day keep the 
 digestion constantly disturbed. Such an infant may fail to digest a modifi- 
 cation containing 1 per cent, of proteids, but will begin to thrive when this 
 percentage has been reduced for a time to 0.75, 0.50, or even lower. In 
 such cases the physician is enabled to accurately vary the dosage of any one 
 or more of the ingredients of his mixture. The method offers a decided 
 advance upon any method hitherto introduced for the feeding of infants 
 with a substitute for mother's milk. It is at once scientific, accurate, and 
 rational. 
 
 As a general rule, it may be stated that after a satisfactory formula has 
 been found the strength of the food may be increased gradually, but as 
 rapidly as the child's digestion will permit. 
 
 In reference to the changes in formula that may be required in any par- 
 ticular case after a prescribed mixture fails to exactly suit the conditions, it 
 may be permitted to quote Holt's admirable summing up : 
 
 " If not gaining in weight, without special signs of indigestion, increase 
 the proportion of all the ingredients ; if habitual colic, diminish the proteids ; 
 for frequent vomiting soon after feeding, reduce the quantity ; for the re- 
 gurgitation of sour masses of food, reduce the fat, and sometimes also the 
 proteids; for obstinate constipation, increase both fat and proteids." 
 
56 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 As a corollary to this it may be added that, except in hot weather or in 
 cases of pre-existing rnilk-infection, sterilization or even pasteurization is 
 unnecessary, and that either of these processes may favor or directly cause 
 constipation. Lime-water may also have the same effect. For a child with 
 healthy digestion lime-water may often be omitted, at first tentatively, with- 
 out any bad results. 
 
 Home Modifications. — It is readily understood that milk-laboratories 
 are as yet inaccessible to a large number of physicians, and that the process is 
 somewhat costly. Fortunately, it is quite possible to apply its principles to 
 home modification, provided the mother have ordinary intelligence and will 
 appreciate the importance of scrupulous cleanliness in all the necessary 
 manipulations. Several methods have been suggested. Rotch (Pediatrics) 
 uses gravity cream and under-milk, obtained by allowing a quart of good 
 milk (averaging 4 per cent, fat, 4.50 per cent, sugar, and 4 per cent, pro- 
 teids) to stand in a jar in ice-water for six hours, and siphoning off 24 
 ounces from the bottom, which leaves, according to his estimate, 8 ounces of 
 a 10 per cent, cream in the jar. Holt, in his recent text-book (Diseases of 
 Infancy and Childhood), proposes dilutions of various percentage creams 
 with solutions of milk-sugar varying in strength from 5 to 10 per cent. 
 According to this method, 16 per cent., 12 per cent., or 8 per cent, cream and 
 whole milk (4 per cent, fat) are used with solutions of milk-sugar of 5, 6, 7, 
 8, and 10 per cent, strengths. An important fact to be remembered is that 
 cream is practically a superfatted milk, essentially differing otherwise from 
 milk in containing a slightly lower percentage of proteids, which vary from 
 3.20 for 20 per cent, cream to 3.90 for 8 per cent, cream, as contrasted with 
 4.00 in the average whole milk from which the creams are obtained ; and that 
 the sugar percentage is also slightly less than that of the milk. 
 
 Sixteen per cent, of butter-fat is about the strength of ordinary skimmed 
 cream which has had about twelve hours to rise. It averages 3.60 pro- 
 teids. 
 
 The 12 per cent, cream may be obtained by mixing two parts of 16 per 
 cent, cream and one part of whole milk, or by skimming average milk after 
 standing in a jar in iced water for about six hours. It averages 3.80 
 proteids. 
 
 Eight per cent, cream may be obtained by mixing one part of gravity 
 cream and two parts of whole milk, or by skimming the milk after standing 
 four to five hours. Removal of the lower milk by siphoning is less likely to 
 disturb the cream layer, and thus partially dilute the cream. Eight per 
 cent, cream averages 3.90 proteids. 1 
 
 These percentages are approximately correct, provided the whole milk 
 maintains a fairly constant average value of 4 per cent, fat and 4 per cent, 
 proteids. Variations here will of course disturb the cream percentages, but 
 for ordinary cases the results are sufficiently close. 
 
 The sugar solutions may be made by dissolving an ounce of milk-sugar in 
 20 ounces, 16^ ounces, 141 ounces, 12-1- ounces, or 10 ounces of boiled or 
 distilled water to produce 5, 6, 7, 8, or 10 per cent, solutions respectively. 
 The use of solutions of such varying strengths enables the modifications to 
 be made without the use of additional plain water, and thus simplifies the 
 preparation. 
 
 For comparison the following tables of dilutions of cream have been 
 accurately worked out : 
 
 1 The percentage figures used by Rotch and Holt, and also in the cream <and whole-milk mod- 
 ification later described, are the standard analyses of the products of the Walker-Gordon dairies. 
 
 ■1 
 
MODIFIED MILK AND PERCENTAGE MILK-MIXTURES. 57 
 
 Table I. — Sixteen Per cent. Cream. 
 
 
 
 
 (Fat, 
 
 16.00 
 
 Sugar 
 
 ,4.20 
 
 Proteids, 3.60.) 
 
 
 part of Cream to 
 
 
 
 
 
 
 
 
 
 
 15 part 
 
 s5# 
 
 Sugar solution = 
 
 Fat 
 
 , 1.00 
 
 ; Sugai 
 
 -, 4.95 
 
 ; Proteids 
 
 , 0.23 
 
 15 
 
 " 
 
 6 
 
 it 
 
 
 = 
 
 " 
 
 1.00 
 
 ; " 
 
 5.89 
 
 u 
 
 0.23 
 
 15 
 
 « 
 
 7 
 
 a 
 
 
 = 
 
 u 
 
 1.00 
 
 it 
 
 6.82 
 
 <( 
 
 0.23 
 
 9 
 
 " 
 
 5 
 
 n 
 
 
 = 
 
 " 
 
 1.60 
 
 " 
 
 4.92 
 
 n 
 
 0.36 
 
 9 
 
 u 
 
 6 
 
 If 
 
 
 = 
 
 « 
 
 1.60 
 
 " 
 
 5.82 
 
 n 
 
 0.36 
 
 9 
 
 11 
 
 7 
 
 u 
 
 
 = 
 
 u 
 
 1.60 
 
 u 
 
 6.72 
 
 u 
 
 0.36 
 
 7 
 
 it 
 
 5 
 
 it 
 
 
 = 
 
 « 
 
 2.00 
 
 u 
 
 4.90 
 
 u 
 
 0.45 
 
 7 
 
 it 
 
 6 
 
 it 
 
 
 = 
 
 " 
 
 2.00 
 
 il 
 
 5.77 
 
 a 
 
 0.45 
 
 7 
 
 " 
 
 7 
 
 n 
 
 
 = 
 
 (( 
 
 2.00 
 
 a 
 
 6.65 
 
 n 
 
 0.45 
 
 5.4 
 
 a 
 
 5 
 
 " 
 
 
 = 
 
 " 
 
 2.50 
 
 u 
 
 4.87 
 
 u 
 
 0.56 
 
 5.4 
 
 " 
 
 6 
 
 " 
 
 
 = 
 
 " 
 
 2.50 
 
 a 
 
 5.72 
 
 n 
 
 0.56 
 
 5.4 
 
 it 
 
 7 
 
 " 
 
 
 = 
 
 « 
 
 2.50 
 
 u 
 
 6.56 
 
 n 
 
 0.56 
 
 4.3 
 
 a 
 
 5 
 
 it 
 
 
 = 
 
 " 
 
 3.02 
 
 " 
 
 4.85 
 
 n 
 
 0.68 
 
 4.3 
 
 " 
 
 6 
 
 " 
 
 
 = 
 
 " 
 
 3.02 
 
 " 
 
 5.66 
 
 n 
 
 0.68 
 
 4.3 
 
 « 
 
 7 
 
 « 
 
 
 = 
 
 " 
 
 3.02 
 
 n 
 
 6.47 
 
 u 
 
 0.68 
 
 3.6 
 
 « 
 
 5 
 
 (t 
 
 
 = 
 
 (I 
 
 3.48 
 
 u 
 
 4.83 
 
 n 
 
 0.78 
 
 3.6 
 
 it 
 
 6 
 
 « 
 
 
 = 
 
 a 
 
 3.48; 
 
 " 
 
 5.61 
 
 n 
 
 0.78 
 
 3.6 
 
 ti 
 
 7 
 
 « 
 
 
 == 
 
 " 
 
 3.48 
 
 n 
 
 6.39 
 
 n 
 
 0.78 
 
 3 
 
 it 
 
 5 
 
 << 
 
 
 = 
 
 " 
 
 4.00, 
 
 u 
 
 4.80, 
 
 u 
 
 0.90 
 
 3 
 
 " 
 
 6 
 
 It 
 
 
 = 
 
 " 
 
 4.00; 
 
 n 
 
 5.55; 
 
 a 
 
 0.90 
 
 3 
 
 it 
 
 7 
 
 " 
 
 
 = 
 
 " 
 
 4.00; 
 
 n 
 
 6.30; 
 
 " 
 
 0.90 
 
 3 
 
 n 
 
 8 
 
 « 
 
 
 = 
 
 " 
 
 4.00; 
 
 n 
 
 7.05 
 
 u 
 
 0.90 
 
 Table II. — Twelve Per cent. Cream. 
 
 (Fat, 12.00; Sugar, 4.30; Proteids, 3.80.) 
 1 part of Cream to — 
 
 11 parts b% Sugar solution = Fat, 1 
 11 " 6 " = " 1 
 
 11 
 7 
 5 
 
 3.8 
 3 
 
 2.4 
 2 
 
 7 
 
 5-7 
 
 5-7 
 
 5-8 
 
 5-8 
 
 5-8 
 
 5-8 
 
 i. 
 
 _ u 
 _ a 
 
 L00; 
 1.00; 
 1.00; 
 1.50 ; 
 2.00 ; 
 2.50; 
 3.00; 
 3.53 ; 
 4.00; 
 
 Sugar, 4.94 ; 
 " 5.86 ; 
 " 6.77 ; 
 " 4.91-( 
 
 Proteids, 
 
 4.88-6.55; " 
 4.85-7.12 ; " 
 4.82-7.07; " 
 4.65-6.76; " 
 4.77-6.77; " 
 
 0.32 
 0.32 
 0.32 
 0.48 
 0.63 
 0.79 
 0.95 
 1.12 
 1.27 
 
 Table III. — Eight Per cent. Cream. 
 
 (Fat, 8.00 ; Sugar, 4.40 ; Proteids, 3.90.) 
 1 part of Cream to — 
 7 parts 5-7% Sugar solution = Fat, 1.00 
 
 3 
 1.6 
 
 1 
 
 5- 
 
 5-8 
 5-10 
 
 1.00 
 
 Sugar, 4.92-6.67 
 
 Proteids, 0.49 
 
 2.00 
 
 " 4.85-7.10 
 
 0.97 
 
 3.07 
 
 " 4.77-6.62 
 
 1.44 
 
 4.00 
 
 " 4.70-7.20 
 
 1.95 
 
 Table IV. — Four Per cent. Cream (whole milk). 
 
 (Fat, 4.00 ; Sugar, 4.50 ; Proteids, 4.00.) 
 1 part of Milk to- 
 ll parts 5-7% Sugar solution = 
 7 " 5-7 
 3 " 5-8 
 1 " 5-10 
 3 parts of Milk to— 
 
 1 part 5-10% Sugar solution 
 
 Fat, 0.33 
 
 Sugar, 4.96-6.79 ; Pre 
 
 )teids, 0.33 
 
 " 0.50 
 
 " 4.94-6.69 ; 
 
 0.50 
 
 " 1.00 
 
 " 4.87-7.12 ; 
 
 1.00 
 
 " 2.00 
 
 " 4.75-7.25 ; 
 
 2.00 
 
 3.00; 
 
 4.62-5.87 
 
 3.00 
 
 It will be noticed that by these various dilutions of cream, and by inter- 
 mediate dilutions not carried out in the tables, a large number of combina- 
 tions of fat and sugar can be obtained, but that the proteid percentage in 
 any instance must bear the same ratio to the fat percentage as holds in the 
 cream from which the dilution is made. Low or mean percentages of fat 
 
58 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 with hi^h percent-ages of proteids cannot be obtained without additional 
 proteids from skimmed milk. The practical value of the method therefore 
 ends with a 1 : 1 dilution of whole milk. Finer variations in the relative 
 proportions of fat and proteids, which are easily managed in laboratory 
 modification, are thus impossible by the method of cream dilution. 
 
 Modifications with Cream and Milk. — For the reasons just stated, as 
 well as the greater convenience in using whole milk as a basis of the mixture, 
 and making up the necessary fat-value with additional cream, the writer has 
 for some time been using such a method for home modification. It has been 
 found that most satisfactory results can be obtained by using a 12 per cent, 
 cream and whole milk (averaging fat 4.00, sugar 4.50, and proteids 4). It is 
 first necessary to decide upon the number of ounces of total mixture, and fix 
 the proteid and fat percentages desired. Then the number of ounces of 
 mixed milk and cream can be found by the proportion 
 
 (1) 3.90 : P.: Q : x, 
 
 in which Q is the total quantity of mixture, and P the proteid percentage : 
 the value of x gives the number of ounces of milk and cream required to give 
 the chosen percentage of proteids. The value of x being found, it remains 
 to divide this quantity into two parts, C and M. the first of which represents the 
 quantity of cream required, the second the quantity of milk. This is readily 
 done by means of the formula 
 
 (2) = QXF a -* x 
 
 in which Q represents the total quantity of mixture, F the fat percentage de- 
 sired, and x the quantity of mixed milk and cream already determined by 
 formula (1). The quantity of milk, itf, is at once found by subtracting the 
 value of C from that of x. To illustrate : let it be desired to find the quan- 
 tities of milk and cream to make a mixture of 40 ounces containing proteids 
 1.50 and fat 3.00. 
 
 Formula (1) becomes 
 
 3.90 : 1.50 : : 40 oz. : x 
 
 whence x = 15.4 oz. 
 
 Equation (2) becomes 
 
 a= 120 i 6 M=7 . 3oz 
 
 O 
 
 and consequently, M=8.1 oz. 
 
 Taking the same example, let it be required to get 4 per cent, of fat. 
 The total quantity of milk and cream will be the same as in the previous 
 case, but the quantity of each will differ. Here, from formula (2), (7 = 
 12.3 oz., and consequently M= 3.1 oz. The remainder of the 40 ounces of 
 total mixture is to be made up by the addition of boiled water, barley-water, 
 oatmeal-water, or whatever diluent is chosen. Lime-water, if desired, may 
 also be added to the mixture in the proportion of 5 to 10 per cent. In the 
 above examples 2 to 4 oz. of the diluent would be lime-water. 
 
 It will readily be seen that the calculation of proteids is not quite exact, 
 since the varying proportions of milk and cream cause variations in the 
 average value of the proteids ; but, at the most, these vary only between 
 
MODIFIED MILK AND PERCENTAGE MILK-MIXTURES. 59 
 
 •3. SO and 4.00. so that an average of 3.90 very satisfactorily represents this 
 value. It is also evident that this assumed constant factor cannot be used 
 for a proteid percentage higher than itself; but as such a combination would 
 consist almost entirely of whole milk, the constant (3.90) should be taken 
 very close to 4.00. For instance, if a 4.00 fat and 3.90 proteid mixture 
 were desired, the constant factor should be taken as 3.99, and it would be 
 found from formula (1) that 39.1 oz. of mixed milk and cream would be 
 needed, the proportions of 0.4 oz. cream and 38.7 oz. milk being obtained 
 from the other formula. 
 
 There are a few exceptions to the universal application of these formulae 
 that should be noted. In proteid values lower than 1.00, 16 or even 32 per 
 cent, cream may be required ; l in proteid values of 1.00 to 1.25, 16 percent, 
 cream is required for fat values from 3.25 to 4.00 for the lower, and from 3.75 
 to 4.00 for the higher of these proteid percentages ; also, in the higher proteid 
 percentages (2.25 to 4.00) skimmed milk, instead of cream, would be required 
 for fat percentages lower than the proteid percentage. In practice, however, 
 it is extremely rare to use a fat percentage lower than the proteid, so that 
 this method of combination will be found to give most satisfactory working 
 results, which come closer to accurate percentages than either cream-and- 
 undermilk or diluted-cream mixtures. 
 
 The estimation of the quantity of sugar to be added for any desired per- 
 centage is considerably simplified by the fact that, since the quantity of 
 mixed milk and cream remains constant for the same proteid value, the sugar 
 to be added is also constant for the same sugar percentage : the variations in 
 the fat percentage do not alter it. The quantity of dry sugar of milk to be 
 added to the mixture to produce any desired percentage of sugar, S, is rapidly 
 calculated from the formula 
 
 (3) Sugar = j^ • 
 
 In the examples already given, to obtain a 6 per cent, sugar mixture there 
 must be added about 1|- oz. of dry sugar. 
 
 A distinct advantage of this method is that if the quantity of cream be 
 kept constant and the milk gradually increased, the total quantity of mixture 
 being kept constant, both the proteid and fat percentages are gradually 
 increased by an equal increment. When the fat value surpasses 4.00, beyond 
 which it is rarely desirable to go, a half ounce may be dropped from the 
 quantity of cream and its loss supplied by a half ounce of milk. From this 
 point an increase of two or three ounces of milk may be made before the fat 
 value again rises above the point desired, when another half ounce of cream 
 may be replaced with milk. By this means the strength of food may be 
 gradually increased without necessitating frequent changes of formula. 
 
 1 When 16 or 32 per cent, cream is used, the denominator 8 in formula (2) should be 
 made 12 or 28, and the constant factor in formula (1) should be changed to 3.80 or 3.45, to 
 correspond. See papers on this method, Archives of Pediatrics, Jan., Feb., 1898. 
 
SEA-AIR AND SEABATHING IN CONVALESCENCE. 
 
 By W. M. POWELL, M. D., 
 
 Atlantic City. 
 
 The difference between the air of an inland town and that of the sea-coast 
 is that the latter is not only pure, but is saturated with sea-salts from the break- 
 ing of the waves upon the shore and the dashing of spray, which is carried 
 toward the land by air-currents. If the wind is blowing from the sea, this 
 characteristic saline odor may be noticed for some miles inland, but during a 
 "land-breeze" it is hardly perceptible, even upon the beach. E. Freidick, in 
 the Southern California Practitioner, quotes a large number of observers who 
 have demonstrated the presence of sodium chloride in the air at the seaside, 
 and shows that while there is naturally a small proportion of salt in this atmo- 
 sphere, the greatest part of it is due to the diffusion of minute particles of sea- 
 water. The proportion of salt is increased during strong winds, which blow 
 the fine spray inland. 
 
 The air of the sea has a peculiar odor which is difficult to define, but which 
 it is impossible to forget when once it has been inhaled. This odor, which 
 is caused by the evaporation of the extractive matter contained in sea-water, 
 is stronger when the waves dash upon rocks covered with sea-weed than when 
 they break gently upon a sandy shore. It is also more perceptible during a 
 storm than when the sea is calm. 
 
 Upon the border of the ocean the air is under greater pressure than in places 
 of greater elevation, and consequently it contains more oxygen. The range of 
 the barometer, the thermometer, and hygrometer is reduced to a minimum. 
 These facts are only too often neglected in our estimates of the qualities of 
 sea-air ; they are, however, in a great measure responsible for the benefits 
 derived by invalids during a residence at the sea-shore. 
 
 Ozone is one of the constituents of the atmosphere which is found in abun- 
 dance on the sea and adjoining coast. Schbnbein, its discoverer, believed it to 
 be naturally formed out of atmospheric oxygen by the electrical discharges 
 constantly taking place in the air. It is a most powerful oxidizing agent, so 
 destructive to organic miasmata that its mere presence is a warrant of the 
 absence of such noxious elements. It is more abundant by the sea than 
 inland, and in windy than in calm weather. It is well known that the climate 
 of any place where ozone is found in abundance must be healthy and exhila- 
 rating ; hence we have at the sea-shore a pure air, containing oxygen in the 
 form of ozone, besides finely divided sea-salts, as well as water which is ren- 
 dered stimulating by the presence of the same salts. It most cases the breath- 
 ing of this air has a marked invigorating effect, causing a great improve- 
 ment in the appetite, promoting digestion and almost immediately producing a 
 delightful exhilaration of the entire system. " No doubt can be entertained, 
 in view of often-observed facts, that the effect of exposure to sunlight upon 
 animal life is directly invigorating ; and when with this is combined the con- 
 stant inhalation of salt-air, and the daily application of salt water to the whole 
 
 60 
 
SEA-AIB A2T& SEA-BATHING. 
 
 61 
 
 surface of the body and limbs, it is easy to see why children should gain health 
 and strength at the sea-shore." — Packard. 
 
 The temperature on or near the sea may certainly lay claim to greater 
 uniformity than is obtained in localities remote from the coast. During the 
 summer months the heated air of the land may be replaced by the cool breeze 
 from the sea, while in winter the temperature of the coast-line is raised by the 
 admixture of the warmer air from the sea with the colder air of the land. It 
 is estimated that the Grulf Stream in this latitude during winter imparts to the 
 air in contact with it a temperature of at least ten or fifteen degrees above that 
 of the atmosphere of the earth, so that the ocean air in mixing with that of the 
 land imparts to it an agreeable mildness which is unknown in the interior. 
 Another favorable condition is found in the fact that the warmer air from the 
 sea holds a large amount of invisible aqueous vapor in suspension, and as this 
 commingles with the colder air of the land, it is condensed, gives out its latent 
 heat, and becomes visible in the formation of clouds, especially at sundown. 
 Thus that radiation of heat from the earth's surface into space which always 
 takes place on clear nights is prevented. We can therefore safely assume 
 that the mean temperature of the sea-coast is neither so high in the summer 
 nor so low in the winter as that which prevails in the interior. These facts 
 are well illustrated in the following table, prepared by Sergeant W. D. Blythe 
 from the reports of the United States Signal Office, giving for five well-known 
 localities the mean temperature for each month and the year, computed from 
 November, 1879, to December, 1884, together with the average temperature 
 for each of the four seasons : 
 
 
 Winter. 
 
 Spring. 
 
 Slimmer. 
 
 Autumn. 
 
 Year. 
 
 
 j 
 
 
 btl 
 
 
 
 
 §> 
 
 
 
 
 6 
 bp 
 
 
 
 
 0} 
 
 c 
 
 
 8 i 
 
 
 2 
 ® 
 
 < 
 
 C 
 
 eS 
 
 38.6 
 
 — 
 < 
 
 46.7 
 
 57.8 
 
 2 
 < 
 
 47.7 
 
 «3 
 
 a 
 
 1-3 
 
 66.9 
 
 72.6 
 
 be 
 
 3 
 < 
 
 71.6 
 
 > 
 70.4 
 
 68.8 
 
 i 
 
 58.5 
 
 > 
 o 
 
 44.5 
 
 2 
 p 
 < 
 
 57.3 
 
 3 
 O 
 
 s 
 < 
 
 Atlantic City. X. J. . . 
 
 36.8 32.4 
 
 35.7 
 
 35.0! 
 
 52.5 
 
 Barnegat, X. J 
 
 36.4! 31.9 
 
 35.1 
 
 34.5 
 
 38.3 
 
 46.0 
 
 57.2 
 
 43.8 
 
 65.5 
 
 72.2 
 
 71.1 
 
 69.9 
 
 68.0 
 
 57.7 
 
 44.2 
 
 56.6 
 
 52.0 
 
 Boston, Mass 
 
 31 .4 J 26.4 
 
 30.1 
 
 29.3! 
 
 33.9 
 
 43.6 
 
 55.3 
 
 44.3 
 
 65.8 
 
 69.9 
 
 68.8 
 
 68.2 
 
 63.5 
 
 51.7 
 
 40.0 
 
 53.4 
 
 48.4 
 
 Xew York City 
 
 34.4: 30.0! 33.6 
 
 32.7 
 
 36.7 
 
 47.0 
 
 59.3 
 
 47.7 
 
 68.3 
 
 72.6 
 
 71.6 
 
 70.8 
 
 67.5 
 
 56.2 
 
 43.2 
 
 55.6 
 
 51.6 
 
 Philadelphia, Pa. . . . 
 
 36.1 31.7 37.1 
 
 35.0 1 
 
 40.2 
 
 49.9 
 
 62.6 
 
 50.9 
 
 71.5 
 
 75.1 
 
 73.7 
 
 76.8 
 
 69.3 
 
 57.7 
 
 44.6 
 
 57.2 
 
 54.1 
 
 As a sea-breeze prevails on a large majority of the days during the summer 
 months, the average summer temperature is much lower on the sea-coast than 
 farther inland. On some days the difference is greatly marked, and few of us 
 have failed to experience the relief afforded by the first breath of sea-air after 
 spending a day in the hot city. 
 
 It is self-evident that the pleasantest climatic conditions are those which 
 present the most even temperature, with only a moderate amount of wind and 
 rain. The tables on the following page, compiled from the same source, give 
 some interesting statistics of rainfall, temperature and wind at various well- 
 known stations of the Signal Office. 
 
 Touching the question of health, the national mortuary table offers important 
 data. There we find that while such model cities of the interior as Roches- 
 ter and Milwaukee, swept as they are by the cleansing winds of the great 
 lakes, show a death-rate respectively of 23.39 and 24.52 per 1000; while 
 Philadelphia, the healthiest, save London, of the world's great cities, shows 
 21.20 ; and while nearly thirty people to the thousand die annually in 
 Charleston — the death-rate among the resident population of a sea-coast 
 town like Atlantic City is 12.5. There are only two places in the United 
 States — Ashtabula, Ohio, and Los Angeles, California — where the death- 
 rate shows any approximation to this last percentage. 
 
62 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Annual Precipitation, in inches and hundredths, as recorded at the U. S. Weather Bureau Stations on 
 or near the Atlantic Coast, 1882 to 1891, inclusive; also the Average Annual Precipitations, com- 
 puted from observations covering periods of from three to twenty-one years. 
 
 Stations. 
 
 1882. 
 
 1883. 
 
 1884. 
 
 1885. 1886. ! 1887. 
 
 1888. 
 
 1889. 1890. 
 
 1891. 
 
 Average 
 amount. 
 
 
 
 
 
 
 
 
 57.56 55.03 
 
 51.64 
 43.04 
 
 3 yrs. 
 
 18 " 
 
 53.44 
 
 Atlantic City, N.J 
 
 55.29 
 
 44.64 
 
 53.70 
 
 38.45 
 
 44.80 
 
 37.76 
 
 44.10 
 
 38.43 
 
 33.04 
 
 42.81 
 
 Baltimore, Md 
 
 42.11 
 
 40.52 43.88 
 
 46.04 
 
 53.11 
 
 43.59 
 
 43.53 
 
 42.35 
 
 46.96 
 
 54.21 
 
 16 " 
 
 43.11 
 
 Barnegat (closed) 
 
 
 
 
 
 
 
 
 
 
 
 8 " 
 
 50.20 
 
 Block Island, R. I 
 
 57.65 
 
 39.69 
 
 63.05 
 
 39.37 
 
 54.50 
 
 44.55 
 
 29.18 
 
 32.80 
 
 31.51 
 
 39.03 
 
 11 " 
 
 44.4S 
 
 Cape Mav closed) 
 
 
 
 
 
 
 
 
 
 
 
 10 " 
 
 46.70 
 
 Charleston, S. C 
 
 57.01 
 53.26 
 
 51.35 
 53.34 
 
 60.22 
 55.92 
 
 67.93 
 52.04 
 
 65.94 
 
 44.61 
 
 49.46 
 53.13 
 
 52.25 
 46.22 
 
 47.84 
 47.52 
 
 45.90 
 41.32 
 
 16 " 
 15 " 
 
 58.92 
 
 Jacksonville, Fla 
 
 54.86 58.60 
 
 51.04 
 
 Narragansett Pier, R. I 
 
 
 
 
 
 . . i 50.97 
 
 53.66 
 
 57.15 
 
 45.21 
 
 44.46 
 
 5 " 
 
 52.38 
 
 New Orleans, La 
 
 50.18 
 
 69.85 
 
 60.01 
 
 64.18 
 
 54.83 i 64.97 
 
 45.15 
 
 48.45 
 
 47.17 
 
 38.62 
 
 23 " 
 
 51.78 
 
 Newport (closed) 
 
 
 
 
 
 
 
 
 
 
 
 6 " 
 
 59.98 
 
 New York City 
 
 46.61 
 
 38.83 
 
 55.34 
 
 42.32 46.73 
 
 46.63 
 
 52.95 
 
 58.68 
 
 52.30 
 
 51.44 
 
 21 " 
 
 45.76 
 
 Norfolk, Va 
 
 57.67 
 
 54.30 45.05 
 
 43.25 34.33 
 
 47.74 
 
 56.64 
 
 70.72 
 
 50.22 
 
 50.63 
 
 21 " 
 
 52.21 
 
 Portland, Me 
 
 38.94 
 
 31.99 
 
 52.51 
 
 39.75 52.63 
 
 49.07 
 
 34.24 
 
 41.92 
 
 51.97 
 
 43.28 
 
 20 " 
 
 42.68 
 
 Sandy Hook 
 
 32.14 
 
 42.09 
 
 52.72 
 
 38.42 closed. 
 
 
 
 
 
 
 12 " 
 
 50.40 
 
 Washington, D. C 
 
 46 79 
 
 45.71 
 
 49.96 
 
 44.84 1 58.17 45.38 
 
 61.33 
 
 41.59 
 
 52.95 
 
 51.22 
 
 21 " 
 
 45.06 
 
 Wilmington, N. C 
 
 52.29 
 
 64.00 
 
 62.70 
 
 60.42 56.43 51.47 
 
 55.07 
 
 59.31 
 
 41.33 
 
 48.00 
 
 21 " 
 
 56.24 
 
 
 Monthly 
 
 %nd Annual Mean 
 
 Temperatw 
 
 esfor 
 
 1889. 
 
 
 
 
 
 Stations. 
 
 Jan. 
 
 Feb. 
 
 Mar. 
 
 Apr. 
 
 May. 
 
 June. 
 
 July. 
 
 Aug. 
 
 Sept. 
 
 Oct. 
 
 Nov. 
 
 Dec. 
 
 Mean. 
 
 Asbury Park, N. J. . . 
 Atlantic City, N. J. . . 
 New York City . . • • 
 
 36.2 
 37.6 
 37.6 
 
 28.5 
 29.5 
 28.0 
 
 40.4 
 38.8 
 41.5 
 
 49.1 
 48.6 
 51.6 
 
 62.5 
 59.0 
 62.0 
 
 69.6 
 66.2 
 70.4 
 
 71.5 
 71.8 
 73.5 
 
 70.8 
 69.3 
 71.5 
 
 66.6 
 64.4 
 65.8 
 
 51.9 
 51.8 
 52.0 
 
 45.6 
 47.0 
 
 46.0 
 
 42.1 
 43.6 
 41.4 
 
 52.9 
 52.3 
 53.5 
 
 Annual Movement of Wind, in miles, at U. S. Weather Bureau Stations on the Atlantic Coast 
 for ten years, ending Bee. 31, 1891. 
 
 Stations. 
 
 Atlantic City, N. J. 
 Barnegat, N. J. , . 
 
 Block Island, R. I. 
 
 Cape May, N. J. . . 
 
 Sandy Hook, N. J . 
 
 1882. 
 
 1893. 
 
 1884. 
 
 1885. 
 
 1886. 
 
 1887. 
 
 1888. 
 
 1889. 
 
 1890. 
 102.520 
 
 1891. 
 
 86.498 
 117.564 
 
 132.595 
 
 123.041 
 
 122.601 
 
 80.769 
 128.939 
 
 130.575 
 
 128.330 
 
 128 933 
 
 75.232 
 125.081 
 
 127.478 
 
 134.584 
 
 139.149 
 
 76.150 
 124.061 
 
 122.608 
 
 closed 
 
 144.879 
 
 79.553 
 closed 
 
 125.698 
 
 74.879 
 132.975 
 
 88.825 
 147.384 
 
 104.930 
 148.944 
 
 106.500 
 
 "I 
 
 { 
 
 138.672 
 
 closed 
 
 
 
 
 } 
 
 
 
 
 
 
 \\ 
 
 Avarage. 
 
 87.585 
 (4 years) 
 
 123.911 
 (8 vears) 
 
 133.531 
 (3 vears) 
 
 128.653 
 (5 vears) 
 
 134.847 
 
 Diseases benefited by Sea-air. — It is often asked, What diseased con- 
 ditions are benefited by a sojourn at the seaside? and, What, if any, are 
 acted upon unfavorably ? Dr. A. W. Bell, author of Climatology and Mineral 
 Waters of the United States, says that, considering the purity of the vapor 
 and perfect solubility of the salt, it is difficult to conceive of any possible 
 state of the human system under which the inhalation of such air would be 
 detrimental. I fully agree with this author, and believe that sea-air is pref- 
 erable to any other during a tedious convalescence. I know of no place 
 where children improve more quickly than at the sea-shore. I have stud- 
 ied this subject closely since 1883, when I was resident physician at the 
 Children's Sea-shore House at Atlantic City, New Jersey. Since that time 
 I have been connected with the same institution, where upward of seven 
 hundred children, both convalescents from various acute (non-contagious) 
 diseases and those affected with chronic ailments and strumous manifes- 
 tations, are admitted yearly during the summer months. No one without 
 experience can realize the benefit obtained by these little suffers, who remain 
 at the Home for a fortnight to several weeks, according to the gravity of 
 their cases. Here are sent, chiefly from Philadelphia, desperate cases of 
 entero-colitis, patients almost completely prostrated by the heat, and other 
 moribunds. Yet nearly all recover through the influence of the sea-air and 
 
SEA-AIR AXD SEA-BATHING. 63 
 
 clean, healthful surroundings, with little or no aid from medicine. During the 
 summer of 1892. in the latter part of July and the first week in August, the 
 heat in Philadelphia and vicinity was intense. At this time I had more cases 
 of severe entero-colitis than for several years, but they all recovered rapidly, 
 save one, a child sixteen months old, who died four hours after its arrival at 
 the coast. At the Children's Seashore House, where my friend Dr. W. H. 
 Bennett was in charge,' the cases were more severe than usual, but all termi- 
 nated favorably. 
 
 It is an unusual circumstance for entero-colitis to develop at the sea-shore, 
 and most of the cases seen there are brought from the neighboring cities or 
 interior. Simple diarrhoea from indigestion, teething, etc. of course occurs. 
 
 Convalescents from scarlatina, measles, and the eruptive fevers generally do 
 well by the sea. 
 
 The subacute nasal and pharyngeal catarrhs that we so often meet with 
 in the spring as the results of repeated winter colds, which are usually so 
 obstinate, invariably do well at the shore, where a complete cure is usually 
 effected in a few days. Even cases of acute bronchitis seem to recover much 
 more rapidly, and chronic forms are much improved. My experience with 
 phthisis in children at the sea-shore has been limited : I have only seen a 
 few cases, and they were far advanced. These children seemed to do well for 
 the first week ; the appetite improved, and sleep was more refreshing, although 
 the cough remained about the same. After this they remained at a standstill, 
 the improvement in appetite not being maintained and rest becoming dis- 
 turbed again. These cases improved for the first few days when taken home, 
 but fell back rapidly. 
 
 Asthmatic patients are frequently sent to the sea-shore, with, as a rule, 
 most favorable results. Doubtless a long stay is beneficial to all such cases, 
 especially those associated with chronic bronchitis. Patients arriving during 
 a paroxysm nearly always experience an immediate relief, especially in cases 
 of hay asthma ; but should the attack orginate at the sea-coast, removal to the 
 city may in turn prove beneficial. Hyde Salter says : "I think it is a law, with- 
 out an exception, that nervous affections are less prone to occur in proportion 
 to the general bodily vigor, and what, for want of a more definite term, we 
 must call the tone of the nervous system. Anything, therefore, that invigor- 
 ates renders asthmatics less prone to their attacks. In this way sea-bathing 
 is often of great service to asthmatics. By raising the standard of the general 
 health it tends to prevent those humoral derangements which are often the 
 exciting cause of asthma." 
 
 Cases of a strumous origin invariably do well by the sea : the appetite 
 improves, the color returns to their cheeks, and they gain in flesh. Russel, 
 who was the first to appreciate all the benefits derivable from the salt air, 
 always had the hair of strumous children cut close, and exposed them freely 
 to the cool sea-air with the neck uncovered ; and he sent them back to their 
 homes with their limbs strengthened and carrying in their countenances the 
 evidence of the restorative powers of his remedy. When the strumous diath- 
 esis has further advanced, the effect of sea-air, although still of great utility, 
 is much slower. There are many cases of cure, even when the glands of the 
 neck have been greatly swollen, under the influence of two or three seasons 
 passed by the sea. Roccas tells us that such a deeply ingrained constitutional 
 disease as scrofula cannot be eradicated without a prolonged stay in a marine 
 atmosphere. When the glands are ulcerated, Whitt many years ago recommended 
 fomentations with sea-water and poultices made with it. It is supposed to facil- 
 itate the resolution of the swollen glands, even when they have become very 
 
64 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 large and have existed for a long time. The following case, reported by Rob- 
 ert of Marseilles, fully confirms these assertions: " A lady coming from the 
 interior of France brought to me her son, about fifteen years of age. The 
 youth was enfeebled to the last degree, having been ill ever since he was nine 
 years old. During all this time he had labored under scrofula of the neck, 
 which was entirely surrounded with cicatrices of old ulcers. At the time I 
 saw him the right elbow and one of the feet were affected; the elbow-joint 
 was not diseased interiorly, but the ligaments which surrounded it were ; and 
 there were fistulous openings which had persisted for a length of time. As 
 regards the foot, it was puffy and much enlarged, and he could scarcely bear it 
 to be placed upon the ground : abscesses had formed several times, which had 
 cicatrized, but there was another now threatening to open on one side of it. 
 The most alarming feature of the case, however, was the terribly low state of 
 the patient's constitution. His spirits were dejected; his face had the look 
 of one prematurely old : his skin was dry and flabby ; and his limbs almost 
 entirely denuded of their flesh. Moreover, he was tormented with an almost 
 continual diarrhoea. I advised the mother to establish her son upon the sea- 
 coast, to make him pass the whole day upon the beach, and to make him use 
 the sea-baths. Under this influence his general health began to improve, and 
 then the swellings of the elbow and the thickening of the foot began to sub- 
 side. Afterward I recommended that he should bathe daily, and that he should 
 learn to swim. He fulfilled my orders so literally that he passed almost the 
 whole of the latter part of the summer in the water. Always on the beach, 
 he could find no other amusement so pleasant as that he derived from swim- 
 ming. In a marvellously short time, considering the amount of disease, the 
 youth was quite cured, and became what he still remains — a strong, healthy, 
 and vigorous man." 
 
 Rickets is another common disease of childhood in which the benefits of 
 residence by the sea are marked. The influence of sea-air upon this malady 
 seems to exert a marvellous amount of good, and West, in recommendation 
 of it, says that " even where marked deformity has already taken place 
 amendment will be sure to follow." I fully agree with this authority, but 
 will state that my experience in the past two years with this affection has 
 been limited, as the stay of my patients during the summer months is hardly 
 sufficient to show improvement if the disease is far advanced. But I do believe 
 a prolonged stay by the sea, say a year or more, will bring about a complete 
 cure. 
 
 Children suffering from Pott's disease, hip-joint disease, and arthritis of the 
 knee all do well, gaining in flesh and improving in appetite without medical 
 treatment. 
 
 Rheumatic cases, especially when chronic, do well by the sea-coast, and I 
 know of no better treatment for this disease than warm sea-bathing. Fortu- 
 nately for this class of patients, most prominent sea-coast resorts now can 
 offer all facilities for warm sea-baths. These establishments are fitted with 
 every convenience, including a lounging-room or "sun parlor," where one 
 may take a nap after the bath. In cases of rheumatism the best results will 
 be obtained from baths given on alternate days, followed by thorough friction 
 of the body by a masseur or an intelligent nurse. 
 
 Cases of chorea during convalescence improve rapidly at the sea-shore. 
 Although many writers highly recommend sea-bathing in this disease, I do not 
 agree with them. Indeed, in one case, almost well, I am sure a relapse was 
 occasioned by fright caused by a wave striking the child. Warm sea-baths, 
 followed by a gentle massage, are preferable. 
 
SEA- AIR AND SEA-BATHING. 65 
 
 Sea-air has a very grateful influence in inducing sleep. Often sick chil- 
 dren brought to the sea-coast sleep the first night better than for many nights 
 before, ft will be found that many children who are not ill after a few days' 
 stay will complain of drowsiness and willingly take their afternoon nap. 
 
 'The obstinate bronchitis which so often remains for an indefinite time 
 after whooping cough is frequently cured by a few weeks' stay at the shore. 
 In the paroxysmal stage of the disease, while the coughing spells are no less 
 violent than elsewhere, children do not seem to lose flesh and color, no doubt 
 because their appetite is kept up by the bracing effect of the clear atmosphere, 
 and they are kept in the open air more than they would be in a city home. 
 
 Cases of infantile paralysis make a slow but steady improvement during a 
 long stay by the sea. Most diseases of the skin and the inflammatory dis- 
 eases of the eye are not improved by sea-air, unless these troubles have a 
 strumous origin, in which case a long stay, by improving the general health, 
 will indirectly improve the local condition. f 
 
 Sea-bathing*. — It is a popular belief that sea-bathing is both strength- 
 ening and hardening ; and there is but little doubt that this opinion is well 
 founded. It does not follow, however, that it should be practised by all with- 
 out medical advice. Many hold that a plunge into water which is of lower 
 temperature than air protects the system against attacks of catarrh and chill, 
 and renders it indifferent to sudden climatic changes, whilst a few contend 
 that perfect immunity from colds may be ensured by continuing the morning 
 plunge throughout the year. We may say, without doubt, that sea-bathing, 
 more than any other agent known, renders the body less sensitive to the influ- 
 ence of cold and to the injurious effects of prolonged exposure; but this, of 
 course, is due to its invigorating and strengthening properties alone, and not 
 to the element of temperature. 
 
 It is a remarkable fact that many persons who cannot profitably bathe in 
 fresh water can do so in the sea ; and the explanation doubtless is that the 
 abstraction of caloric from the body in salt water is less than in fresh, by rea- 
 son of its greater density. Probably, also, the saline ingredients have a more 
 stimulating effect upon the skin and induce a more energetic reaction. 
 
 The most important . characteristic of sea- water is its saline composition, 
 and it is impossible to over-estimate the influence of the sea-salts in marine 
 meteorology. It has been estimated that the average quantity of saline matter in 
 sea-water is 3 per cent., consisting of chloride of sodium, sulphate of magnesium, 
 sulphate of sodium, also muriate of magnesium and lime, with salts of iodine 
 and bromine. Many, however, estimate the saline ingredients at 4 per cent. 
 The above constituents are uniform as to presence, but are unequal in quantity 
 in various parts of the world, so that in the Baltic a pint of water contains 
 nearly forty grains of salt; on the coast of Great Britain it contains more 
 than half an ounce ; in the Mediterranean, much more ; and in some ports 
 south of the equator the quantity amounts to more than two ounces. It is 
 in consequence of its saline character that sea-water does not evaporate from the 
 skin so readily as fresh water. Even when the body is carefully dried particles 
 of saline matter remain adherent, and find their way into the pores of the skin 
 — as may be proved by the application of the tongue to the surface — and keep 
 up a tingling glow long after the bath is over. We all know that persons 
 when soaked to the skin by salt water do not take cold as easily as when 
 caught in a shower of rain. This is explained by the fact that the pungent 
 action of the sea-salts so stimulates the cutaneous circulation as to enable it to 
 resist the depressing effects of the cold produced by the evaporation of the 
 fluid portion. Sea-bathing, besides having all the beneficial effects of an ordi- 
 
 5 
 
66 AMEBIC AN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 nary cold bath, has others peculiar to itself. The contact of the salt water 
 and of the salt which adheres after the water left by the bath has evaporated 
 stimulates the skin, increasing the circulation and exciting the sudoriferous 
 glands. The beating of the waves against the surface of the body affords a 
 passive exercise, with some of the advantages of massage ; while to the more 
 robust a healthful exhilaration and delightful active exercise are furnished by 
 the plunge through the waves and the vigorous movements constantly required 
 while in the surf. 
 
 At the resorts in the neighborhood of New York and Philadelphia the sea- 
 bathing season is usually considered to be between the first day of June and 
 the last day of September, as in this interval the temperature of the water 
 ranges higher than at any other season. 
 
 The best time for taking a sea-bath is just before high tide. At that time 
 the water has been somewhat warmed by passing over the hot sand. More- 
 over, the bathing is safer, from the fact that the tide still coming in would 
 tend to wash the bather to the shore if he should lose his foothold, and, as the 
 water covers a portion of the beach which was exposed to view a few hours 
 before, there is less risk from dangerous holes and quicksands. But at most 
 sea-shore resorts it has been found more convenient to bathe at the same hour 
 each day — namely, at about 11 A. M., or two or three hours after breakfast, 
 when the morning meal is digested and the system is beginning to feel the 
 effects of the conversion of food into force, and is therefore better prepared 
 to withstand the shock of the cold plunge. It is unwise, however, to bathe 
 within two hours after any meal : whilst digestion is proceeding more blood 
 is attracted to the digestive organs, in order that the process may be efficiently 
 performed. But if we divert a portion of the blood to the surface of the 
 body by the action of the cold bath, digestion is suddenly interrupted, assimi- 
 lation checked, and congestive headache, cramps in the stomach, etc. are caused. 
 In order to answer several of the questions which naturally arise, it is neces- 
 sary to describe the phenomena, which are as follows : On entering the water 
 there is a shock, accompanied by a sensation of chilliness and shivering ; there 
 is a respiratory embarrassment and a feeling of fulness in the head. Next 
 follows a reaction, in which all these symptoms are relieved, and there is an 
 agreeable sensation of warmth. If the bath is unduly prolonged, there follows 
 another sensation of chilliness : the teeth chatter, the fingers and lips become 
 blue, the respiration irregular and rapid, and the pulse weak and small. In 
 the sea-bath each wave reproduces in a less degree the first shock, and at 
 the same time hastens the development of the second chill. From the above 
 description it would appear that the proper duration of the bath is a period 
 short of the second chill, and the length of this period must depend upon the 
 temperature of the water, the force of the waves, the strength of the patient, 
 and a number of other circumstances. 
 
 I do not consider it wise to allow children to remain in the water over five 
 minutes, and then they should be at once taken to their bath-house and not 
 allowed to play on the beach in their wet bathing-suits. Before entering the 
 water their heads should be wet, and they should be taken cautiously to the 
 first line of breakers, where, in a stooping posture, the waves may wash over 
 them. If children are afraid of the water, they should not be forced. The 
 proper way is to accustom them gradually to the sea. Have them dressed in 
 their bathing-clothes and allow them to play on the beach, when they will of 
 their own accord go to the water's edge and gradually find their way in. 
 Many children do not dread the water, and they may do much in allaying the 
 fears of the more timid. I think three or four sea-baths a week quite sufficient 
 
SEA-AIB AXD SEA-BATHING. 67 
 
 for even the strongest child. A thorough rubbing down should always be 
 given, and the child quickly dressed, and allowed to resume its play in a sunny 
 spot unexposed to the wind. There is no advantage in taking an infant (under 
 two vears) into the sea, and the practice as usually carried out seems almost 
 inhuman : for these the heated salt-water bath is an excellent substitute. 
 
 The Management of Children at the Sea-shore. — At all times of the 
 year the sea-shore is most beneficial to sick children, but it has only been 
 a comparatively few years since the practice of going to the sea-side resorts 
 during the winter and spring months came in vogue ; previously, the three 
 summer months were the only ones considered advisable to spend by the 
 sea. At the present time it is deemed almost as necessary to take a child 
 convalescing from an illness to the sea-shore in the winter and spring months 
 as in summer. 
 
 In selecting a place of residence by the sea it is well to be near the surf. 
 Houses situated at a distance from the beach are never as cool as those close to 
 it. Therefore, in taking a sick child to the shore it is always advisable, 
 especially during the summer months, to select a house in close proximity to 
 the sea. Here the exhilarating breeze comes uncontaminated from the ocean. 
 
 The clothing of the child during its stay at the sea-shore should be slightly 
 heavier than that worn in the city or country ; hence it is always better to use 
 woollen under-garments, light and loose in texture. Long stockings should 
 invariably be worn, even in the warmest weather, as toward evening the air 
 becomes several degrees cooler, and, if the breeze is blowing from the sea, 
 at times almost cold. 
 
 Little change need be made in the food of children during their stay. 
 The advantages, claimed by some authors, of a largely marine diet have 
 probably been over-estimated, and much blame has been attached by others to 
 fish, oysters, etc. for the frequent disorders of the digestive apparatus from which 
 adults suffer at the sea-shore. From my own experience, however, the acute 
 attacks of indigestion that we occasionally see are usually brought about by 
 the elaborate menu which is found at our largest hotels, in contrast to the 
 plainer home table which most are accustomed to. On arriving at the sea- 
 shore the appetite is naturally sharpened by the change of air, and over-eating 
 is the result. 
 
 Much thought should be given to the necessity of exercise. Children 
 seldom need much urging, but the want of it among adults probably interferes 
 with many of the benefits which otherwise would be gained. 
 
 For very young children, next to the walk in the nurse's arms, the drive 
 upon the beach should be recommended. The perfect evenness of the surface 
 renders it possible to take a very ill child into the open air frequently with the 
 greatest benefit. One of the best forms of exercise for sick children is play- 
 ing in the warm, dry sand. A spot should be selected where the sun does not 
 beat too strongly, but which is at the same time perfectly dry. It is, as we 
 all know, an unceasing source of amusement to children, and the harmless 
 character of their little falls and tumbles during play often encourages them 
 to efforts which they would not otherwise attempt. 
 
PART I. 
 
 INJURIES INCIDENT TO BIRTH AND DISEASES 
 OF THE NEWBORN. 
 
 By EDWARD P. DAVIS, A. M., M. D., 
 
 Philadelphia. 
 
 The mortality of the first year of life is variously estimated. Bernheim, 
 from an extensive series of statistics, places it at 37-^j- per cent, of all chil- 
 dren born. Winckel states that 10 per cent, of children born perish before 
 the eleventh day of life ; of these, -^ per cent, perish during labor itself, 3-^- 
 per cent, die as a consequence of some injury received during labor, while 
 %To P er cen t- perish from diseases contracted at or after birth. We shall 
 first consider morbidity and mortality among children arising from injuries 
 received at birth. 
 
 Caput Succedaneum. 
 
 The most frequent lesion sustained by the foetus during delivery is the 
 formation of a tumor upon the head, usually known as caput succedaneum : 
 this is commonly recognized after delivery as a somewhat boggy tumor, formed 
 by infiltration of the scalp and fascia over the cranium, and usually situated 
 upon the parietal bone opposite to that which came most in contact with the 
 bony pelvis of the mother. The mechanism of its production is commonly 
 thought to be as follows : In a normal presentation and position, the back of 
 the child being to the left side of the mother's pelvis, and the vertex occupy- 
 ing the left anterior half of the pelvis, during the stage of expulsion the left 
 half of the vertex of the child's skull receives the greater portion of the 
 impact of force during descent and rotation. The continued pressure upon 
 this portion of the foetal skull temporarily checks the free circulation of blood 
 and lymph through the tissues of the scalp and fascia. There remains upon 
 the opposite half of the vertex a portion of the head less pressed upon by the 
 bony pelvis ; here, naturally, the blood and lymph of the scalp-tissues are pre- 
 vented from circulating through the left side of the foetal head by pressure, 
 and accumulate and distend the tissues of the right half of the vertex. The 
 result is a tumor upon the side of the foetal head opposite that which actually 
 engaged during the first stage of labor. The position which the child's head 
 occupied in the mother's pelvis may then be reasonably inferred from the loca- 
 tion of the caput succedaneum ; thus in the usual labor this tumor occurs in 
 the right parietal region of the head. Should the child occupy a second posi- 
 tion, its back to the right of the mother, its vertex situated in the right ante- 
 
INJURIES AND DISEASES OF THE NEW-BORN. 69 
 
 rior half of her pelvis, the caput succedaneum can be found upon the left 
 parietal portion of the foetal head. Caput succedaneum is usually of no prac- 
 tical importance, as it disappears in a few days after labor. The infiltrated con- 
 dition of its tissues, however, forms an excellent field for the growth of infect- 
 ing bacteria. Should the mother's birth-canal be in a septic condition during 
 labor, or should, through the carelessness of the nurse in washing the child, 
 some injury occur to the tumor, the entrance of septic infection results in 
 inflammation, and, in rare cases, in abscess of the scalp. The caput succeda- 
 neum is larger the longer the labor lasts, is usually of a bluish-red color, and 
 does not distinctly fluctuate or pit upon pressure. 
 
 Occasionally the tumor embraces both parietal bones : this may be caused 
 by long delay in the expulsion of the child, the head remaining for some time 
 in the external genitals of the mother. Upon post-mortem examination extrav- 
 asations of blood varying in size may be found in the vicinity of the tumor, 
 and do not indicate criminal violence after birth. Two of these tumors may be 
 found, a primary and secondary : the first is formed in the usual manner ; the 
 second is produced while the head is upon the pelvic floor and after ante- 
 rior rotation has occurred. If delivery then be delayed, a secondary tumor will 
 form, and may be distinguished from the first by its situation in the median line. 
 In shoulder presentations the tumor is found upon the shoulder which pre- 
 sents. 
 
 So far as the treatment is concerned, Bouchut suggests the application of a 
 solution of ammonium chloride, a solution of camphor, or an alcoholic mixture 
 containing camphor. If this does not secure the disappearance of the tumor, 
 he would aspirate it. Winckel and other o'bstetric authorities incise the tumor 
 if it persists beyond the sixth or eighth day, and make pressure upon the 
 parts with salicylated cotton. If abscess forms, incision and irrigation with 
 a J per cent, solution of creolin are indicated. 
 
 Cephalhematoma. 
 
 By cephalh hematoma Naegele, who first described it, designated a blood- 
 tumor on the fcetal head, called true cephalhematoma when beneath the 
 periosteum of the skull, and false cephalhematoma when beneath the aponeu- 
 rosis of the scalp. Virchow explains the formation of cephalhematoma by 
 referring to the way in which the pericranium grows — namely, by proliferation 
 of inner layers of the periosteum. If, then, the pericranium is separated 
 from the cranium by the extravasation of blood, the bone-producing layers 
 of the periosteum are still formed, but are prevented by the blood-clot from 
 uniting with that portion of the bone for which they were intended. They 
 join, however, to the bone at the border of the extravasated clot, where the 
 bone is still attached. 
 
 Fig. 1. 
 
 Vertical Section through Cephalhematoma. 
 
 Much discussion has arisen as to the method of formation of cephalhe- 
 matoma. Some ascribe its presence to traumatism only, while others seek an 
 
70 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 explanation in a pre-existing condition of the infant's tissues. It is to be 
 differentiated from caput succedaneum by several important distinctions. The 
 latter arises during birth, is born with the child, appears upon that portion of 
 the head turned during labor toward the excavation of the pelvis, is more 
 prominent after difficult labors, has an ill-defined border, frequently crosses 
 sutures, is discolored in appearance, and doughy upon manipulation, and tends 
 to disappear rapidly after delivery. On the contrary, cephalhematoma does 
 not occur, as a rule, after difficult labor, appears usually upon that parietal 
 bone which did not present in the pelvic excavation, has a sharply-defined 
 border, does not extend across sutures, does not discolor the scalp above the 
 tumor, and usually gives the sensation of fluctuation in the centre of the mass. 
 Cephalhematoma also tends to increase steadily in size for some time after labor. 
 
 With such radical differences the pathology of these tumors must differ 
 widely. That of caput succedaneum has been already given. In studying 
 the pathology of cephalhematoma we have been struck by the fact that 
 instances under our observation have been, as a rule, in ill-nourished children 
 born without especially difficult labor. In the wards of the Philadelphia 
 Hospital we have frequently observed these cases in children born of ill- 
 nourished mothers and poorly nourished at the time of birth. This leads us 
 to believe that a pre-existing malnutrition lies at the basis of these tumors ; 
 thus, cases are reported where, in addition to the cephalhematoma, a profoundly 
 anemic condition of various organs of the child's body was present. In no 
 case does this tumor occur as an extravasation of blood beneath the internal 
 periosteum of the skull ; but extravasations of blood within the cranial cavity 
 are also described under the title of " intracranial cephalhematoma." Partridge 
 describes two cases in which coagulated blood was found beneath the dura 
 mater. No injury to the bones of the cranium existed in these cases, the 
 brain-substance was softened, and the blood found beneath the membranes and at 
 the base of the brain seemed to have been extra vasated from the sinuses and from 
 the laceration of minute blood-vessels. One of these children died very 
 shortly after labor ; the other survived for several days. We recall a similar 
 case where delivery was easily effected by the forceps ; the child perished, 
 however, in thirty-six hours after birth, and upon post-mortem examination 
 blood was found extravasated beneath the membranes, while the underlying 
 cerebral matter was softened. Here also no injury to the bones, membranes, 
 or sinuses could be detected. 
 
 Cephalhematoma is more frequently found in males than females, according 
 to Burchard, in the proportion of more than three to one. The tumor is 
 usually found upon the right side of the head. The children of primipare 
 are most liable to this complication in the proportion of three to one. As a 
 rule, cephalhematoma does not pulsate, although isolated cases are reported in 
 which indistinct pulsation was observed. While fluctuation is usually present, 
 it may be very obscure. This results from the presence of coagulated blood, 
 as well as the breaking down of the clot in the centre of the tumor. It is 
 observed that if the tumor be opened soon after formation, bright-red blood 
 escapes; later the blood resembles the fluid found after old extravasation. 
 The deposition of bony material on the under surface of the periosteum 
 occasions a crackling sensation when the tumor is palpated. The fluid escapes 
 irregularly from beneath the tumor ; sensitiveness is very rarely a prominent 
 feature. The bony ring surrounding the tumor forms gradually; thus 
 Bouchut observed a case before birth in which no ring was present. Semmel- 
 weis is said to have seen cephalhematoma in a child delivered by Cesarean 
 section. 
 
INJURIES AND DISEASES OF THE NEW-BORN. 
 
 71 
 
 Several tumors may develop in the same individual ; thus we recall a case 
 under observation in the Philadelphia Hospital in which double cephalhe- 
 matoma appeared on the head of a male child born after a normal labor. Triple 
 cephalhematoma has been observed by Oui after a precipitate birth in which 
 
 Fig. 2. 
 
 Double Cephalhematoma. 
 
 the infant fell to the ground, the cord rupturing three or four centimetres from 
 the umbilicus. Upon examination a tumor was found upon each parietal bone, 
 and one upon the occipital. The tumors were treated by incision and evacua- 
 tion under careful antiseptic precautions, and uninterrupted recovery ensued. 
 
 The occurrence of cephalhematoma is readily understood when the loose 
 attachment of the pericranium to the bone is remembered ; Valleix found that 
 in almost all infants ecchymosis between the pericranium and the skull is 
 present after labor. It requires, then, but a constitutional liability to ecchy- 
 mosis by reason of malnutrition to readily account for the occurrence of 
 such tumors. Cephalhematoma, again, may develop after birth as a surgical 
 injury, as instanced in cases described by Treves and Nelaton, as also in a re- 
 markable case in a bleeder reported by St. Germain. 
 
 Cephalhematoma may be also produced by injudicious pressure exercised 
 during the child's toilette. HUter observed double cephalhematoma occurring 
 on the fifth day after birth, and caused by the carelessness of a midwife, who, 
 in washing the child, rubbed its head with undue force. The tumors persisted 
 as long as the individual had charge of the child, but disappeared soon after 
 she was discharged. 
 
 No one cause can be invariably assigned for the production of cephalhe- 
 matoma : the size of the mother's pelvis seems to exercise but little effect, for 
 Merttens in 21 cases found 6 in which the pelvis was normal, and only 5 in 
 which slight pelvic contraction was present. In these cases the contraction 
 was not of such nature as to interfere with labor. That the pressure of the 
 pelvis has sometimes nothing to do with these cases is shown by Spiegelberg's 
 observation of a case of premature birth at six months, in which the child 
 perished before the rupture of the membranes ; he was able to examine the 
 head in utero, and detected the tumors before the expulsion of the child. He 
 considered the tumors caused by interference with the oxygenation of the 
 
72 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 foetal blood, and oftentimes by premature efforts at respiration. Merttens 
 reports a similar case in which he diagnosticated this complication before 
 delivery. The foetus in this latter instance had a congenital hernia of the 
 diaphragm, and haematomata were found in other portions of the body. 
 
 The diagnosis of cephalhaematoma in distinction from caput succedaneum 
 has already been stated. Hernia cerebri may be present, but occurs usually 
 in the occipital region and in the line of sutures. Pressure upon the hernia 
 produces symptoms of positive disturbance of the nervous system. 
 
 Aneurism presents a pulsating tumor of darker color, which neither has 
 the appearance nor affords the history of cephalhaematoma. The effort to 
 class this affection among the hydrocephali is scarcely successful in the light 
 of our present knowledge of both. Blood-tumors found in the occipital region 
 in the dead foetus are often caused by difficult labor, and are dark in color 
 from the decomposition of effused blood. In encephalocele direct examination 
 of the head by palpation will enable the physician to make the diagnosis. 
 Tumors in living children, the result of direct violence, are usually painful on 
 pressure and lack the sharp outline of cephalhaematoma. Occasionally, in 
 advanced rachitis, where craniotabes is present, soft pieces of bone in the skull 
 may simulate a blood-tumor when palpation is made through the scalp. 
 
 The usual plan of treatment consists in making gentle pressure by a pad 
 of antiseptic cotton conveniently held in place by a night-cap. Occasionally 
 lotions containing dilute alcohol or some acetous preparation are employed, but 
 there is no evidence of their positive value. It must be remembered that the 
 tumor, as a rule, will have reached its largest size six or eight days after the 
 birth of the child. Unless haemorrhage be excessive and the tumor becomes 
 rapidly very large, it may be let alone for the first ten days of the child's 
 life. Should infection occur and inflammation supervene, it must be freely 
 opened at once, emptied of its contents, and the sac thoroughly disinfected, 
 while continuous but gentle pressure is made by an antiseptic dressing. If no 
 complication occurs, at the end of the first eight or ten days of the child's life the 
 scalp over the tumor should be shaved, the surface thoroughly disinfected, 
 preferably with boric acid, and the tumor punctured with a bistoury or large 
 trocar. After evacuating the fluid contents pressure by an antiseptic dressing 
 is indicated. Some prefer free incision in place of simple puncture. We have 
 met with a case in which puncture and evacuation were followed by reaccumu- 
 lation of fluid, and in which it was finally necessary to open the tumor freely, 
 empty it, and pack it with iodoform gauze, the gauze having to be renewed 
 several times before adhesion between the bleeding surfaces took place. 
 Occasionally the loss of blood in these cases is considerable ; as a rule, how- 
 ever, haemorrhage is not a serious complication. 
 
 The susceptibility of infants to poisoning by antiseptics should be remem- 
 bered in treating cephalhaematoma. Mercurial and carbolic solutions may be 
 preferably replaced by solutions of thymol, 1 : 1000, or saturated solutions 
 of boric acid. Iodoform gauze may be employed without hesitation as tampon 
 material. 
 
 HEMATOMA OF THE StERNO-ClEIDO-MaSTOID MUSCLE. 
 
 A peculiar induration is frequently observed in the sterno-mastoid muscle 
 of new-born children, regarding which different beliefs have been held. Ana- 
 tomical study of the subject shows that the lesion is an intramuscular fibrosis, 
 caused by direct violence to the neck of the child, usually occurring at deliv- 
 ery. Most of these cases result from delivery in breech presentation ; the 
 
INJURIES AND DISEASES OF THE NEW-BORN. 73 
 
 forceps causes some ; and, rarely, the lesion follows spontaneous birth. Schmidt 
 reports the case of a child, seven days old, delivered by the breech, in which 
 the right sterno-mastoid was shortened, and the right half of the face smaller 
 and flatter than the left. The report of a post-mortem examination upon a 
 case pointing to a possible intra-uterine origin of this condition is made by 
 Heusinger. The head was directed toward the left, the right sterno-mastoid 
 muscle was 9 cm. long, the left only 6J, and was a soft, white, tendinous sub- 
 stance. In 23,293 children examined at birth at the Paris Maternity, Guy on 
 found 132 cases of monstrosity, but no case of torticollis, which militates 
 against the congenital occurrence of hematoma of the sterno-mastoid. In 64 
 post-mortem examinations Huge found 13 cases of this complication. In a 
 recent valuable paper Spencer describes 15 cases found in 300 autopsies ; his 
 researches show that both sexes and the muscles of both sides of the neck are 
 equally affected. Small, prematurely- born children are especially liable to this 
 injury. Breech or footling presentation was observed in 10 of the 15. The 
 forceps had been employed in 2 cases, while in 2 no instrumental aid was 
 employed : in 2 of the bodies examined both muscles were affected. Spencer 
 notes but two cases of contracted pelvis ; one of his cases was that of triplets, 
 complicated by placenta praevia centralis, with extraction through perforation 
 in the placenta. His microscopic sections show clearly rupture of muscular 
 fibre, with extensive effusion of blood. It has been shown by Witzel that, as 
 a consequence of this complication, contracting fibrous bands may form, giving 
 rise to permanent wry neck. Jacobi believes that the forceps is frequently the 
 effective agent in producing this injury to the foetus. 
 
 HAEMORRHAGE IN THE NEW-BORN. 
 
 A considerable number of cases of foetal death occurring within the first 
 forty-eight hours after labor are preceded by obscure symptoms which render 
 an exact diagnosis difficult or impossible. The intelligent study of such cases 
 by post-mortem examinations shows us that haemorrhage is usually the cause of 
 the fatal issue. As in the adult, haemorrhage may depend upon an alteration 
 in the condition of the blood itself, and also upon direct mechanical injuries 
 which result in its escape from the vessels. In the first category of cases it 
 has long been a familiar observation that syphilitic children, stillborn, show 
 extensive disintegration of blood, with extravasation of blood-serum from the 
 serous surfaces of the body. Children dying from acute infections on the part 
 of the mother, and stillborn or perishing soon after, often display such a tend- 
 ency to haemorrhage ; thus, small-pox, typhus, typhoid, scarlatina, and, as a 
 rule, the acute infections as a class, predispose to the occurrence of haemor- 
 rhage. There is also direct proof from bacteriological examination that the 
 foetus in utero may be infected by various micrococci, and that this infection 
 may result in haemorrhage and death at labor or very soon afterward. The 
 occurrence of multiple punctate haemorrhages accompanying umbilical sepsis is 
 a not infrequent illustration of this form of haemorrhage. In the recent litera- 
 ture of the subject Tavel and Quervian report a case of multiple haemorrhage 
 following umbilical infection by streptococci. Death occurred on the thirteenth 
 day, the infection having occurred very shortly after birth. A thorough exami- 
 nation of the specimens showed infection with streptococci and other bacteria 
 to be the cause of the haemorrhages. These haemorrhages were found in the 
 connective tissue beneath the epidermis, beneath the serous membranes and 
 mucous membranes, and also in the kidneys. A second illustrative case is also 
 reported, in which, in a prematurely-born child, death occurred with symptoms 
 
74 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of pneumonia. Examination revealed the fact that the pneumonia had been 
 caused by infection with staphylococci. The peculiar form of the haemorrhage 
 — namely, into the parenchyma of various organs — excluded hemorrhage from 
 mechanical injury. Further, the rapid and easy birth of a small foetus tended 
 to exclude the possibility of mechanical injury. 
 
 By far the most frequent cause, however, of haemorrhage in the new-born 
 is direct mechanical injury received during birth. Such injury is usually 
 suspected after difficult extraction by the forceps or by version. As pel- 
 vimetry is more extensively practised the induction of premature labor will 
 render these cases more and more infrequent ; but at present they occur with 
 sufficient frequency to form an important complication of labor. Under the 
 head of apoplexy neonatorum Ashby and Wright describe cases of haemor- 
 rhage from the pia mater following compression of the umbilical cord and 
 pressure upon the brain-substance during birth. Convulsions may be present 
 in such cases, and if paralysis occurs it is probably peripheral, resulting from 
 effusion of blood at the base of the brain, on the pons, or the origins of the 
 cranial nerves. McNutt has reported 10 cases of cerebral haemorrhage follow- 
 ing labor ; in 7 of these cases the head presented ; in 3, the breech. In all 
 the latter cases paralysis occurred, but only localized convulsions. McNutt 
 infers that haemorrhage, limited to the convexity of the cerebral hemispheres, 
 is more apt to follow delivery in breech presentation. 
 
 Various forms of cerebral haemorrhage are described by other observers, 
 and especially in cases following prolonged application of the forceps or forcible 
 extraction after version. In our own observation we recall the case of an 
 infant delivered with axis-traction forceps without especial difficulty ; progress- 
 ive feebleness of respiration, failure to nurse, and apparent exhaustion caused 
 death in thirty-six hours after birth. On post-mortem examination, over the 
 parietal regions of the skull the tissues of the scalp were intensely congested, 
 although no gross lesion, as rupture or fracture, could be discerned. Beneath 
 these portions of the skull and scalp the cortex of the cerebrum was filled with 
 punctate haemorrhages, and over the point of greatest convexity the brain- 
 substance was materially softened. Similar cases, which would not be found 
 infrequent if post-mortem examinations in such patients were extensively held, 
 are readily explained by the anatomy of the cranium and its contents in the 
 new-born. Virchow and others have shown that the blood-vessels of the 
 infant's brain are thin and small, and most readily injured by abnormal pres- 
 sure. An interesting example of this fragility is found in cerebral haemor- 
 rhage following death from asphyxia, where mechanical injury to the cranium 
 can be excluded. 
 
 In medico-legal practice Richardiere emphasizes the fact that such cerebral 
 haemorrhage may be differentiated from haemorrhage occurring later in life by 
 the absence of inflammation of the arachnoid and of the dura mater. Menin- 
 geal haemorrhage in the new-born is often accompanied by subpleural ecchy- 
 moses ; death usually results suddenly. A most valuable recent contribution to 
 the literature of this subject is that of Spencer. In a total of 180 bodies exam- 
 ined, 130 were in a condition which enabled a critical examination of the 
 tissues to be made : in 85 injuries to the brain were found, consisting of con- 
 gestion and haemorrhage ; these conditions varied in severity, in situation, and 
 in extent. (Edema was a frequent accompaniment. The children had been 
 delivered in various ways, and many of the cases occurred in children the 
 subjects of disease. The accompanying plate shows a typical condition of 
 meningeal haemorrhage (Plate I.). Its frequency will be appreciated when 
 it is known that 4^. per cent, of all haemorrhages occurring in the new- 
 
PLATE I. 
 
 Visceral Haemorrhage in the Newborn (Spencer, Transactions Obstetrical Society, Tendon, vol 33) 
 
INJURIES AND DISEASES OF THE NEW-BORN. 75 
 
 born are meningeal in character. Spencer also describes a case, similar 
 to the one which we have mentioned, of haemorrhage into the substance of 
 the brain. It is interesting to note that, so far as the causation of cerebral 
 hemorrhages is concerned, the forceps is the most frequent agent in producing 
 them, and next presentation by the breech or foot. As determining causes 
 softness of the skull and relaxation of the sutures are of considerable 
 importance. 
 
 In Spencer's cases, next in frequency and importance to haemorrhage into 
 the brain comes parenchymatous haemorrhage into the liver, kidneys, and supra- 
 renal capsules. Well-marked congestion was frequently observed; haemor- 
 rhage was present in 28 T ^- per cent.. This haemorrhage was often upon 
 the upper surface of the liver and followed birth in head presentations. Such 
 haemorrhages usually appeared as blebs filled with blood. Of equal frequency 
 was haemorrhage into the substance of the kidneys, usually beneath the cap- 
 sule. Such cases were most frequent in breech presentations (Plate I.). 
 The suprarenal capsules were also the seat of frequent haemorrhage. Injuries 
 to the lungs in the form of congestion and haemorrhage were next in fre- 
 quency. Most often this took the form of subpleural bleeding ; less frequently, 
 as haemorrhage into the lung-substance. 
 
 These pulmonary apoplexies are often followed by pneumonia, and are a 
 frequent cause of death. Such infants are usually cold and blue, with sub- 
 normal temperature and feeble cry, and do not nurse. The abdominal and 
 pelvic viscera, besides those mentioned, are also the frequent site of congestion 
 and haemorrhage. As regards the causes, Spencer recognizes a delicate condi- 
 tion of the blood-vessels as of great importance. Alteration of the blood, 
 already described, is also recognized, while asphyxia predisposes to haemorrhage. 
 Direct mechanical violence is a familiar exciting agent. 
 
 Experience abundantly proves that most cases of severe haemorrhage arise 
 where disproportion in size between the foetus and the pelvis exists; there 
 can be no rational prophylaxis of these injuries that does not rest upon an esti- 
 mate of the mother's size and the relative size of the foetus. We cannot too 
 strongly urge, as we have already done, that pelvimetry be uniformly practised 
 by obstetricians, and that, in addition, an effort be made in all cases to estimate 
 the relative size of the foetus and the birth-canal. To be of service to the patient 
 such efforts at diagnosis should be made between the seventh and eighth months 
 of pregnancy. 
 
 So far as the treatment of the infectious disorders which attack the blood, 
 resulting in haemorrhage, is concerned, the faithful practice of antiseptic pre- 
 cautions will diminish very largely these complications. The need for such 
 observances is proven by the familiar fact that at the present time the mortality 
 of infants in private houses is greater than in well-conducted maternities, the 
 reason being that the practitioner considers the private house and the private 
 patient objects for less anxiety than the hospital patient; neglecting antiseptic 
 precautions because the patient is a private one the result is often disastrous. 
 
 Asphyxia. 
 
 Interference with the oxygenation of the foetal blood results in asphyxia. 
 By far the most common and dangerous causes of this complication are 
 those which arise while the child is still in the uterus, and which have 
 nothing to do with the access of the external atmosphere to the child's lungs. 
 When this is kept in mind, it will be seen that asphyxia is a complication of 
 labor itself, not so much a condition arising at delivery and requiring subse- 
 
76 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 quent treatment. The most frequent cause of this condition is pressure upon 
 vessels of the placenta or umbilical cord, resulting in blood-stasis in the foetus; 
 or occasionally sudden collapse and death on the part of the mother. The 
 symptoms of asphyxia in the foetus are those of carbon-dioxide poisoning — a 
 rapid, feeble pulse, pallid appearance of the surface of the body, with the phe- 
 nomena caused by intense congestion of various organs, ending in heart-failure. 
 Asphyxia has been variously divided, some writers describing an apoplectic 
 form and others a pallid form. These are but variations of the same condition, 
 and are distinctions without essential differences. During the first stages of 
 asphyxia the phenomena of congestion predominate : the face of the child is 
 suffused, the mucous membranes bluish, the heart-beat at first slow and more 
 vigorous than normal, while the reflexes still remain. As the process goes on 
 and congestion has been followed by engorgement and oedema, the surface of 
 the body is pale, the pulse small, rapid, and feeble, while the mucous mem- 
 branes have the peculiar grayish-blue appearance characteristic of impending 
 death. In the first stages of asphyxia the pulse in the umbilical cord is pres- 
 ent, and may be vigorous. In the second stage the cord is pulseless, and shares 
 the pallid appearance of the foetus. 
 
 The complications of labor which most frequently cause asphyxia are par- 
 tial detachment of the placenta, compression of the umbilical cord, pressure 
 upon any large portion of the foetal body, especially upon the head and brain, 
 or the sudden death of the mother. So soon as the tissues experience what has 
 been styled " hunger for oxygen," there ensue reflex respiratory movements : 
 by experiment these may be demonstrated to happen within the uterus before 
 the rupture of the membranes ; they frequently occur during the second stage 
 of complicated labor. They result in the inspiration of amniotic liquid or the 
 secretions of the mother's birth-canal ; if these respiratory efforts are vigorous 
 and prolonged, inspiration pneumonia may result — a catarrhal pneumonia 
 caused by the inspiration of mucus or pus, developing, if the child survives, 
 immediately after birth, and frequently proving fatal. 
 
 The child before labor is in a condition of physiological apnoea. The blood 
 of the foetus contains an excess of haemoglobin at the moment of birth, stated 
 by Cattaneo to be relatively 120^- per cent. No differences can be distin- 
 guished between arterial and venous blood in the umbilical cord in the amount 
 of haemoglobin contained. So perfect is the provision of nature for supplying 
 the foetus with oxygen that anaemia on the part of the mother does not seem 
 to influence the amount of haemoglobin in the foetal blood nor in the blood of 
 the child immediately after birth. The rapidity and ease with which the foetal 
 blood absorbs oxygen is illustrated by the fact that in from thirty-six to forty- 
 eight hours after birth the blood of the new-born contains its greatest amount of 
 haemoglobin. Late ligation of the umbilical cord results in more haemoglobin in 
 the foetal blood. Curiously enough, a small placenta increases the amount of 
 haemoglobin in the foetal blood, while a large placenta diminishes it. At the 
 moment of birth the circulation of blood in the placenta and the child is 
 markedly interrupted, oxygenation is materially lessened, and the foetus 
 undergoes a period of more or less danger. It can be readily understood 
 how delayed labor, where the exhausted uterus in tetanic contraction presses 
 upon the child and the placenta, may occasion death from asphyxia, and 
 this without extensive gross lesions. 
 
 Asphyxia, again, may depend upon defective muscular and nervous develop- 
 ment in the foetus. As a result, the foetus fails to make respiratory movements 
 after delivery, and perishes from actual weakness. Diseases which affect the 
 respiratory apparatus, either by structural changes or mechanical pressure, may 
 
INJURIES AND DISEASES OE THE NEW-BORN. 11 
 
 cause asphyxia. Pulmonary syphilis, enlargement of the liver, dropsy, and 
 various tumors come under this head. These cases usually perish from atelec- 
 tasis. The blood-vessels in such cases rupture easily, and small multiple haemor- 
 rhages abound. 
 
 Prognosis in cases of asphyxia depends upon the condition of the ner- 
 vous centres. If the asphyxia is but partial, and the stage of congestion be 
 present, as evidenced by the dark reddish-purple complexion of the child and 
 the slow but full pulsations of the heart and umbilical cord, recovery in 
 the majority of cases will ensue. If, however, the child is pallid, the heart- 
 beat rapid and feeble, and the cord pulseless, the prognosis is grave. More 
 than 1 per cent, of children born living perish from asphyxia ; while cases have 
 been reported where children, born asphyxiated, subsequently developed serious 
 pathological conditions of the nervous system. Recalling what has been stated 
 regarding the richness of the foetal blood in haemoglobin, cases where children 
 born asphyxiated have survived for hours, although thought to be dead, are 
 readily explained. Beale described a case in which the mother died from post- 
 partum haemorrhage shortly after delivery ; the midwife in charge reported the 
 birth of dead twins, which she put in a basket in a shed ; on examination three 
 hours afterward, one child was found breathing feebly. Efforts to establish 
 respiration were fruitless. The temperature in the shed was very low, the 
 weather being cold. Children have respired feebly eighteen minutes after 
 birth and twenty-five minutes after birth in breech presentation. Beale reports 
 successful efforts, lasting several hours, to resuscitate a child thought to be dead. 
 A case is reported where a child was buried a foot under ground, and not 
 exhumed for five hours, when evidences of life resulted from efforts at resusci- 
 tation continued for two hours. It is curious to observe that the chances of 
 recovery in asphyxia are much better when the infant is exposed to cold than 
 when to heat, probably from the fact that a low temperature retards the metabol- 
 ism of the cell-elements of the body, and thus the nervous centres retain their 
 irritability longer. 
 
 Treatment of asphxyia is prophylactic and curative. In prophylaxis the 
 conditions which will result in prolonged labor should be anticipated and 
 removed. Complicating factors which will subject the child to great pressure 
 must also be obviated. The judicious use of the forceps is a direct prophylaxis 
 against asphyxia, as are version and extraction. On the other hand, both of 
 these procedures are direct causes of asphyxia in unsuitable cases. We must 
 again repeat that no intelligent prophylaxis of asphyxia can be undertaken 
 which does not include a preliminary examination of the mother's birth-canal 
 and an estimation of the relative size of the foetus and the mother. Prolapse 
 of the umbilical cord, resulting in pressure and asphyxia, is best treated by 
 anaesthetizing the mother and terminating labor, if possible, by manual inter- 
 ference ; thus, the cord may be taken in the hand and passed up into the 
 uterus, the head brought into a proper position, and delivery expedited by the 
 forceps ; or, if pulsation in the cord has ceased, version and extraction may be 
 performed. There is no repositor for the cord comparable to the hand of the 
 obstetrician, for the hand can recognize pulsation, can remedy coiling of the 
 cord about the foetus, and may so change the position of the cord as to lead to 
 the recovery of the foetus. 
 
 In cases of contracted pelvis, or in disproportion between the foetus and 
 the pelvis, operative procedures have for one of their purposes the saving of 
 the child from asphyxia, which otherwise must prove fatal. So soon as the 
 head is accessible during labor, the practitioner should ascertain, if possible, 
 whether the cord is coiled about the neck ; if so, it should be gently drawn 
 
78 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 down and loosened ; and if the head be born, the cord tightly coiled about the 
 neck, and a large body and shoulders hinder delivery, it is well to cut the cord 
 and deliver the child rapidly. The cord may be clamped with artery-forceps, 
 or, better, tied. The diagnosis of cord around the child may sometimes be 
 made before expulsion by hearing a murmur in the umbilical cord during 
 auscultation of the abdomen. 
 
 The treatment of the actual condition of asphyxia after delivery will 
 depend largely upon the degree of asphyxia present. There are certain precau- 
 tions which should be taken in every birth. The nurse should have ready 
 a saturated solution of boracic acid to which has been added a teaspoonful of 
 glycerin to the half pint. This should be at hand in a small, clean earthen 
 bowl. In the bowl should be a half-dozen pieces of old, soft handkerchief, 
 two inches square. When the head is born, the physician turns the mouth and 
 eyes of the child in such a position that they will not come in contact with the 
 discharges of the mother. The nurse or physician should then thoroughly 
 cleanse the mouth and fauces with the bits of linen soaked in the boracic solu- 
 tion. Mucus or secretions in the child's mouth will thus be removed, and 
 one danger of asphyxia obviated. In the stage of asphyxia where congestion 
 is the principal symptom, the stimulus of contact with the external air will 
 often secure respiratory movements : spanking the child is a familiar method 
 of procedure which undoubtedly has good results. In such cases the cord may 
 be promptly tied and cut; and if the congestion be pronounced, it is well to allow 
 a drachm or two of blood to flow from the foetal cord before ligation. The 
 child should then be promptly inverted to favor the expulsion of mucus from 
 the air-passages. If the heart-beat be good, a little cold water sprinkled upon 
 the chest will usually result in the establishment of respiration. Should the 
 heart-beat be good, but respiration not ensue, the child may be laid in a bath- 
 tub filled with water at a temperature of 100 ° F., and passive respiratory 
 movements may be instituted. Cold water also may be sprinkled upon the 
 chest. In these cases a prognosis may be based upon the action of the heart ; 
 if that be strong, the physician should not despair of securing respiratory move- 
 ments. 
 
 In the more severe forms of asphyxia the child can endure no loss of blood ; 
 it may be promptly inverted and held in that position for several moments, its 
 mouth being thoroughly emptied of mucus and secretions : passive respiration 
 is then to be instituted, and to secure the actual entrance of air into the lungs 
 the Schultze method is undoubtedly pre-eminent. It consists in taking the 
 child with both hands, the child's head raised between the upper portion of 
 the palms, the fingers grasping the scapulae of the child, the thumbs resting 
 upon the anterior surface of the thorax. The child is then raised above the 
 head of the physician until it turns a three-quarter somersault ; it is then 
 brought down with a swinging motion to within a short distance of the floor. 
 When the body of the child is raised over the head of the physician expira- 
 tion results : as the child swings forward and downward the action of gravity 
 and the pressure of the physician's hands result in a powerful inspiratory 
 action. The value of the Schultze method consists in its efficiency in intro- 
 ducing air into the lungs ; it is not, however, a stimulus to the reflex excita- 
 bility of the nervous system, and if this has been lost, an infant's lungs may be 
 filled with air and yet the child readily perish. The dangers of this method 
 have been pointed out by Meyer and Heydrich. Fracture of the clavicle with 
 perforation of the lung and emphysema are reported by these observers as occa- 
 sionally following this method of resuscitation. 
 
 A manifest objection to the Schultze method is the disturbance and shock 
 
imrumES and diseases of the new-born. 79 
 
 which must necessarily follow ; in deeply asphyxiated children, where the 
 heart-beat is scarcely perceptible, it is preferable to practise the inverted 
 posture, with the application of warm flannel to the surface of the body and 
 the continuation of gentle respiratory movements. Air may be introduced 
 into the lungs by mouth-to-mouth insufflation or by the passage of a tracheal 
 tube. Lusk advises the use of the catheter, not only to remove mucus, but to 
 favor direct insufflation ; or the chest-walls may be compressed to secure 
 expiration. "When circulation reappears, Silvester's method is then of service, 
 the tongue of the child being drawn forward. When heart-beats are perceptible, 
 the warm bath, with sprinklings of cold water upon the face, is useful. 
 Finally, he advises Schultze's method to favor complete re-establishment 
 of the circulation. Schultze claims for his method an immediate action in 
 relieving overloaded blood-vessels, the swinging of the child producing empty- 
 ing of the ventricles and favoring the return current from the pulmonary vein. 
 The value of direct insufflation by the catheter, preceded by the removal 
 of mucus, can scarcely be over-estimated. We recall a case in a foreign 
 hospital where the assistant in charge had abandoned an asphyxiated infant as 
 dead ; permission was given several American students to practise the passage 
 of the balloon catheter, an English catheter having a rubber bulb at the 
 distal end, whose compression and expansion favor suction and insufflation. 
 To our surprise, the child became resuscitated under the use of the 
 catheter, and ultimately recovered. Forest places the child first on its face, 
 its head down, and expels fluids from the mouth by pressure upon the back. 
 The child is then put in a bath or tub of hot water in a sitting posture, 
 supported by one of the operator's hands across its back, its head bent back- 
 ward. The physician grasps the child's hands with his other hand, carries 
 them upward until the child is suspended by the arms, leans forward himself 
 and blows air into the child's mouth ; the infant's arms are then lowered, its 
 body is doubled forward, and its thorax pressed between the hands of the 
 physician. Air is thus expelled. Especial advantage is claimed for this 
 method from the fact that the hot water maintains capillary circulation and 
 tends to assist in promoting the action of the heart. Reynolds places the 
 infant upon its back, head downward, resting upon the operator's forearm, 
 held nearly perpendicularly to the floor, retained in that position by his 
 fingers hooked over its shoulders. In this position the child's arms fall down- 
 ward by the sides of its head, and their weight, aided by that of the thorax 
 itself, draws the ribs into the position of complete expansion of the chest. 
 The thorax is compressed against the forearm by the other hand, and suddenly 
 released, when a most satisfactory respiration is the result. This method 
 combines a favorable posture for the escape of fluids from the trachea and for 
 the afflux of blood to the brain, with a ready method of artificial respiration. 
 Duke places the infant face downward, its thorax resting upon the open palm 
 of the left hand ; the ribs are gently compressed by the other hand : the 
 mouth is cleansed, and the finger passed down the pharynx to admit air. If 
 this is not successful, the child is plunged into a hot bath. Richardson urges 
 that the child's body remain quiet during efforts to establish respiration. The 
 feeble condition of the heart strongly contraindicates violent disturbance to 
 the child. The position of the body should be horizontal. Air introduced 
 should be warmed to 90° F. Manual respiration by Silvester's or Hall's 
 method is recommended, and Richardson describes an apparatus composed of a 
 pair of bulbs by which air may be pumped into the respiratory passages. Two 
 pieces of tubing are passed to the nostril, and a bulb upon one injects air, 
 while a bulb upon the other favors the discharge of mucus and vitiated air. 
 
80 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 He also describes a method of using a simple bellows in connection with a 
 nasal tube. The treatment of asphyxia by tracheotomy is seldom successful ; 
 there is rarely an impediment in the respiratory passages of the child which 
 cannot be overcome by the introduction of the catheter. 
 
 In reviewing the treatment of asphyxia we desire to call attention to the 
 pathology of the aifection and to the relative value of different methods of 
 treatment. The removal of mucus from the nostril, trachea, and bronchial 
 tubes can be most readily effected by suspending the child in an inverted 
 position ; this favors also afflux of blood to the medulla and respiratory centre. 
 Gentle, passive respiratory movements should be employed, but so conducted 
 as to give the child the least disturbance possible. The return of the circula- 
 tion and the reflexes should be eagerly awaited, and so soon as these phenomena 
 are present the prognosis becomes much more favorable. The warm bath 
 and the application of a mild counter-irritant — cold water, spirits, simply a 
 current of air from bellows directed against the epigastrium — usually cause 
 respiratory movements. In strong children, when the reflexes are present 
 and the heart-beat becomes perceptible, Schultze's method, practised gently 
 for a short time, is of value. Should the circulation fail, it is admissible to 
 inject hypodermatically -j-J-g- of a grain of strychnia and a few minims of 
 tincture of digitalis. If mucus is not expelled by the inverted position, the 
 use of the catheter with suction and insufflation is advisable. When respiratory 
 efforts have become established, but repeatedly fail, a mild faradic current of 
 electricity and the inhalation of oxygen under pressure are of decided value. 
 One pole of the faradic battery should be placed at the back of the neck, and 
 the other over the thorax and alternately over the epigastrium. Bonnaire 
 obtained good results in foetal asphyxia by inhalation of oxygen — a procedure 
 which we have repeated with like good results in fcetal asphyxia and that of 
 older children complicating pneumonia. As Lusk remarks, in cases of deep 
 asphyxia patience, watchfulness, and a hopeful spirit are prerequisites of 
 success. 
 
 Following asphyxia, the infant is exposed to danger of death from inani- 
 tion, and, as has been stated, from catarrhal pneumonia. The use of the 
 incubator is of especial value in maintaining the circulation in these cases, 
 and favoring the gradual expansion of the lungs if atelectasis be present. 
 Winckel has obtained good results from the permanent hot bath at a tempera- 
 ture of 98.6° to 100° F. every twelve to twenty-four hours. Such children are 
 fed every two hours. The 
 
 bowels are promptly emp- Fig. 3. 
 
 tied by rectal injections. 
 Winckel has devised a bath- 
 tub for such cases, an illus- 
 tration of which is append- 
 ed. We add also an illus- 
 tration of a modification of 
 Auvard's incubator, which 
 we have used successfully 
 in the Philadelphia Hos- 
 pital and in the Maternity 
 Department of the Jeffer- 
 son Hospital. 
 
 The interior of the box is divided into two parts by an incomplete horizon- 
 tal partition, placed about six inches above the bottom of the box. In the 
 lower part, which is intended for hot cans, two openings are necessary — one at 
 
 The Permanent Bath. (Winckel). 
 
INJURIES AND DISEASES OF THE NEW-BORN. 
 
 81 
 
 the side, occupying the whole length of the side, closed by a sliding door 
 opened at pleasure from either end, as a means of placing the hot cans. The 
 
 Fig. 4. 
 
 Incubator. 
 b, b, lid with glass plate ; v, glass plate ; H, ventilating tube ; O, slide closing hot-air chamber ; M, hot-water cans. 
 
 other opening is at one end of the box, closed by a door not fitting tightly, to 
 admit a small amount of air. The upper part, arranged to receive the infant, 
 
 Fig. 5. 
 
 Interior of Incubator. 
 
 is covered on top by a plate of glass, fitting completely, with two buttons or 
 knobs to admit of its being easily raised. On the top is also arranged a small 
 metal tube containing a small rotary fan 
 very easily moved by a weak current of 
 air. In the opening where the two com- 
 partments join a sponge is placed, wet 
 with water to humidify the air, and a 
 thermometer by which to regulate the 
 temperature. 
 
 Cases are not infrequently met with 
 where death occurs soon after labor with 
 
82 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 symptoms of partial asphyxia : a clear diagnosis is often impossible, until post- 
 mortem examination reveals partial heart-clot, syphilis, atelectasis, or lobular 
 inspiration pneumonia as the cause for this mortality. 
 
 HEMORRHAGES FROM MUCOUS SURFACES. 
 
 The new-born infant often presents haemorrhages from mucous surfaces of 
 the body. Among the most frequent of these is a discharge of blood from the 
 vagina, occurring at birth and persisting afterward. An examination of the 
 mucous membrane in these cases frequently detects a condition of capillary 
 granulation which bleeds easily upon the slightest movement of the child. In 
 a case recently under our observation at the Maternity Department of the 
 Jefferson College Hospital an ill-developed female child presented this phe- 
 nomenon at birth. A blood-count made of this child, and compared with that 
 of a healthy infant, shows the following : 
 
 Healthy Child. — Red corpuscles per cubic millimetre, 5,450,000, by 
 counting forty squares (Thoma-Zeiss haemocytometer). White corpuscles per 
 cubic millimetre, 11,000. Proportion of white to red, 1 : 495. Haemoglobin, 
 65 per cent, of normal. Blood-plates by objective, blood prepared by means 
 of Hayem's solution: the number was much less than the usual amount, which 
 should be about 250,000. The red corpuscles were irregularly formed, some 
 crenated, some small and granular, others apparently rolled or turned upon 
 themselves, resembling very much a bread roll. While this irregularity 
 existed, their appearance was that of normal corpuscles, and the percentage 
 of haemoglobin (65) proved them to be almost normal. In children the per- 
 centage of haemoglobin is not so great as in adults ; in the young or in any 
 case where the growth is rapid the red corpuscles are always irregular in 
 appearance, which is not at all indicative of disease. The slight increase 
 in red corpuscles is normal to the new-born. (Plate II. Fig. 1.) 
 
 Ancemic Child. — Red corpuscles per cubic millimetre, 2,000,000. White 
 corpuscles per cubic millimetre, 12,000. Proportion of white to red, 1 : 166. 
 Haemoglobin, 35 per cent, of normal. By careful examination no blood- 
 plates could be found. In this case the red corpuscles were irregular, crenated, 
 granular, and many disintegrated. By actual count this specimen would give 
 over five million red corpuscles per cubic millimetre, but counting normal 
 corpuscles would give only two million. The object of the count being to 
 know the number of oxygen-carriers per cubic millimetre, it would give a 
 wrong idea to enumerate those disintegrated and diseased corpuscles. There 
 was a slight increase in the number of white cells, but their appearance was 
 normal. 1 (Plate II. Fig. 2.) 
 
 The condition underlying such haemorrhage is that of anaemia or malnutri- 
 tion of the blood, with resulting ecchymoses. In parts accessible to treatment, 
 as the mouth, vagina, rectum, or bladder, injections of hot dilute creolin solu- 
 tion or boracic solution are indicated. Treatment of the anaemia, however, 
 by administration of food, by arsenic, inunctions with oil, and the administra- 
 tion of olive or cod-liver oil will result in gradual recovery. 
 
 Obstetric Paralysis and Injuries to the Nervous System. 
 Direct injury to the nervous system received during birth has long been 
 recognized as among the dangers to which the infant is exposed. Paralysis of 
 
 1 For the examination and description of the blood in these cases I am indebted to Dr. D. 
 B Kyle, Instructor in the Examination of the Blood in the Jefferson Medical College. Dr. 
 AV. H. Wells, one of the physicians to the Jefferson Maternity, has prepared the drawings 
 illustrating the appearance of the corpuscles. 
 
Blood of Healthy Child one month old. Haemoglobin normal. Drawn from Thoma-Zeiss Hsemocy- 
 tometer. Objective | Reicherts. Blood-count by Dr. Kyle ; drawing by Dr. Wells. 
 
 Fro. 2. 
 
 Blood of Aneemic Child suffering from Haemorrhage from Mucous Membranes. Total corpuscles. 
 5,000,000, of which 2,000,000 were normal. Blood-count and drawing as in preceding figure. 
 
INJURIES AND DISEASES OF THE NEW-BORN. 83 
 
 the facial nerve caused by pressure with the forceps upon the nerve at its fora- 
 men of exit often follows instrumental delivery. The brachial plexus is also 
 frequently injured by the same agent. Hemiplegia, idiocy, and impaired cere- 
 bral development have been ascribed as consequences of injury received at 
 birth. The view previously held, that the forceps is a valuable agent for 
 compressing the foetal head and exercising leverage and forcible rotation, has 
 given place to the belief that the forceps is essentially a tractor, and that the 
 mechanism of rotation depends upon the relation in size and symmetry between 
 the head and the pelvis, and, as well, the resistance of the pelvic floor. Murray 
 has shown by experiment and clinical observation that the foetal skull is com- 
 pressible in an antero-posterior direction by the sliding of the occipital and 
 frontal bones under the ends of the parietal bones. This compression is not 
 accompanied by any appreciable increase of the transverse diameter. The 
 antero-posterior shortening is compensated for by a vertical elongation of the 
 skull, providing for the accommodation of the cranial contents. These con- 
 clusions are, however, based upon the employment of axis-traction, without 
 which such compensatory elongation cannot be confidently assumed. Murray 
 was also careful to avoid forcible traction. Under such circumstances it may 
 be held that moderate pressure with forceps, resulting in compensatory elonga- 
 tion of the vertical diameter of the foetal skull, need not be expected to cause 
 paralysis, haemorrhage, or fracture. This pressure, however, must be gradually 
 applied, and traction made in the axis of the pelvis ; otherwise a portion of 
 the head will be forced against the promontory of the sacrum, and injury must 
 result. When gentle axis-traction fails to cause the head 'to descend, a diag- 
 nosis of disproportion between the head and the pelvis should be made, and 
 efforts at forcible delivery should cease. 
 
 The results of injudicious delivery with forceps are well illustrated by 
 Lane. A boy sixteen years old, delivered at birth with forceps, exhibited a 
 groove three and a quarter inches long from the right coronal suture to the 
 lambdoid ; the floor of this groove seemed one-fourth of an inch below the scalp ; 
 the left arm was weaker than the right, and its movements defective. The 
 left leg was weak. Reflexes were exaggerated and clonus was present. The 
 depressed portion of bone was raised ; the bottom of the depression encroached 
 upon the area of the skull. Prompt amelioration of the epilepsy followed. 
 Duchenne, Gueniot, De Paul, Rogers, and others have described injuries to 
 the brachial plexus caused by forceps and by manual extraction of the child. 
 Erb has clearly described injuries to the brachial plexus accompanying delivery 
 in breech presentation. Hoedamaker describes injury to the fifth and sixth 
 cervical nerves resulting from delivery in breech presentation when the arms 
 become extended above the head. Feriberg describes a case of paralysis 
 caused by pressure upon the brachial plexus during delivery after version ; 
 paralysis was but temporary, the patient subsequently making a good recovery. 
 
 The medico-legal aspect of injuries to the new-born child requires the dif- 
 ferentiation of lesions received during birth by forceps or the pressure of the 
 mother's pelvis, and injuries occurring by precipitate labor without assistance 
 or by the wilful act of the mother or an accomplice. Dittrich reports cases of 
 depression in foetal bone, bounded by a well-defined ridge, following applica- 
 tion of the forceps in cases of contracted pelvis. Kustner describes funnel- 
 shaped depressions in the foetal skull following forcible delivery by forceps. 
 Von Hofmann has found a spoon-shaped depression the most frequent form of 
 lesion in a considerable number of cases. Fracture of the orbital region of the 
 skull has been observed by Lihotzky to follow forcible forceps delivery. Rup- 
 ture of a meningeal vein and death from haemorrhage have been observed and 
 
84 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 reported by Koffer in the clinic of Gustav Braun. Kundrat reports an inter- 
 esting case of depression upon the parietal bone of a new-born infant, with 
 cerebral haemorrhage, in which the evidence seemed to show that the lesion 
 was caused by direct violence on the part of the mother after the birth of the 
 child. Von Hofmann has further drawn attention to injuries to the foetal 
 cadaver which might occasion suspicion of intentional violence during birth. 
 Naturally, defects in the ossification of the skull may result in lesions accom- 
 panying normal labor and simulating injuries at birth. 
 
 Fritsch describes the characteristics of injuries caused by precipitate labor, 
 the child falling upon the floor or ground, to be as follows : The fracture begins 
 in a suture, and extends outward to the middle of the bone ; usually there is 
 but one fissure, which ends where the bone is thickest. The parietal bone is 
 most often affected, the fissure ending in the parietal eminence. As a general 
 distinction, it is to be observed that direct violence is accompanied by haemor- 
 rhage ; that injuries examined immediately afterbirth, where fracture occurs, 
 show frequently a well-defined border to the lesion, which tends to grow less 
 sharp in contour if the child survives. Kundrat also lays stress upon the rela- 
 tive breadth of the sutures as a factor in influencing haemorrhage during birth. 
 
 A most interesting question arises as to the bearing of these injuries upon 
 the future health and development of the child. Osier found, in the records of 
 the Philadelphia Infirmary for Nervous Diseases, 9 cases of paralysis following 
 forceps delivery ; in 6 of these it was reported that the forceps injured the 
 child : some of them had scars following labor. In all cases the paralysis grad- 
 ually appeared within a short time after labor. M. Allen Starr describes 
 cases of brain-atrophy manifesting itself in hemiplegia, mental defects, and 
 sensory defects, accompanied frequently by epileptiform seizures, and result- 
 ing from congenital conditions or lesions occurring at birth. Sachs and Peter- 
 son in 49 cases of congenital cerebral palsy found 16 in which some difficulty 
 in labor occurred. These statistics are now more comprehensive than those 
 of Little and Gaudard, Wallenberg and Osier. Sachs and Peterson, however, 
 include all forms of cerebral paralysis and of tedious labor as well as instrumental 
 delivery. Sachs has expressed the opinion that prolonged labor does more 
 injury to the child's brain than the proper application of forceps. 
 
 We have considered the prophylactic treatment of these conditions under 
 that of the treatment of visceral haemorrhage. The question arises, however, 
 What shall be done in a case in which a child is born and survives with such 
 an injury ? Although we find no record that such a procedure has been at- 
 tempted, yet the suggestion of Nancrede and other surgeons that depressed bone 
 be elevated by surgical interference is certainly rational. We believe that where 
 pressure-symptoms are present, or where the lesion is extensive and follows 
 severe pressure, such should be the line of treatment. The success attained in 
 operating immediately after birth upon cases of umbilical hernia gives encour- 
 agement to the belief that surgical' interference in these cases is justifiable. It 
 is interesting to note a superstition common among the laity in some quarters 
 to the effect that the doctor by manual pressure and counter-pressure is ex- 
 pected to shape the head of the child during the first few days after its birth. 
 
 Fractures and Dislocations of the Trunk and Extremities. 
 
 The skeleton of the foetus may be fractured while in the uterus. Such 
 fractures, however, must be carefully distinguished from congenital malforma- 
 tion, which closely simulate fracture. Amniotic adhesions during the first and 
 second months of intra-uterine life are the most frequent causes of these mal- , 
 
INJURIES AND DISEASES OF THE NEW-BORN. 85 
 
 formations. An apparent scar is often present in these cases, and must be 
 referred to precipitate flexion of undifferentiated layers in the embryo. Spurious 
 callus may be present, caused by defective development of the bone, although 
 the amount of callus is less than after actual fracture. Sperling would dis- 
 tinguish between malformation and fracture by the fact that in malformation 
 the fingers and toes of the limb affected show defective development, while in 
 fracture such defective development of fingers and toes is absent. Hodgen de- 
 scribes a foetal skeleton containing sixty-five fractures which he thinks were 
 caused by muscular action during uterine life. He describes also, in a healthy 
 child, a fracture of the clavicle, which was not discovered for several days after 
 birth ; the child was large and was delivered by forceps. 
 
 The most frequent fractures in the long bones are those of the clavicle, 
 humerus, and femur. Fracture of the clavicle near its acromial end is occa- 
 sionally complicated by severe injury to the brachial plexus, as illustrated in 
 a case reported by Knight ; permanent injury of the shoulder with paresis fol- 
 lowed. Fracture of the clavicle is most frequently caused by forcible extrac- 
 tion of the shoulders. 
 
 Fracture of the humerus most frequently occurs in the delivery of the after- 
 coming head when the arms become extended above the head. Fracture of 
 the femur usually results from difficult version and extraction. Fractures of 
 the bones of the leg, of the ribs and sternum are rarely met with, and only in 
 cases of forcible extraction through highly-contracted pelves. 
 
 Dislocations of the foetal skeleton are frequently confused with fracture, and 
 are caused by the same manipulations which give rise to solutions of conti- 
 nuity. Dislocation and separation of the epiphyses of the humerus at the elbow- 
 joint have been not infrequently observed after manipulation. 
 
 The treatment of fractures and dislocations of the trunk and extremities is 
 based upon the principles of surgery commonly followed. Difficulty has been 
 experienced in maintaining the fragments in apposition by reason of restless- 
 ness in the child, and the necessity to move it frequently when it nurses and 
 when it is cleansed. Fractured clavicle will heal without deformity with a very 
 simple retention dressing if the infant be kept assiduously upon its back. 
 Fracture of the humerus and of the femur may be treated to advantage by some 
 form of splint material which can be dipped in hot water, moulded to the child's 
 limb, and retained in position by a simple roller bandage. Firm and unyield- 
 ing dressings must be avoided in these cases, as the danger of injury to the 
 tissues by pressure is very great. Fractured ribs and sternum may be success- 
 fully treated by a broad flannel bandage pinned smoothly about the chest. 
 Dislocations require the same principles of treatment which should be followed 
 in managing fractures. 
 
 The prognosis in fractures of the foetus is usually good. As most of them 
 are of the " green-stick " variety, a favorable result without deformity is the 
 rule rather than the exception. When congenital malformation is present, the 
 practitioner should be guarded in his prognosis. He may remedy webbed 
 fingers and toes by dissecting them apart, but he will scarcely hope to see a 
 congenitally malformed limb become perfectly developed. 
 
 Umbilical Hemorrhage. 
 
 If the umbilical cord be tied firmly with an aseptic ligature after its pulsa- 
 tions have ceased, if the stump be powdered with boracic acid or salicylic acid 
 1 part to powdered starch 3 or 5, and if reasonable care be exercised to protect 
 it from violence, haemorrhage from the umbilicus or umbilical inflammation 
 
86 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 rarely occurs. The cord may be best protected by enclosing it in a small mass 
 of antiseptic cotton, directing the extremity of the stump upward and to the 
 child's right, and pinning a flannel binder comfortably tight about the abdo- 
 men. In cases, however, where syphilis, haemophilia, septic infection, and 
 acute fatty degeneration, with hemoglobinuria, are present, haemorrhage 
 may occur when the cord separates, or even before that time. This complica- 
 tion is not very frequent, Winckel having observed it but once in 5000 infants. 
 Bouchut quotes Grandidier's analysis of 202 cases, from which he concludes 
 that the haemorrhage begins most often at night, and often accompanies colic, 
 vomiting, somnolence, and jaundice, with ecchymoses of the skin. Bleeding 
 occurs rather more frequently before the cord is entirely separated, and usually 
 between the fifth and ninth days. The haemorrhage takes the form of arterial 
 oozing, the blood often failing to coagulate. The haemorrhage may persist 
 from one hour to several weeks. The mortality from umbilical haemorrhage is 
 estimated at 80 per cent. 
 
 The treatment is frequently futile. A needle, armed with a silk ligature, 
 may be passed beneath the vessels and securely tied ; two surgical pins may 
 be passed beneath the bleeding tissue at right angles to each other, and the 
 ligature may be looped around the pins. Pressure is indicated in treating 
 umbilical haemorrhage ; it is best made with antiseptic cotton on which iodo- 
 form has been freely sprinkled. 
 
 Umbilical Polyp. 
 
 The umbilicus may fail to heal perfectly, and abundant granulations, bleed- 
 ing upon touch, and polypoid growths may develop ; they are best treated by 
 the application of nitrate of silver or other suitable escharotic. 
 
 Umbilical Hernia. 
 
 A protrusion of the abdominal contents may accompany defective closure of 
 the umbilicus. While it is indicated to palliate this condition by suitable dress- 
 ings, yet it has been found possible to secure a radical cure by operation very 
 soon after birth. Runge describes a case operated upon successfully sixteen 
 hours after birth. In the majority of cases a cure may be effected, in a period 
 varying from one to six months, by the application of an umbilical button. 
 This consists of a hard-rubber disk convex on the applied surface, which is 
 held in position by a broad band of surgeon's adhesive plaster. 
 
 Gastro-intestinal Hemorrhage. 
 
 This complication depends upon a purpuric condition, and manifests itself 
 most frequently from the fifteenth to twentieth day after birth. Kiwisch 
 reports cases of haemorrhage from the intestinal tract following the normal 
 birth of apparently well-nourished children. The first symptoms were dis- 
 charge of blood and restlessness, occurring from twelve to thirty hours after 
 labor. The abdomen became dull and tumid, the patients were pallid, and in 
 some instances vomited blood ; death ensued within forty-eight hours. 
 
 According to Grynfeltt, gastro-intestinal haemorrhages usually take place 
 during the first three days after birth (Rilliet, Silbermann, Dusser), though in 
 a case of this author's it occurred on the fourth and fifth days, and in two 
 instances, seen by Rilliet, the children were fifteen and twenty weeks old. 
 Sex seems to play no special predisposing role, but the influence of morbid 
 
INJURIES AND DISEASES OF THE NEW-BORN. 87 
 
 antecedents in the parents appears to be a factor of some importance. Pinard, 
 Champetier. Auvard, and others have noted syphilis in the progenitors, but 
 this is regarded by Grynfeltt as only a cause acting indirectly in deteriorating 
 the health of the parents. Haemophilia has certainly been proven in some 
 instances. 
 
 The pathogeny is quite as obscure as the etiology. The lesions observed 
 at autopsies are the most variable. Ulcerations of the stomach and intestines 
 have been found ; again, only a simple congestion ; while other cases have shown 
 a complete absence of visible lesion. Grynfeltt advances a theory suggested by 
 observations of Billard, and confirmed by personal studies of the histology of 
 the digestive mucous membranes of new-born infants. These show that the 
 vascular supply of the mucous membrane of the stomach and intestines is 
 exceedingly rich at this period of life. Adding to this state of physiological 
 congestion a congestion or impeded circulation in the liver, he finds it easy 
 to ascribe the cause of such haemorrhages to exaggerated tension in the portal 
 area. This view, he believes, is supported by the fact that these haemor- 
 rhages, at first sudden and profuse, quickly cease, thus resembling a true 
 depleting loss of blood. 
 
 The first symptom is usually the haemorrhage itself. Blood flows from the 
 mouth following efforts at vomiting, or from the rectum, more or less mixed 
 with faeces or in clots ; quite often both phenomena are coincident, haemate- 
 mesis being usually the earlier. When one alone occurs, haematemesis is by far 
 the more frequent. In spite of the gloomy prognosis evidenced by the statistics 
 of Dusser (43 deaths in 78 collected cases), a more hopeful view must be 
 taken. 
 
 In treatment, tannin in syrup of rhatany offers an efficient astringent 
 potion. One and a half to two and a half grains of ergotin in mucilage are 
 employed with satisfaction by Widerhofer of Vienna. 
 
 Icterus Neonatorum. 
 
 The physiological icterus of the new-born infant appears on the third or 
 fourth day of life, is characterized by a yellowish pigmentation of the face 
 and breast, persists for about a week, and does not seem to disturb the patient's 
 general condition at all. The urine is dark in color, containing bile-stuff, 
 while the stools lack the color usually given by their mixture with bile. The 
 cause of such icterus is thought by Birch-Hirschfeld to be swelling of Glisson's 
 capsule, commencing at the umbilical vein, and by oedema preventing the free 
 discharge of bile through the hepatic vessels; hence the jaundice is hepato- 
 genic. Hofmeier thinks icterus is caused by the enormous number of red 
 blood-corpuscles which are formed in the liver and hinder the production and 
 discharge of bile. The entrance of this coloring matter into the blood is 
 furthered by catarrh of the duodenum and congenital stricture of the ductus 
 choledochus. Halberstam found undissolved bile-stuff in the urine of children 
 with icterus, and the epithelium of the kidneys infiltrated with the same 
 coloring matter. 
 
 The harmless character of this jaundice and its spontaneous disappearance 
 should not make it a subject of anxiety to the physician or parents ; it some- 
 times is due to slight changes in diet or any temporary disturbance of the 
 child's general surroundings. Beyond the regulation of the bowels by the 
 most simple laxatives, no treatment should be employed for this condition. 
 Infective jaundice will be considered under the head of infections which attack 
 the foetus. 
 
$8 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 The Infections attacking the New-born. 
 
 The recognition of bacteria, ptomaines, and toxines as causes of disease has 
 served to explain many disorders of the foetus and infant at birth not previ- 
 ously understood. Most frequent of these infections are those by the micro- 
 cocci of gonorrhoea and the streptococci of suppuration. Gonorrhoea in the 
 mother affords the best of grounds for fearing gonorrheal infection in the new-born 
 child. The most usual site of this infection is the conjunctiva, and ophthal- 
 mia neonatorum is a familiar sequence of maternal gonorrhoea. The treat- 
 ment of this disorder will be considered in another section of this book. We 
 are interested, however, in the practical prophylaxis of such infection : if the 
 practitioner could be absolutely positive that the mother had never been 
 infected by the gonococcus, prophylaxis would be entirely unnecessary. In 
 hospital patients, however, there is always room for suspicion ; and in private 
 cases, although there may seem no adequate reason to fear such a complication, 
 yet its appearance will often surprise and disappoint the attending physician. 
 No information will be gained in this matter from interrogating the patient : 
 if she has ever been infected, her husband has certainly not told her the cause 
 of the disorder, and her physician may have kept her in like ignorance. 
 Furthermore, in women who have never been infected by the gonococcus there 
 occurs at the latter portion of pregnancy a vaginal discharge which is capable 
 of setting up a mild conjunctivitis in the infant. Hence a practical rule may 
 be followed to advantage, that where a vaginal discharge persists during the 
 latter portion of pregnancy the use of antiseptic douches is certainly indicated. 
 These douches may be, preferably, creolin or bichloride of mercury : the first 
 has the advantage of impairing the natural condition of the mucous membrane 
 of the vagina less than does the mercurial ; it is also a safer substance to put 
 in the hands of a patient. On the contrary, its odor is disagreeable to some, 
 and when used in a strong mixture it causes considerable irritation and burning. 
 In a strength of one teaspoonful to the quart the resulting mixture is seldom so 
 irritating as to cause discomfort. The quantity used should be not less than 
 a quart, and the douche should be preferably taken while the patient is in the 
 recumbent posture. The douche-bag should hang not higher than three feet 
 above the patient's body, and the force of gravity alone should be employed in 
 giving the douche. If bichloride of mercury be chosen, 1 : 5000 is sufficiently 
 strong for such use. 
 
 In patients admitted to hospitals, suffering from the effects of previous 
 gonorrhoea or having acute gonorrhoea, the treatment must be more radical ; 
 here a preliminary thorough cleansing of the vagina should be made with 
 green soap and creolin, the mixture containing 2 per cent, of the creolin: 
 following this, creolin douches, four times in twenty-four hours for the ten 
 days preceding labor, will be found of advantage. Should the mucous 
 membrane not tolerate such frequent douches, the vagina may be tamponed 
 with iodoform gauze containing 50 per cent, of iodoform, and the number of 
 douches be reduced one-half. In all hospital cases a preliminary douche of 
 green soap and creolin may be used to advantage ; in private practice a pre- 
 liminary douche of bichloride, 1 : 5000, may also be employed to the advantage 
 of mother and child. 
 
 Aside from ophthalmia, gonorrhoea may infect the infant at birth upon 
 other mucous membranes. Rosinski describes the results of interesting inves- 
 tigations made by him upon gonorrhoea occurring in the mouths of new-born 
 infants. The lesions caused by this germ in the mouth develop only where 
 the pavement epithelium has been removed. These cells are especially fragile 
 
PLATE III. 
 
 Fig. 1. 
 
 Gonorrhoea of the Mouth in the Newborn (RosinsKi). 
 
INJURIES AXB DISEASES of THE NEW-BOBN. 89 
 
 in the young child, and hence the readiness with which infection occurs. It is 
 interesting to note that in gonorrhoea! ophthalmia it is very rare to find that 
 the lachrymal sacs become involved ; it is also true that the cylindrical epi- 
 thelium of the naso-pharynx seems also to resist successfully invasion by the 
 gonococcus. Clinical observation shows that these cases develop usually 
 between the fifth and tenth day of life, resulting often from infection from 
 the genital canal occurring at birth, and oftentimes through direct infection 
 at the hands of attendants. This is especially true where the epithelium 
 of the mouth is destroyed through eiforts at cleansing. These cases are 
 remarkable for the fact that they affect the general health so little ; the 
 children nursing well and seeming free from pain. The lesions are yellowish 
 plaques, surrounded by a border of pale-reddish tissue, in which the process 
 of healing usually begins upon the third day by a reaction zone of deeper 
 color. The epithelium is renewed from the borders of the plaque, pus-cells 
 being thrown off as the healing progresses. Scar-tissue is never developed 
 in these cases. The accompanying plate gives an excellent idea of the 
 appearance of the lesions. (Plate III.) 
 
 The treatment of gonorrhoea affecting the mouth of the new-born con- 
 sists in careful avoidance of injury to the epithelium ; the finger should not 
 be inserted into the mouth of an infant suffering from this disorder : the 
 affected surfaces should preferably be sprayed with a solution of hydrogen 
 peroxide or a saturated solution of boracic acid. Such treatment is usually 
 amply sufficient to secure the recovery of the patient. The infant's general 
 condition often requires attention in these cases, and its food and hygiene are 
 matters of great importance. 
 
 General Septic Infection. 
 
 Streptococci, bacteria, and ptomaines of septic infection usually find 
 entrance to the foetal body through the granulating surfaces upon the umbil- 
 icus ; the result is arteritis and phlebitis of the umbilical vessels, resulting in 
 the formation of thrombi and the infiltration of the surrounding tissues with 
 bacteria and ptomaines. Both umbilical arteries are usually involved, the 
 infection extending from the umbilicus to the bladder. The umbilical ring 
 may ulcerate, or may have healed entirely while the infection has proceeded 
 within the abdomen. According to Weber and Runge, the tissue about the 
 arteries is usually first involved ; the iliac vessels and the retroperitoneal con- 
 nective tissue usually escape ; in two-fifths of cases Runge found pneumonia 
 or pleurisy with small metastatic abscesses. Peritonitis and pyaemic metastases 
 in the abdominal viscera and the joints have also been observed. In umbilical 
 phlebitis the capsule of the liver and the liver itself become involved. Peri- 
 carditis, pleuritis, and other pysemic complications are often present. The 
 symptoms of such infection are often obscure. The umbilicus may become 
 inflamed shortly after birth ; the child has fever, is restless, holds its legs and 
 thighs flexed, and often becomes jaundiced. Death may occur in convulsions, 
 but occasionally recovery ensues. The treatment of umbilical septic infection 
 is largely prophylactic : thorough antisepsis as regards the physician, nurse, 
 and external genital organs of the patient, a suitable and cleanly dressing for 
 the umbilicus, such as previously given, and scrupulous cleanliness while the 
 cord is drying and becoming separated, render umbilical septic infection a 
 rarity. If the child be too feeble to 'have the full bath for the first month of 
 life, it is comparatively easy to allow the cord to remain undisturbed. Where, 
 however, the child is bathed daily in the bath-tub, such of the cotton as may 
 
90 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 become wet should be carefully removed, the cord repowdered, and fresh cot- 
 ton applied. 
 
 The constitutional treatment of an infant suffering from septic infection 
 through the umbilicus consists in the reduction of excessive fever by judicious 
 spono-ino 1 with warm or cool water, and the free administration of dilute alcohol 
 and nourishing food. While quinine, if it can be taken, is a useful auxiliary, 
 yet alcohol is the drug of most importance for such cases. Infants suffering 
 from severe infections often bear strychnia as a stimulant better than might be 
 expected from theoretical considerations only. 
 
 Erysipelas. 
 
 The micrococcus of Fehleisen may obtain an entrance at the umbilicus, 
 and erysipelatous inflammation of the subcutaneous and cutaneous tissues may 
 result. This process may go on even to the extent of gangrene and sloughing 
 of the affected parts. Cases of mixed infection resembling erysipelas may 
 develop, complicated by diphtheria, as in illustrative cases reported by J. Lewis 
 Smith from the records of the New York Infant Asylum. The infection may 
 localize itself in multiple abscesses beneath the skin, or, extending to the peri- 
 toneum, may cause death from acute peritonitis. 
 
 The treatment of erysipelatous infection of the umbilicus and surrounding 
 parts consists in thorough applications locally of peroxide of hydrogen, boracic 
 acid, or thymol solution, 1 : 1000. Following this, equal parts of iodoform and 
 boracic acid may be employed freely. When pockets of pus form, they should 
 be promptly opened with a knife or scissors and thoroughly douched with an 
 antiseptic. The child's general strength must be assiduously supported by 
 alcohol, food, and strychnia or quinine. As a stimulant in severe prostra- 
 tion, hypodermatic injections of camphor in oil, or administration, by the 
 mouth, of freshly-made English breakfast tea, with rum, will be found of ser- 
 vice in some cases. 
 
 Acute Peritonitis in the New-born. 
 
 Acute peritonitis occasionally arises very soon after birth as a complication 
 of erysipelas or from some pathological process developing in the intestine. 
 The communication in lymphatic channels between the intestine and the peri- 
 toneum seems unusually free in the infant, and as a result peritonitis rapidly 
 supervenes. Cassell describes three interesting cases of this sort. Lorain, 
 Quinquaud, and Silbermann have also reported illustrative cases of this dis- 
 order. 
 
 Tubercular and Typhoid Infection. 
 
 There exists certain ground for belief that the foetus in utero may become 
 infected by tubercle bacilli and also by the bacilli of typhoid. The first 
 few days after birth may witness acute miliary tuberculosis or the development 
 of a well-marked typhoid condition. As regards the former, the usual clinical 
 signs of acute tuberculosis will be present : it must be remembered, however, 
 that the infant rarely survives acute tuberculosis long enough for the formation 
 of lung-cavities, and hence physical signs will often be lacking. The character 
 of the fever, the rapid, uninterrupted course of the disorder, with increased dul- 
 ness over the thorax, and the development of harsh and bronchial breathing, 
 will usually enable the physician to make a diagnosis. 
 
INJURIES AND DISEASES OF THE NEW-BORN. 91 
 
 While treatment up to the present time has been practically unavailing, 
 it is of interest to note the experiments of Pinard in using injections of the 
 serum of dog's blood in these cases ; in a series of twenty-one infants so treated 
 he believes that benefit has resulted, the remedy seeming to act as a powerful 
 tonic and stimulant. 
 
 The intra-uterine transmission of typhoid infection is well illustrated by a 
 case recorded by Giglio. The presence of the typhoid germ was demonstrated 
 in the tissues of an apparently normal foetus and placenta born forty-six days 
 after the beginning of typhoid fever in the mother. 
 
 The treatment of typhoid in the new-born is practically that in the adult, 
 reference being had to the ease with which the infant is stimulated or de- 
 pressed. The prognosis in such cases is exceedingly grave. 
 
 Inspiration Pneumonia. 
 
 In prolonged labor, complicated by a septic condition of the mother's 
 birth-canal, premature inspiratory movements on the part of the foetus may 
 result in the inspiration of septic material : lobular septic pneumonia may 
 result, and, occurring, soon after birth, frequently proves rapidly fatal. Here, 
 again, the efforts of the physician lie in prophylaxis, in delivering the patient 
 promptly, and maintaining so far as possible an aseptic condition of the birth- 
 canal until labor shall terminate. 
 
 Tetanus. 
 
 The infant may become infected with tetanus, and this disorder may appear 
 in well-marked type from the sixth to the ninth day after birth. The tetanus 
 bacillus usually finds its entrance at the unhealed umbilicus. Brieger has 
 shown the specific cause of this disorder, and Beumer and Peiper have con- 
 firmed by clinical observation the identity of trismus and tetanus of the new- 
 born with inoculative and wound tetanus. The mortality among infants is 
 exceedingly large, and recovery is the rare exception. Appearing with symp- 
 toms of restlessness, night-terrors, and frequent cries, the child often becomes 
 nauseated, has slight diarrhoea, and is then attacked by trismus. This, at 
 first intermittent, finally becomes persistent, and develops into tetanic contrac- 
 tions of the entire body. Icterus is usually present. The disorder rarely lasts 
 more than three or four days, the child perishing in collapse from twelve to 
 twenty-four hours after the beginning of the convulsions. High temperature 
 is usually present at the time of death. On post-mortem examination effusion 
 of blood and serum in the cerebral tissues is frequently found. The violence 
 of the convulsions may give rise to haemorrhages into the muscular interspaces 
 or into the tissues of the mediastinum. 
 
 In treatment hydrate of chloral and alcoholic stimulants give most pros- 
 pects of relief. Holt has reported a case which recovered under the free use 
 of bromide of potassium. A specific method of treatment by the injection of 
 a substance similar to tuberculin has not, so far as we know, yet been employed 
 in this disease. There would certainly seem to be reasons for testing its value. 
 
 Mastitis. 
 
 Mastitis in the new-born infant is to be regarded as a mild septic infection 
 when the disorder comes to the point of suppuration and phlegmonous inflam- 
 mation. The mammary glands of new-born children frequently become 
 engorged and tender, but this condition subsides if the glands be let alone and 
 
92 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 protected from external violence. When, however, infection occurs, pus- 
 formation may take place and a septic mastitis may result. Such a compli- 
 cation, however, is exceedingly rare where antiseptic precautions are habitually 
 taken in the treatment of labor cases. A distinction must be made clinically 
 between simple engorgement of the breast and infection. In the former the 
 child's temperature remains but little disturbed, its appetite is unimpaired, its 
 rest remains practically as before. If the glands be carefully but gently 
 washed with soap and water and bathed with bichloride, 1 : 10,000, a thin layer 
 of absorbent cotton put over them, and a soft flannel bandage pinned snugly 
 about the breast and supported over the shoulders by shoulder-straps or some 
 other simple device, the glands may remain undisturbed for several days unless 
 fever or restlessness indicates inflammation. On the other hand, where infec- 
 tion is present and pus has formed, prompt emptying of the gland by incision, 
 with disinfection of the cavity, is indicated. 
 
 Infections of the Blood. 
 
 Profound alterations of the blood and nutritive cellular processes in the 
 new-born, the probable result of infection at birth, have been described under 
 various names by different observers. 
 
 Hecker and Yon Buhl describe a disorder of infants born in asphyxia 
 characterized by cyanosis, vomiting, icterus, profuse parenchymatous haemor- 
 rhage, accompanied by acute fatty degeneration of visceral epithelium and 
 heart-muscle. Phosphorus- and arsenic-poisoning were excluded in diagnosis, 
 and the malady was named "acute fatty degeneration of the new-born," or 
 Buhl's disease. Its pathology is not perfectly explained, but it may be classed 
 among the infective disorders resulting in the extensive disintegration of the 
 blood. 
 
 Acute haemoglobinuria of the new-born was first clearly described by 
 Winckel, who reported twenty-three cases of the disorder. It is characterized 
 by swelling of Peyer's patches and the mesenteric glands, blackish-red staining 
 of the pyramids of the kidneys, with stripes of haemoglobin coloring, fatty 
 degeneration of the liver and other viscera. Haematogenic icterus is present, 
 the haemoglobin being extensively changed into bilirubin. The urine is dark 
 brown-reddish in color, contains haemoglobin, epithelium, casts, and micro- 
 cocci. Chemical poisons as a cause were excluded in diagnosis. The mothers 
 showed no infection, the children were usually well developed. The mortality 
 was 19 out of 23. The cause of the disorder is not clearly demonstrated. It 
 is undoubtedly an infection which attacks the blood, resulting in haemoglo- 
 binaemia, Prophylaxis and treatment, beyond the faithful employment of 
 antiseptic precautions, are practically without avail. 
 
 Heematogenic jaundice, accompanied with multiple oozing of blood, has 
 been recently described in an interesting paper by Partridge. In the case 
 reported recovery ensued. In 1166 infants born at the Nursery and Child's 
 Hospital, New York, 11 cases of haemorrhage occurred, with a mortality of 75 
 per cent, At the Sloan Maternity Hospital, in 850 patients there were 14 
 cases ; mortality over 60 per cent. No intelligent family history of bleeding 
 was obtained. 
 
 Somewhat similar to these cases are those of the disorder known as 
 
 Mel^na Neonatorum. 
 Infants dying with profuse haemorrhage from the stomach and intestine have 
 revealed an ulcer of the duodenum as a cause. In explaining these phenomena 
 
INJURIES AND DISEASES OF THE NEW-BORN. 93 
 
 Landau assigns as a cause thrombosis of the umbilical vein, resulting in em- 
 bolism in the vessels of the stomach and duodenum. Persistence of the ductus 
 arteriosus and haemophilia also have been assigned as causes. Kundrat in exam- 
 ining Winckel's case found excessive secretion of the gastric juice, which had 
 partly digested the mucosa of the intestine and occasioned haemorrhage. In 
 other cases bloody stools and vomiting of blood persisted for several days. 
 Recovery occasionally ensues. 
 
 The prognosis is exceedingly grave, and treatment is practically unavail- 
 ing. The milder preparations of iron may be given by the mouth, and hot or 
 cold applied to the surface of the body as the condition of the child indicates. 
 An abdominal compress may also be useful. 
 
 In closing this consideration of the infective disorders of the new-born we 
 must again emphasize the fact that while we are not, in the present stage of 
 our knowledge, in a position to particularize regarding the precise nature of 
 the infective agent and its mode of operation, still, the fact remains reasonably 
 proven that these cases result from some direct infection occurring just before 
 or during birth. It remains, then, the positive duty of the practitioner to see 
 to it that rigid asepsis — and, better, antisepsis — is employed regarding his 
 hands and instruments, those of the attendant, and also the external organs of 
 the patient. Ehrendorfer, writing upon this subject, draws attention to the 
 dangers of infection, not only from mother to child, but from one child to another 
 in hospital wards. The practice of putting a number of children in the same 
 crib is objectionable, as is the custom of bathing a number of children in the 
 same bath-tub, and, still worse, of using the same towels or cloths for a number 
 of baths. From the moment of birth each infant should have its own toilet 
 appliances, be they of the simplest description. In cleansing the child absorb- 
 ent material which can be thrown away and not used a second time is prefer- 
 able. Separate vessels for bathing the child's body and for washing the head 
 and face are also desirable. In this way septic matter from the umbilicus is 
 kept away from the mouth and eyes, and vice versa. Nurses may be drilled 
 to advantage in these niceties in the care of infants, which are not simple 
 matters of aesthetic neatness, but are founded upon pathological facts. 
 
PART II. 
 
 THE DIATHETIC DISEASES. 
 
 LITHiEMIA. 
 
 By B. K. RACHFORD, M. D., 
 
 Cincinnati. 
 
 Lith^imia (tidoz, stone; aljua, blood) is a term which was introduced 
 by Murchison to designate a group of symptoms which he thought to be due 
 to an excess of uric (lithic) acid in the blood. Austin Flint, Sr., used the 
 term uricaemia for the same purpose. Alexander Haig and others have 
 written largely upon the subject under the name uricacidaemia. A number of 
 recent writers have grouped the same set of symptoms under the title lithuria. 
 Concealed gout and American gout have also been very largely used in 
 naming the same clinical manifestations. The writer has made a number of 
 contributions to this subject under the title leucomai'ne-poisoning. All of 
 these terms have found their way into medical literature, and all of them are 
 more or less inaccurate. The term lithaemia heads this chapter not because 
 of its propriety, but rather because of its long and widespread use by medical 
 writers in describing a condition which is known by its symptomatology 
 rather than by its pathology. We know that lithic acid is not responsible 
 for all, or even the greater portion, of the symptoms of lithaemia. This 
 term is therefore a misnomer and conveys a false idea of its pathology. Yet 
 it is my belief that the time for rechristening this disease must await a fuller 
 knowledge of its pathology than we have at present. Lithaemia is essentially 
 an auto-intoxication resulting, as I believe, from the presence of an excess of 
 the alloxuric bodies in the body media. Uric or lithic acid, from which the 
 disease is named, is one of these bodies, and xanthin, hypoxanthin, hetero- 
 xanthin, and paraxanthin are the other important members of this group. 
 The relative importance of these bodies as disease-producers is not at the 
 present time clearly made out, and need not therefore further engage our 
 attention. 
 
 Etiology. — Heredity holds first place among the etiological factors of 
 lithaemia. In fact, one may say that this disease as it occurs in infants and 
 children is essentially an inheritance from lithaemic ancestors. 
 
 An excess of proteid food may be a factor in developing lithaemia. It is 
 believed that the alloxuric bodies have their origin either directly or indi- 
 rectly from the proteid food. The more proteid food, therefore, the body 
 is called upon to metabolize, the more of these waste products will be 
 formed. 
 
 Inactivity will predispose to lithaemia. This factor is especially potent 
 
 94 
 
LITHJEMIA. 95 
 
 when associated with an excessive intake of proteid food. It is probable that 
 sedentary habits increase the liability to lithaemic attacks by furnishing 
 diminished opportunities for the oxidation of the poisonous alloxuric bodies, 
 since it is a recognized fact that these bodies, however they may be formed, 
 may. under favorable conditions, be oxidized into non-toxic uric acid and 
 urea. Active exercise in the open air, by furnishing the most favorable 
 conditions for the oxidation of these bodies, will diminish the dangers of 
 auto-intoxication. 
 
 Excretion of the Alloxuric Bodies. — The alloxuric bodies are excreted by 
 the kidneys, the skin, and the intestinal canal. In this work the kidneys 
 play the most important role. These bodies are removed by the kidney cells 
 from the blood into the urine. Their presence, therefore, in great excess in 
 the urine means that immediately before they were in solution in excess in 
 the blood. Disease of the kidneys may cause an abnormal retention of these 
 bodies in the blood. The excretion of these bodies by the skin is of especial 
 importance when the kidneys fail to do their part of the work. The un- 
 doubted value of many of the hot springs in the treatment of lithaemic condi- 
 tions depends upon the fact that the hot alkaline bath promotes the cutaneous 
 elimination of the alloxuric bodies. In the hot months the skin is more 
 active than in the cold months, and this may be one of the explanations of 
 the comparative infrequency of lithaemic attacks in summer. The intestinal 
 canal is a most important channel by which an excess of the alloxuric bodies 
 may be eliminated from the blood and the tissues. In practice one often 
 finds it necessary to call upon the intestinal canal to assist the skin and 
 kidneys in the excretion of these bodies. 
 
 Symptoms. — In order to avoid confusion by the mingling of symptoms 
 from totally different causes, I shall speak first of the symptoms which are 
 thought to be due to uric-acid deposits in the urinary passages. The newly- 
 born lithaemic infant is prone to eliminate an excess of urates in the first 
 days of life. In such infants uric-acid crystals may be precipitated into the 
 tubules of the pyramids of the kidneys and cause thereby much pain and 
 irritation. These uric-acid infarctions may subsequently be washed out of 
 the tubules and serve as the nuclei of urinary calculi. Jacobi says the vast 
 majority of renal and vesical calculi have their origin in this way. 
 
 Quite recently I saw r an infant two days old. It was crying bitterly, and 
 seemed to be in great pain : its temperature was 104° F., and had been nearly 
 that high for twenty-four hours. I learned that this infant had been born 
 of lithaemic parents, and that it had passed urine but once since birth. The 
 urine passed at that time was small in quantity and tinged with blood. As 
 treatment it was given a warm bath, a cathartic, and water to drink. Two 
 days later it was convalescent, with the renal secretion established. The 
 urine passed by this infant on the third day deposited a red sand of urates 
 on the diaper. This case is typical of a class of cases which represent the 
 earliest manifestations of infantile lithaemia. When fever and long-continued 
 paroxysms of crying occur in newly-born infants coincident with the passage 
 of urine so heavy with urates as to deposit a red sand on the diaper, one is 
 justified in making the diagnosis of this special uric-acid type of lithaemia. 
 These lithaemic infants may, as they grow older, continue to suffer from 
 attacks of painful urination accompanied by an elevation of temperature and 
 irritation of the external genitalia. The paroxysms of crying which occur 
 during and immediately following the passage of urine are very characteristic. 
 In the interval between these fits of crying the child is fretful, and grows 
 more so as the time approaches when it can no longer resist the inclination 
 
96 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 to urinate. The urine is acid and contains an excess of urates and oxalates. 
 In some patients it is so irritating as to cause a vulvo-vaginitis in the female 
 infant and urethral irritation in the male. The clinical picture here pre- 
 sented is by no means peculiar to infants and children. In adults it is also 
 common to find frequent and painful urination associated with the passage 
 of urine small in quantity, high in specific gravity, and heavy with urates. 
 
 Nocturnal incontinence of urine in children may be a lithaemic symptom 
 resulting from the irritable condition of the urinary passages and the insta- 
 bility of the spinal nerve-centres that not uncommonly occurs in these chil- 
 dren. If one recognizes the fact that lithsemia is at times an important 
 factor in producing incontinence of urine, one will succeed in curing cases 
 of incontinence that have resisted other forms of treatment. I wish to note, 
 however, that lithsemia does not rank among the most common causes of 
 this neurosis. 
 
 True arthritic gout, resulting from uratic deposits in the tissues about the 
 joints, is very rare in childhood, and moreover does not come within the 
 scope of this paper. 
 
 The symptoms and treatment of urinary gravel are elsewhere described 
 in this book. 
 
 With this outline of the role that uric acid plays in the symptomatology 
 of lithaemia we may pass to the consideration of those symptoms of lithsemia 
 which in the present state of our knowledge cannot be attributed to uric 
 acid. The writer believes that these symptoms are the result of auto-intoxi- 
 cation caused in part, at least, by the alloxuric bodies other than uric acid. 
 
 G astro-enteric Symptoms. — The gastro-enteric symptoms of lithgemia in 
 infancy and childhood are little understood, and they are of vast importance. 
 The history of the following cases, which are extreme examples of this type 
 of lithsemia, will best serve to emphasize these symptoms : 
 
 Case A. — Male infant, eight months of age ; has a gouty ancestry on both sides. This 
 infant has had since he was two months old, at intervals of four to six weeks, the most 
 characteristic lithaemic attacks. These attacks commence with nausea and vomiting, 
 and very soon the infant refuses, and the stomach rejects, all food. The nausea and 
 vomiting continue for from two to four days, and during this time nothing is retained 
 by the stomach. These symptoms are accompanied by fever and by very rapid breath- 
 ing, which is not explained by any pulmonary condition. The odor of the breath is 
 sickening, the bowels are constipated, and toward the close of the attack the baby is 
 prostrated and emaciated to an alarming degree. Accompanying and immediately fol- 
 lowing these attacks the stools are very putrid and sometimes oily in character. These 
 lithaemic paroxysms come and go without apparent cause. They are quite independent 
 of the wholesomeness and digestibility of the food, and the duration of the attack is but 
 slightly influenced by medication. 
 
 Case B. — Age four years, a brother of infant A ; has been having very similar lithaemic 
 attacks since he was an infant a few months old. His attacks were formerly character- 
 ized by obstinate constipation, with fever, nausea, vomiting, and rapid breathing. The 
 nausea and vomiting would continue for three or four days, and would then disappear 
 as suddenly as they came, leaving the patient to slowly convalesce during the next few 
 days. These attacks came and went without apparent cause. The mother soon learned 
 to expect them every six or eight weeks, and also learned that they were self-limited. 
 The point of special interest in this boy's case is that recently these attacks have changed 
 in character. At the present time vomiting is no longer a prominent symptom. They 
 are now characterized by headache with nausea, and followed by a more or less pro- 
 longed narcotism, during which the child falls into a deep sleep from which he awakens 
 somewhat improved. In brief, one may say that the gastro-intestinal paroxysms of his 
 infancy are being transformed into true migraine. This substitution of one form of 
 lithaemic paroxysm for another is quite characteristic of the disease. 
 
 The disease may manifest itself in young infants by attacks of gastric 
 pain, associated with rapid breathing, nausea, vomiting, and fever. The 
 
LITH^MIA. 97 
 
 gastric paroxysms may be so severe that all food is rejected for a period 
 of from one to five days. The temperature may reach 104° or 105° F., but 
 sometimes in the most severe cases the fever ranges between normal and 
 10:2° F. In these attacks the patient may be prostrated to the last degree, 
 occasionally having a subnormal temperature. Toward the close of these 
 acute attacks the infant or child may be much emaciated. 
 
 Occasionally these lith^emic paroxysms are ushered in by convulsions, 
 which may recur with such regularity as to become quite characteristic symp- 
 toms of such attacks. These gastric paroxysms are self-limited. In dura- 
 tion and severity they are influenced but slightly by medical treatment. The 
 nausea and vomiting go almost as quickly as they came, but there is left 
 more or less abdominal tenderness and gastro-intestinal irritation, from 
 which the infant or child slowly convalesces. The stools following these 
 attacks are putrid, and in young infants are sometimes oily in character. 
 The interval between the attacks may be as short as one week, or months may 
 intervene. In the less severe forms of lithgemia the infant or child may be 
 quite well during this interval, but, unfortunately, this is not always so. 
 Some of these lithsemic children remain pale and frail-looking at all times. 
 They are peevish and hard to please; they are as relentless as they are 
 exacting in their demands. Lithsemic infants and children are mentally pre- 
 cocious, and when ill and peevish between the acute attacks they exercise this 
 precocity in devising ways and means to secure the constant attention of all 
 around them. 
 
 From the gastro-enteric type of lithaemia above described there are many 
 variations. In children these attacks may occur, as they commonly do in 
 adults, with little or no elevation of temperature. They may or may not be 
 accompanied by convulsions, headache, gastric pain, or dyspnoea. The dys- 
 pnoea when it does occur is an interesting symptom, since it is not due to 
 pulmonary causes, but is, like all the other symptoms, toxic in origin and to 
 be classed as a nervous symptom. In rare instances vomiting of blood may 
 occur both in the child and the adult, but this symptom does not change the 
 prognosis or delay the return of the digestive organs to their normal condi- 
 tion. It is of importance in that such a lithgemic attack might be mistaken 
 for gastric ulcer. 
 
 In infancy, childhood, and adult life a chronic intestinal fermentation 
 may be dependent upon a lithsemic condition, but in these cases the symp- 
 toms which are always present as a result of chronic intestinal fermentation 
 are at times aggravated into more acute attacks of gastro-intestinal disturb- 
 ance. These acute gastro-intestinal attacks recur without apparent cause 
 and at more or less regular intervals, in that way breaking in upon the 
 milder gastro-enteric symptoms, which are constantly present. This type 
 of litheemia is, in the adult, commonly associated with great mental depres- 
 sion. It may also here be noted that the pain from these gastric attacks is 
 not uncommonly so severe in the adult as to demand for its relief the hypo- 
 dermic use of morphine. The lithaemic attacks of infancy and childhood are, 
 fortunately, not so painful as they may be in later life. The gastro-enteric 
 symptoms of lithsemia at all ages may vary in severity from a slight nervous 
 dyspepsia to an attack of pain and vomiting so severe as not only to strike 
 down, but even to endanger the life of, the patient. 
 
 Nervous Symptoms. — Nervousness in a great variety of manifestations is 
 to be observed in lithaemic individuals. It might almost be said that the entire 
 symptomatology of lithaemia at all ages may be directly or indirectly referred 
 to the nervous system! Infants and children with strong inborn lithreniic 
 
 7 
 
98 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tendencies have very unstable nervous systems. The increased reflex excita- 
 bility of these children predisposes them to general nervous irritability. 
 They are commonly quick-witted, bright-faced, small and slender of stature, 
 and flit about with quick and nervous movement. But lithsemic, unlike 
 tuberculous, precocity is not, as a rule, coupled with physical inferiority ; 
 neither is lithaernic precocity so fitful, so asymmetrical, and so short-lived as 
 the tuberculous. Lithaemic children, in fact, are, under proper restraint, capa- 
 ble of the highest intellectual development in after-life. 
 
 Eclampsia may be a symptom of lithsemia. In this connection the fol- 
 lowing abstract of a case reported by Irving Snow to the American Pediatric 
 Society in 1893 is of interest. This case was reported under the title " Gas- 
 tric Neurosis in Childhood," and the clinical history of this child conforms 
 in almost every particular to the gastro-intestinal form of litheemia above 
 described. The lithaemic attacks from which this child suffered commenced 
 when it was nineteen months old. The most characteristic symptom of 
 these attacks Avas the initial convulsion. This was followed by from three to 
 five days of fever and vomiting, and then rapid convalescence supervened. 
 These spells were periodic ; they came and went without apparent cause at 
 intervals of a few weeks. Convulsions continued to mark the onset of the 
 attacks until the child was four years old, when the convulsions ceased, but 
 otherwise the attacks were unchanged, except that they were more frequent 
 and possibly more severe. After the cessation of the convulsions the attacks 
 were characterized by " vomiting, fever, hypersecretion, and irritability of 
 the stomach, which were independent of dietetic errors or of organic disease." 
 Following the report of this case, similar cases were reported by Holt, 
 Christopher, Rotch, Seibert, Forchheimer, and Caille, and the opinion was a 
 common one that these cases were very frequently observed in practice, but 
 that their etiology was obscure and their classification uncertain. I have 
 here introduced the abstract of this case and the discussion which followed 
 for the purpose of emphasizing the fact that eclampsia is not uncommonly 
 associated with other well-marked lithaemic symptoms. I desire to emphasize 
 this clinical relationship, since my laboratory experiments have demonstrated 
 that eclampsia may be a symptom of lithaemia. The fact of greatest import- 
 ance pertaining to lithaemic eclampsia is that these convulsions may continue 
 to recur till finally we may have established the type of epilepsy which has 
 been described as migrainous epilepsy. 
 
 Migraine is one of the most common, as well as one of the most charac- 
 teristic, symptoms of lithaemia in adult life, and it is but slightly less im- 
 portant as a manifestation of this condition in childhood. These paroxysmal 
 and commonly unilateral headaches occur at more or less regular intervals 
 without apparent cause ; they are sometimes associated with nausea, vomit- 
 ing, and gastric pain, and not infrequently with disorders of vision. They 
 are self-limited, and, as a rule, end in narcotism, which produces a sleep from 
 which the patient awakens convalescent from the attack. Migraine is quite 
 common in late childhood, and may occur in very young children. These 
 lithaemic headaches may present two distinct clinical types : one that is asso- 
 ciated with nausea and vomiting, and commonly called " sick headache;" 
 and the other, in which there is not the slightest trace of these symptoms, 
 may be designated as migrainous neuralgia. These clinical types of migraine 
 are important from a therapeutic standpoint, since they do not yield alike to 
 the same line of treatment. 
 
 In concluding the nervous symptoms of lithsemia it may be broadly stated 
 that headache, gastric pain, nausea, vomiting, eclampsia, and rapid breath- 
 
LITHJEMIA. 99 
 
 ing (asthma) are lithaemic symptoms which may occur in paroxysms, and 
 which may be commingled in varying degrees of intensity to make the clinical 
 picture of an individual attack. 
 
 Eczema is one of the most common of lithaemic manifestations in infants 
 and children. Special note should be made of the importance of this symp- 
 tom, since the successful treatment of this form of eczema depends upon the 
 recognition and treatment of the lithaeniic element. Lithaemic eczema may 
 occur in well-nourished children with a family history of lithaeinia, and is to 
 be carefully differentiated from tuberculous eczema, since the two types 
 require radically different constitutional treatment. 
 
 Urine in Lithcemia. — The urine excreted during a lithaemic paroxysm is, 
 as a rule, scant and unusually acid in reaction. It is highly colored, and 
 the specific gravity is generally considerably increased : on standing it 
 deposits a red sand of urates. In the urines passed immediately following 
 lithaemic headache, lithaemic eclampsia, and certain other of the more severe 
 forms of lithaemia the poisonous xanthin bodies, paraxanthin and hetero- 
 xanthin, may be found in enormous excess of the normal minute quantities 
 of these substances present in the urine of non-lithaemic individuals. Special 
 note should be made of the fact that albumin may occur in the urine during, 
 and for some days after, a lithaemic attack, and then entirely disappear. This 
 recurrent and transient albuminuria is not a very common symptom of lith- 
 aemia, but when it does occur it is a very characteristic and significant one. 
 It is, in fact, a danger signal, which being interpreted means that most care- 
 ful treatment must be begun and continued if the kidney is to be saved from 
 irreparable damage. 
 
 Treatment. — The dietetic treatment of lithaemia is of the first importance 
 in infancy, as it is at all periods of life. Mother's milk is an ideal food for 
 lithaemic infants, but when it becomes necessary to supplement this food it is 
 best to do so with cow's milk to which cereals have been added. I have 
 been much impressed with the importance of adding barley- or rice-water to 
 cow's milk as a food for these children. Jacobi for many years has enthusi- 
 astically advised that cow's milk as a food for infants should always be mixed 
 with cereals, and it is my experience that this is of special importance to 
 lithaemic infants. Beef-juice and meat soups and teas are at all times con- 
 traindicated. When the lithaemic infant becomes a child, the milk and 
 cereals, including bread, should continue to occupy the most important place 
 upon his bill of fare. Milk and cereals are, in fact, ideal foods for lithaemics 
 of all ages. As the child develops, it becomes necessary to add eggs, fish, 
 and poultry to his diet. These foods are very much to be preferred to 
 butcher's meat as a means of furnishing proteid food to the rapidly develop- 
 ing lithaemic child. Butcher's meat may, however, be allowed in small 
 quantities once a day to lithaemic children who lead an active out-door life. 
 In advising as to the proscribed and prescribed proteid foods for lithaemic 
 children it is well to keep in mind that the following foods are to be recom- 
 mended in the order named : Milk, eggs, fish, oysters, poultry, game, and 
 butcher's meat. At the beginning of this list we have the best, and at the 
 end the worst, foods for lithaemics of all ages. Fresh fruits and fresh vege- 
 tables should enter largely into the diet of all lithaemic children, and these 
 foods, together with milk, eggs, and cereals, should constitute the almost exclu- 
 sive diet until they are old enough to live a very active out-door life. Then, 
 as above indicated, fish, poultry, and in small quantities butcher's meat, may 
 be added. In the treatment of adults I advise that they eat moderately of 
 simple food and abstain absolutely from wine and malt liquors. In- this bit of 
 
100 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 advice we have a condensed statement of the dietetic management of lithae- 
 mia. Over-eating is a factor in its cause, and under-eating is a factor in its 
 cure. Lithaemics for this reason should be advised against taking an excess 
 of food of any kind. Meats may be taken only in such quantities as are 
 necessary to supply the proteid waste and repair of the body, but it will be 
 found that most lithaemics take meat largely in excess of this quantity. It 
 will therefore be necessary to place restrictions on the quantity of meat 
 taken, and substitute poultry, game, fish, oysters, eggs, as above directed. 
 No harm, however, can come to lithaemics leading an active life from the 
 moderate use of these simple proteid foods. The only care necessary is 
 to avoid an excess of these foods and to see that they are prepared in a sim- 
 ple and digestible form. Fries and salads are objectionable, and fresh pork, 
 lobsters, and crabs are not to be commended. Sweets, such as candies, 
 pastries, and preserves, are to be used sparingly if at all. The knowledge 
 that sweets are injurious to lithaemics is a bit of information, born of clinical 
 experience, upon which almost all writers are agreed. Sweets are therefore 
 to be restricted, even though we cannot trace the connection between this 
 class of foods and the nitrogenous poisons which are thought to be the cause 
 of the symptoms of lithaemia. Milk, cereals, fresh fruit, and fresh vegetables 
 should continue to be the most important foods of lithaemics throughout life. 
 
 Exercise in the open air is scarcely less important than diet to lithaemic 
 children. They should, therefore, be encouraged in all kinds of out-door 
 athletic sports. It will be found that many of these lithaemic children re- 
 quire a great deal of urging and commanding in order to have them take the 
 proper amount of exercise in the open air. It is a common observation that 
 lithaemic children are averse to out-door exercise and very fond of in-door 
 intellectual pursuits. The out-of-school companions of lithaemic children 
 should be bicycles, skates, and tennis racquets instead of books. Wholesome 
 exercise in the open air is necessary to the proper physical and intellectual 
 development of any child, but lack of exercise is especially baneful to one of 
 inborn lithaemic tendencies. Exercise promotes the nitrogenous metabolism ; 
 it furnishes the conditions for the more complete oxidation of the alloxuric 
 bodies into harmless nitrogenous extractives. The air in which the exercise 
 is taken should be as pure as possible. City children of this type should 
 have two or three months of active out-door life in the country every year. 
 They may be sent to the seashore, the mountains, or a neighboring farm 
 with almost equal advantage. Fothergill believed that a certain amount of 
 pure country air was absolutely necessary to the satisfactory development of 
 lithaemic children. 
 
 Before beginning the medical treatment of lithaemia one should make a 
 careful search for such reflex factors as may possibly contribute toward pre- 
 cipitating lithaemic paroxysms. If eye-strain exists, it should be corrected. 
 If pelvic or rectal disease be present, it should be treated. In short, all 
 reflex factors should, if possible, be removed before other treatment is com- 
 menced. While I am convinced that the reflex factors have had undue 
 prominence given them in the study and treatment of lithaemic paroxysms, 
 yet I am not pessimistic enough to believe that they should be disregarded 
 in the treatment of these conditions. Pelvic disease, I think, especially de- 
 mands treatment when it occurs in cases where the lithaemic paroxysms coin- 
 cide with the menstrual period. The failure of medicinal and dietetic treat- 
 ment to cure certain lithaemic paroxysms may sometimes be due to the fact 
 that there is present some eye, preputial, or pelvic disease which continues 
 to act as a potent reflex factor in calling forth these paroxysms. 
 
LITHjEMIA. 101 
 
 The medicinal treatment of lithnemia should aim to cure constipation and 
 to favor the elimination and promote the oxidation of the alloxuric bodies 
 which are believed to be the materies morbi of this affection. In infants and 
 children it may advantageously be begun with small doses of calomel and 
 soda repeated at short intervals until catharsis begins. After a day or two 
 of rest from medication our little patients may be given some form of elimi- 
 native treatment. Volumes have been written on the drugs which are given 
 for the purpose of eliminating the poisons of lithoemia, and there always has 
 been, and possibly will be for some time to come, much confusion as to their 
 comparative value. It is my belief that the salts of salicylic acid are the most 
 valuable eliminative medicines we have. After the preliminary calomel course 
 it is my custom to order some salicylate, the one selected depending upon the 
 age of the child and the nature of the symptoms. Salol is especially useful. I 
 have seen lithsemic infants suffering from chronic intestinal fermentation with 
 gastric crises very much benefited by one grain of this drug after each nursing. 
 Other antiseptics will not accomplish the same result, and it is not, therefore, 
 simply a question of intestinal antiseptics. The salol in these cases must 
 be continued for weeks or months in doses to suit the age of the child. If the 
 lithaemic manifestation be an eczema, salol is equally advantageous ; in such 
 cases I also commonly give a few grains of phosphate of sodium or benzoate 
 of lithium dissolved in each portion of food. An infant two years of age 
 may be given in this way twenty grains of the phosphate of sodium and three 
 grains of the benzoate of lithium in twenty-four hours. In a word, salol, 
 phosphate of sodium, and benzoate of lithium are the medicines usually relied 
 upon in the treatment of infantile lithaemia, and great good can be accom- 
 plished by their intelligent use in connection with such dietetic, hygienic, or 
 local treatment as the special manifestations suggest. Should the phosphate 
 of sodium fail to regulate the bowels (almost all of these cases are constipated), 
 it becomes absolutely necessary to supplement this treatment with a laxative 
 which will evacuate the upper intestine. Enemas and suppositories may be 
 used as assistants to other laxatives, but they are not to be relied upon exclu- 
 sively. I wish here to especially insist that this laxative treatment is as 
 absolutely necessary in the lithsemia of infants and children as it is in adults. 
 Salicylate of sodium may be advantageously substituted for salol in children 
 over five or six years of age. The salicylate of sodium derived from winter- 
 green is preferable, because it is more palatable and less irritating to the gastric 
 mucous membrane. It should, if possible, be given in a little Seltzer water, 
 which may for convenience be obtained in siphon. The siphon of Seltzer 
 should be kept in a cool place, and the water may be drawn into a glass con- 
 taining the dose of salicylate. In this way it is possible to give the drug 
 for an indefinite time without disgusting the palate or irritating the stomach. 
 
 While the salicylates are our best remedies in all forms of lithsemia, the 
 salts of lithium are also of value in certain manifestations of the disease. The 
 natural lithia waters may be used, and it is much in their favor that these 
 waters are tasteless, and therefore readily taken by infants and children. 
 Much of their efficacy, however, is due to the water itself rather than to the 
 lithia it contains. Many lithsemic patients drink little, and will be greatly 
 benefited by simply increasing the quantity of liquid taken in twenty-four 
 hours. Mention has previously been made of the importance of giving 
 newly-born infants water to drink, since it is often needed to dissolve and 
 thereby favor the excretion of urates that might otherwise irritate the 
 inflamed urinary passages. For the same reasons lithoemic patients of all 
 ages are benefited by drinking water, and much of the benefit derived 
 
102 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEX. 
 
 from drinking sulphur and other waters at the springs comes from the large 
 quantity of liquid taken, rather than the contained medicinal agent. Yet 
 in givino- full credit to water as a remedy one must not overlook the fact 
 that many natural waters contain salts — lithia, for example — that are of real 
 value in the treatment of lithaemia. Of the lithia salts, the benzoate and citrate 
 are much to be preferred, and I would select the benzoate, as it gives the best 
 results. For infants the dose is gr. ss-j three times a day dissolved in milk ; 
 to older children it may be given in tablet form or dissolved in water. The 
 citrate of lithium is somewhat less efficient, but more palatable, than the 
 benzoate. 
 
 The soda salts are of great value in the treatment of lithaemia, and the 
 mineral waters which are composed largely of these salts — such, for example, 
 as Carlsbad — have a well-deserved reputation. The following prescription 
 has long been a favorite with me for older children and adults: 
 
 1$;. Sodii salicylatis (from wintergreen) . . . 3rj ; 
 
 Sodii phosphat., dry Jjiv ; 
 
 Sodii sulphat., dry liss. — M. 
 
 Sig. A teaspoonful, more or less, in a small glass of Seltzer water 
 before breakfast every morning or every second morning. 
 
 It is important that dry salts be used in this prescription. The dose is 
 to be regulated by the cathartic effect. Violent daily catharsis is not to be 
 desired, but a decided laxative effect must be produced. In connection with 
 this treatment I commonly use one of the following prescriptions : 
 
 First : A one-grain salol-coated pill of permanganate of potash (Upjohn), 
 which is to be given directly after each meal to all lithsemic patients having 
 pronounced gastro-intestinal symptoms. (Sick headache and the gastro- 
 enteric types of lithgemia belong to this class.) 
 
 Second : A capsule containing from two and a half to five grains of salol 
 and from one-twelfth to one-quarter grain of cannabis Indica, which is to be 
 given after each meal to all patients in whom the lithsemic paroxysms are 
 not associated with gastro-enteric symptoms. (Migrainous neuralgia and 
 lithremic epilepsy belong to this class.) 
 
 These prescriptions are to be used in connection with the soda salts, and 
 are especially adapted for the treatment of lithsemia in late childhood and 
 adult life. They are not suited to young children or to frail and wasted 
 lithaemics of any age. 
 
 Dilute nitro-muriatic acid and colchicum have long held a place among 
 medicines which are of value in the treatment of lithaemia. Both may be 
 given to older children and adults, but are not to be employed in infants and 
 young children. The dilute nitro-muriatic acid in five-drop doses, well 
 diluted, before meals, is a valuable remedy in the treatment of lithsemic 
 headaches in older children. The wine of colchicum in five- to eight-drop 
 doses may be tried for the relief of painful lithsemic paroxysms of any kind. 
 
 For stout and vigorous patients the natural waters are of great value, 
 especially those of the thermo-alkaline springs of Virginia and Arkansas 
 and waters of the Carlsbad type. The Bedford Springs of Pennsylvania, 
 the Crab Orchard Springs of Kentucky, the St. Clair and Mount Clemens 
 Springs of Michigan, the Saratoga Springs of New York, and the West Baden 
 and French Lick Springs of Indiana may also be recommended. 
 
HEREDITARY SYPHILIS. 
 
 By HENRY D WIGHT CHAPIN, M. D., 
 
 New York. 
 
 No period of life is exempt from syphilis, which has been aptly styled 
 "the least venereal of the venereal diseases." It is a chronic infectious pro- 
 cess, doubtless of microbic origin, the ravages of which are modified by age, 
 conditions of body, and environment. The micro-organism most commonly 
 associated with syphilis as a probable causative agent has been found by Lust- 
 garten within the cellular protoplasm of syphilitic products. He describes it 
 as a bacillus from three to seven micro-millimetres in length, with often a 
 slightly wavy shape. Unfortunately, pure cultures have not been made of 
 this bacillus, and the fact that the lower animals do not contract syphilis pre- 
 vents the possibility of proof by inoculation. 
 
 Syphilis in early life may be either hereditary or acquired. It is not neces- 
 sary to consider acquired syphilis at length in a work devoted to diseases of 
 children, as it presents no essential differences from the same affection in adult 
 life. It may be well to bear in mind, however, that syphilis detected in infancy 
 is not necessarily inherited, but may be acquired. A primary sore upon the 
 genital tract of the mother may infect the infant during birth, though the 
 possibility of this has been denied. 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. In such a case a chancre will appear at the 
 point of contact, followed in due time by the after-lesions of the disease. There 
 are certain peculiarities in the effect of the syphilitic virus upon young proto- 
 plasm which will be noted under the Morbid Anatomy. 
 
 The subject will be here considered under the two heads of hereditary 
 syphilis in infancy, and the taint as it is seen in childhood or when appar- 
 ently delayed. 
 
 Hereditary Syphilis in Infancy. 
 
 The disease may be acquired from the father or mother, or from both 
 parents, the poison being lodged in the spermatozoa of the male or the ovum 
 of the female. 
 
 Paternal Influence. — While it has been denied by some observers that 
 the father alone can transmit syphilis, the consensus of opinion is in favor of 
 the possibility of such transmission, which can and does take place. The 
 chances of this transmission 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. Without mercurial treatment the sperma- 
 
 103 
 
104 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tozoa can usually transmit the syphilitic poison during the first year after pri- 
 mary infection, and there is great danger to the foetus from syphilitic contagion 
 up to the fourth year. The longer the duration of the disease, the less will be 
 the danger to the offspring, owing to the periods of latency observed during its 
 later stages. If the father be subjected to early and thorough treatment, the 
 probability of transmission of the disease will be much lessened, and such a 
 possibility soon becomes lost with a reasonable lapse of time. If the father 
 infect the mother, as frequently happens, there will be a double syphilization 
 of the offspring, which wili probably be stillborn or soon succumb to an aggra- 
 vated form of the disease. 1 
 
 Maternal Influence. — The influence of the mother upon the growth and 
 development of the foetus contained within her uterus is obviously very great, 
 and hence when she is suffering from constitutional syphilis the disease is 
 transmitted in an active stage to her child. The degree of such transmission 
 depends, as noted above in \h.Q 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 syphi- 
 litic infants caused by renewed manifestations of the disease. It has been con- 
 sidered that the power of transmission is practically lost at the end of six 
 years. As a general rule, it can be stated that the chances of infection of the 
 foetus and the severity of the type, if infected, are in direct proportion to the 
 activity of the syphilis in either or both parents. It has been said that if the 
 mother contract syphilis before the eighth month of utero-gestation, she may 
 transmit the disease to the foetus, although healthy at the time of conception. 
 Dr. Taylor, on the contrary, denies that the syphilis of the mother, acquired 
 during pregnancy, can be conveyed to the foetus through the utero-placental 
 circulation, as the disease is only communicated either by the sperm-cells or by 
 the ovule diseased at the time of conception. One of the peculiar phenomena 
 seen in connection with infants who are born syphilitic is that the mother may 
 apparently be free from any taint of the disease. It has been a subject of 
 much dispute whether these are instances of latent syphilis or whether the 
 women are really healthy. Whatever the cause, these cases show immunity in 
 contracting syphilis. 
 
 In 1837, Colles wrote that " a new-born child affected with inherited syphi- 
 lis, 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 con- 
 tinuing capable of infecting a strange nurse." The substantial truth of this 
 dictum has not been seriously questioned during the many years that have 
 elapsed since its enunciation, although varying explanations have been offered. 
 Fournier states that the inoculation experiments of Caspari and Neumann have 
 proved conclusively that the apparent immunity of the mother, who has borne 
 a child syphilitic by its father, against the contraction of the disease from her 
 offspring, is due to the fact that she has already been infected by syphilis dur- 
 ing the intra-uterine period of the child's life. Thus, conceptional syphilis is 
 to be classed with the hereditary form of the disease, since there is here no pri- 
 mary lesion. This form of conceptional syphilis may remain latent for years. 
 Diday advances as an explanation of Colles' law the idea that all infectious dis- 
 eases may certainly be mitigated to the point of absolute protection by the 
 methodically repeated inoculation of their essential cause (microbic) or of its 
 products (toxic ptomaines, etc.). Bouchard considers that while the foetus 
 retains the supposed pathogenic agent itself, the products dissolved in the 
 blood find their way to the tissues of the mother and set up a nutritive change, 
 1 Dr. F. K. Sturgis strongly denies the paternal transmission of syphilis. 
 
HEREDITARY SYPHILIS. 105 
 
 resulting in what he calls a "bactericidal condition," which renders difficult or 
 impossible the development of the infectious agent when introduced by later 
 inoculation, as from the lips of her child. The doctrine of syphilis being con- 
 tracted by conception, sometimes called "choc en retour," although having 
 wide acceptance, is not acknowledged by all. Kassowitz believes that the 
 women who appear healthy and remain so, even after giving birth to syphilitic 
 children, are really free from specific taint. 
 
 Syphilis of the Placenta. — Dr. Frankel in 1873 published a paper in 
 which he affirmed the existence of three forms of involvement of the placenta 
 by syphilis — i. e., endometritis decidualis, endometritis placentaris, and disease 
 of the villous portion of the foetal placenta. This conclusion was based upon 
 an examination of over one hundred placentae. Zilles in 1885 published the 
 results of a study of three hundred placentae derived from Prof. Saxinger's 
 obstetrical clinic. He finds that placental syphilis can often be diagnosed 
 microscopically, and that it oftenest happens in connection with foetal syphilis. 
 The maternal portion of the placenta or the foetal part only may be affected, 
 while, again, the whole of the placenta may be involved in the disease. Syphi- 
 lis is one of the recognized causes of hydramnios. 
 
 Morbid Anatomy. — The lesions of syphilis, while always essentially the 
 same, will nevertheless be modified by age. Young protoplasm is active, and 
 usually exhibits a marked reaction to irritative processes, so that the tissues 
 are apt to be extensively involved in hereditary syphilis. The lesions may be 
 broadly divided into those involving the skin and mucous membranes, the vis- 
 cera, and the bones. 
 
 Skin and Mucous Membranes. — The skin may be affected by erythema, 
 maculo-papules, or papules. A vesicular and pustular eruption may occasion- 
 ally 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 distribution and course of the various eruptions 
 will be noted more at length under Symptoms. In general, they develop 
 quickly and spread over extensive areas of surface on account of the character 
 of infant protoplasm, noted above, as well as from the activity of the circula- 
 tion in the skin. 
 
 The lesions of the mucous membranes may be in the form of catarrhal pro- 
 cesses, of mucous patches, or of superficial or deep ulcerations. Any or all of 
 these lesions may involve any part of the alimentary tract or of the respiratory 
 tract. They are seen most commonly, however, in the upper part of these 
 areas, in some part of the mouth or fauces in the former case, and in the nose 
 and larynx in the latter. Still, they may likewise occasionally involve the 
 intestine or trachea and bronchial tubes. 
 
 Visceral Lesions. — The viscera are apt to be more extensively involved 
 in hereditary than in acquired syphilis, the lesion being in the form of an inter- 
 stitial hyperplasia more or less diffuse. Circumscribed gummy infiltrations 
 are not so frequent. The growth of interstitial connective tissue, which grad- 
 ually contracts, thereby partially obliterating the parenchyma of the organ, may 
 involve the lungs, spleen, liver, pancreas, and testicle. 
 
 Lungs. — Usually a portion of a lobe, but occasionally a whole lobe, may 
 present a diffuse fibroid infiltration. The part involved is grayish-white in 
 color and tough in consistency, and surrounded by an inflamed pleura. Under 
 the microscope there is seen to be thickening of the septa and compression of 
 the alveoli by fibrous tissue, which is quite vascular. Occasionally a few 
 rounded masses about the size of a hickory-nut may be noted. These gum- 
 
106 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 mata may break down in the centre into puriform matter, but they are not apt 
 to exist in the same subject that the diffuse interstitial inflammation attacks. 
 
 Spleen- — The spleen is generally more or less enlarged from a diffuse inter- 
 stitial hyperplasia. There usually coexists a thickening of the capsule. Accord- 
 in^ to Dr. Gee, the severer the grade of syphilis the greater will be the hyper- 
 trophy of the spleen. This enlargement may remain persistent for a long time 
 after other symptoms have disappeared. 
 
 Diver. — The liver, w T hich is not infrequently affected, is hardened and 
 enlarged from a diffused sclerosis. Occasionally the affection may be circum- 
 scribed. The hepatic cells are compressed and the capillary blood-vessels 
 partly obliterated by the pressure. As in cirrhosis in the adult, section of the 
 liver is accompanied by creaking, and the cut surface presents a yellowish area, 
 interwoven with whitish opaque streaks of fibro-plastic matter. The capsule 
 of Glisson may be thickened upon the surface of the liver, and there may be 
 local peritonitis. Gummata, in the form of small, circumscribed nodules, may 
 be found in the tissue of the liver. They may be seen in association with cir- 
 rhosis. These nodules are yellowish, with a tendency to soften in the centre. 
 
 Pancreas. — Birch-Hirschfeld has called attention to the fact that there may 
 be hyperplasia of the connective tissue of the pancreas, w T hich on section pre- 
 sents the same fibroid appearance seen in the liver and other visceral organs 
 thus affected. He found in a few cases the head of the organ more involved 
 than the remaining part of the gland. 
 
 Testicles. — An interstitial orchitis may affect one or both testicles, produ- 
 cing hardening and slight enlargement of the glands. The hyperplasia may 
 be uniformly distributed through the organ, or the latter may be irregularly 
 involved. The epididymis is not usually affected. Atrophy of the seminal 
 ducts may ensue. Sufficient change in the testicle to be detected clinically is 
 not often seen in hereditary syphilis. 
 
 Kidneys. — Parrot has found small tumors, produced by infiltrations of round 
 cells into the connective-tissue stroma, w T hich compress the tubules, and thus 
 cause a colloid degeneration of the contained epithelium. If this process is 
 extensive, it will eventuate in a general atrophy of the kidney. General 
 nephritis may be seen in hereditary syphilis, but it is difficult to say whether 
 the latter is more than a predisposing cause of the former condition. 
 
 Heart. — Gummata may be found in the heart. Dr. Coupland has reported 
 a case where the walls of this organ w r ere thickened and hardened. 
 
 Boxe Lesions. — Waldemeyer, Kobner, Parrot, and R. W. Taylor have 
 shown that various bony lesions are quite common in hereditary syphilis. 
 Many of these lesions, that were formerly referred to rickets or scrofula, are 
 now recognized as syphilitic. There are two principal w T ays in which the spe- 
 cific 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 ; in the other, the periosteum covering the long bones is principally 
 affected. Both of these varieties involve principally the long bones. 
 
 Osteochondritis. — This inflammatory process is induced only by syphilis, 
 and may be the sole manifestation of the taint. The lesion starts in the car- 
 tilage joining the epiphysis with the diaphysis, where normal growth in length 
 of the bones takes place ; hence deformity of the bone, due to a crippling of 
 its proper development, may ensue. The lesion most commonly affects the 
 bones of the forearm, leg, arm, and thigh, although other bones may be 
 involved, such as the metacarpal and metatarsal bones, the clavicle, sternum, 
 and ribs. 
 
 The number of the bones affected appears to depend, to a certain extent, 
 
HEREDITARY SYPHILIS. 107 
 
 upon the severity of the general poisoning. It has been found in stillborn 
 infants that most of the long bones may be thus aifected, and in those born 
 living, if the bone lesion is multiple, recovery is uncommon. The cartilage 
 affected first becomes thickened and soft from proliferation of cartilage-cells, 
 and there is at the same time lessening of the intercellular substance. This 
 may be felt as a sort of collar-like swelling at the end of the bone affected. 
 The swelling may be visible if the child is not too fat. If, as occasionally 
 happens, one portion or side of the cartilage only is involved, the swelling will 
 be felt not to completely encircle the bone, but as a circumscribed nodule. 
 The disease is apt to be symmetrical and involve the distal oftener than the 
 proximal ends of the bones. There is little change in the integument or sur- 
 rounding tissues in many cases, as the disease is not apt to extend farther than 
 the bone. In such a case the swelling may remain for a long time, accom- 
 panied by little pain or disability. It may originally develop slowly or quickly, 
 and its disappearance will usually promptly follow a proper mercurial treatment. 
 In some cases, however, degenerative changes may ensue, with a breaking 
 down of some part of the swelling. If the morbid process continues, there 
 will be softening, soon followed by ulceration of the skin. If suppuration 
 keeps up, the cartilage will be destroyed and the epiphysis completely sepa- 
 rated from the diaphysis. Even in these cases the joint is not apt to be 
 involved, although cases of subacute synovitis, and even pus in the joint, have 
 been reported. If the ulceration is extensive, the epiphysis, when completely 
 separated, may be extruded. When there is destruction of the cartilage and 
 epiphysis, there will of course ensue arrest of growth and consequent deformity 
 in the limb. Parrot has described cases in which the skin remains unbroken 
 after separation of the epiphysis, inducing a condition of paralysis in the 
 affected part. Dr. Taylor describes cases in which, the intervening cartilage 
 having been destroyed, the epiphysis is united to the shaft only by fibres of 
 periosteum. This membrane may become much thickened, and form a more 
 or less complete cylinder, uniting the two fragments with considerable firm- 
 ness. Bony spiculae shoot from its inner surface between the two osseous sur- 
 faces, and thus eventually bony union is secured. The swollen periosteum 
 may gradually resume a more nearly normal thickness. 
 
 Osteo-chondritis develops early in life, usually Avithin the first month. The 
 lesion may, however, occur later, when it is not apt to become multiple, and 
 may be unsymmetrical in distribution. The question as to whether certain 
 epiphyseal swellings may be due to syphilis or rickets will possibly arise. 
 Other lesions of these two diseases will have to be sought after in order to aid 
 in making a correct diagnosis. Such swellings are pretty surely syphilitic if 
 they occur during the first six months of life, and at all times are relieved by 
 mercurial treatment. Again, the epiphyseal swellings of rickets are always 
 symmetrical, while those of syphilis may be unilateral. 
 
 Periostitis. — This form of lesion 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. There is more or less enlargement of the affected bone. At an 
 early stage of the disease the bones are attacked symmetrically, but later cir- 
 cumscribed nodes may be placed unilaterally. 
 
 Dactylitis. — The phalanges and the metacarpal and metatarsal bones may 
 be enlarged to several times their natural size. After an interval of time the 
 skin may become inflamed and break down from the formation of an abscess. 
 The proximal phalanges are more apt to be attacked than the distal, and sev- 
 eral bones of each hand may be affected. There is not much destruction of 
 
108 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bone, even in severe cases, and, although the disease tends to run a slow course, 
 it is always influenced favorably by treatment. Dactylitis is apt to occur in very 
 young subjects, when it takes the form of a gummatous infiltration. (Fig. 1). 
 
 Fig. 1. 
 
 Syphilitic Dactylitis. 
 
 Craniotabes. — The local thinning of portions of the cranial bones was 
 formerly attributed exclusively to rickets, but is now known to ensue as well 
 in the malnutrition accompanying syphilis. As it is due to pressure of the 
 thin skull between the brain and pillow, it is especially apt to involve the 
 occipital bone. Carpenter considers that both craniotabes and Parrot's nodes 
 are often syphilitic manifestations, although they are more frequently regarded 
 as evidences of rickets : 74 per cent, of cases of craniotabes are syphilitic, 
 according to this author. 
 
 Symptoms. — The symptoms of hereditary syphilis vary widely according 
 to the extent of the poison. When the virus is concentrated, as in cases where 
 both parents are syphilitic, the foetus will be attacked by the disease in the 
 uterus, and, as a result, we shall have abortion more or less early in the preg- 
 nancy. As the disease abates in one or both parents the pregnancies will 
 be longer in duration, until finally apparently healthy infants may be born. 
 
 In some cases the infant will present marked evidences of syphilis at 
 birth : often, however, the onset is delayed until later, and at birth there 
 may be absolutely no manifestation of the disease. In 158 cases analyzed by 
 Diday the first manifestation of symptoms occurred in 86 cases before the 
 completion of one month ; in 45 before the completion of two months ; and 
 in 15 before the completion of three months after birth. The remaining 12 
 cases showed the symptoms in intervals varying from four months to two 
 years. 
 
 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- 
 
HEREDITARY SYPHILIS. 109 
 
 tion, eruptions of bulla?, particularly upon the palms of the hands and soles of 
 the feet, and an extreme degree of coryza, cracked and ulcerated lips, and evi- 
 dences of visceral and bony disease. In the older cases there may be no 
 interference with nutrition, and possibly one or two mucous patches may be 
 the only active manifestation of the disease. In studying the symptoms it 
 may be well to consider the disease as it shows itself in different structures and 
 areas of the body. 
 
 Skin. — One of the early symptoms appearing upon the skin will be the 
 eruption of small round pink spots, disappearing on pressure, and usually 
 appearing first on the lower portion of the abdomen. It may spread from this 
 location and finally involve the whole body. Pigmentation of these spots may 
 ensue, and they may present a dark-red, coppery discoloration. This latter 
 change may be considered as having a diagnostic value. In hereditary syph- 
 ilis the rashes often develop rapidly, and are apt to be less symmetrical than 
 those seen in adults. They are likewise polymorphous, as several different 
 forms of syphilide may be exhibited at the same time in a given case. A pap- 
 ular syphilide may be seen in the form of small or large flat papules, symmetri- 
 cally distributed over the surface. These papules are not so apt to group them- 
 selves into lines and circles as in older subjects with syphilis. They are not 
 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 syphilide is not common, and when seen is apt to 
 be in very severe cases. The vesicles may be associated with pustules, and 
 appear in closely-arranged groups about the mouth or chin or various other 
 parts of the body, especially the nates and hypogastrium. Pustules may form, 
 especially on the face, buttocks, and thighs. The ulceration is deeper and the 
 crusts darker in color than in impetiginous eczema. Pemphigus likewise 
 appears in the severe forms of the disease. It most frequently attacks the 
 palms of the hands and soles of the feet ; it may have a copper-colored areola 
 and develop rapidly. Crops of indolent boils, symmetrically distributed and 
 of a copper-red color, may appear in connection with other eruptions. They are 
 more apt to be seen in badly-nourished infants. In some cases the only appear- 
 ance of syphilis upon the skin will be a smoky discoloration, seen most dis- 
 tinctly in the prominent parts of the face, such as the eyebrows, cheek-bones, 
 and bridge of the nose. The nutrition of the skin is much affected in cases 
 where the cachexia is marked ; it hangs in dry, loose folds, having an unhealthy, 
 earthy appearance. 
 
 Mucous Membranes. — The mucous membranes, as well as the skin, present 
 the earliest manifestations of the disease. One of the most typical lesions is 
 the coryza, which may be the first symptom ncted. First, there may be a 
 serous discharge which attracts little notice ; this, however, gradually becomes 
 worse, and the nasal secretion takes on a purulent or even a bloody character, 
 and may be sufficiently irritating to cause excoriations of the upper lip. The 
 mucous membrane itself becomes thickened, and the inspissated secretion soon 
 dries, forming crusts, which may completely block up the passage through the 
 nostrils and seriously interfere with nursing. The secretion may likewise be 
 offensive. In severe cases, particularly where cleanliness is not practised and 
 the decomposing secretions are allowed to remain in the nostril, there may fol- 
 low ulceration of the mucous membrane, and possibly even necrosis of the 
 adjacent bony parts. There is apt to be a flattening of the bridge of the 
 nose, probably, to a certain extent, due to the interference with normal respi- 
 ration. The inflammation may spread to the pharynx and larynx, although 
 its action is likely to be limited to the Schneiderian membrane. 
 
110 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Mucous patches will be seen in most cases of hereditary syphilis, and, 
 although they appear most constantly on the mucous membranes, they may 
 be present upon the skin, particularly at its junction with the mucous 
 membranes, or upon those parts which are thin and exposed to various 
 secretions. They may occasionally be seen on any part of the cutaneous 
 surface of the body. They are oftenest seen in the mouth, about the nose, 
 upon the scrotum, vulva, labial commissures, and occasionally at the umbil- 
 icus. In the mouth the most frequent situations are upon the angles of 
 the lips, inside of the cheeks, the pillars of the fauces, the tonsils, and the 
 sides and dorsum of the tongue. They consist, in the early stage, of a slightly 
 raised segment of mucous membrane, presenting a whitish surface and red 
 margins. This may soon ulcerate. When the mucous patches appear at the 
 angles of the mouth, deep fissures will often form at the corners of the lips, 
 extending sometimes well out into the cheek. These fissures are sometimes 
 called rhagades, and are diagnostic. The secretions on these mucous patches 
 are very infective. When mucous patches appear on the cutaneous surface, 
 they are slightly raised, with a macerated appearance, and frequently seamed 
 with erosions or cracks. In the late stages of hereditary syphilis mucous 
 patches are not so numerous as in the earlier stages of the disease, but they 
 frequently recur after the child is apparently restored to health. 
 
 Disturbance of Nutrition. — The extent to which the general nutrition of 
 the infant is disturbed will depend upon the severity of the attack. In grave 
 cases there is atrophy of all the structures of the body, the infant presenting 
 a weazen appearance, with a countenance resembling that of an old man. 
 These cases are almost invariably fatal, and are caused by the blighting 
 influence of the virus. In many cases, however, a failure of nutrition will 
 ensue gradually, consecutive to gastro-intestinal disturbance. This may be 
 due to actual specific disease of the liver, stomach, or intestines, or it may be 
 due to indigestion and malassimilation only indirectly caused by feebleness 
 from the cachexia. In bottle-fed babies digestive disturbances are marked 
 and severe, infants upon the breast being much less liable to suffer. In some 
 cases the infant will present very slight disturbance of the general nutrition, 
 being plump and well-nourished throughout the course of the disease, which 
 may be only manifested by mucous patches or mild evidences of the infection. 
 
 Condition of the Blood. — A condition of profound anaemia is frequently 
 seen, particularly in severe cases. Johann Loos states that hereditary syphilis 
 is always associated with an anaemia which under some conditions may reach an 
 extreme degree of intensity. This anaemia is characterized by a diminution in 
 the number of the red blood-corpuscles, by quite a marked alteration in these 
 corpuscles, the appearance of megalocytes and microcytes, and by the appear- 
 ance of nucleated erythrocytes, sometimes in quite notable quantity. It is 
 always characterized by the constant existence of leucocytosis, which may 
 often become extreme, and by the appearance of myelo-plaques in the blood. 
 This anaemia is a very important and significant symptom of the disease, and 
 may directly occasion a fatal issue. He further states that there are only two 
 diseases common to childhood in which the lesions of the blood suggest the 
 changes just described, and these are splenic anaemia and severe forms of 
 rachitis. 
 
 A form of syphilis haemorrhagica neonatorum has been described by 
 Bumstead and Taylor. There may be simply a limited subcutaneous effusion, 
 or the mucous membranes may be the seat of the haemorrhage. Haemorrhage 
 at the umbilicus shortly after birth may be due to this cause. 
 
 Glandular Enlargements. — General adenopathy is not seen in the hereditary 
 
HEREDITARY SYPHILIS. Ill 
 
 form of syphilis. There may be enlargement of the chains of cervical glands 
 consecutive to lesions in the adjacent mucous membranes, and occasionally 
 there may be an affection of the inguinal, axillary, or cervico-maxillary 
 glands without any deeper lesions being noted to account for their existence 
 by septic absorption. The glands are hard, moving without pain in the areolar 
 tissue under pressure by the finger. Some writers consider that enlargement 
 of the epitrochlear glands is pathognomonic of congenital syphilis, but well- 
 marked cases occasionally fail to show this sign upon careful examination. 
 
 Bony Organs. — The frequency with which the bones are involved in 
 hereditary syphilis has been noted in the morbid anatomy of the disease. In 
 every case the long bones should be carefully examined for enlargement and 
 thickening at the epiphyseal and distal ends. In cases where suppuration has 
 taken place the epiphysis may be separated from the shaft, and crepitation 
 will then be found upon careful handling. The joint itself may occasionally 
 be involved in the inflammation, showing the well-known symptoms of arthritis. 
 Where the bones are much affected there will be some disability of the limb, 
 possibly extending to complete paralysis. Immobility in such a case is with- 
 out doubt due to the affection of the bones. 
 
 Dactylitis. — In the early period of the disease an enlargement of the 
 phalanges is frequently seen, and occasionally also of the metatarsal and 
 metacarpal bones. The proximal phalanx is more frequently attacked than the 
 distal ; the affestion may spread to all of the phalanges, but is more apt to 
 involve only one, which may be enlarged to double its normal size. This 
 enlargement is the result of specific inflammation of the bone and periosteum, 
 and runs a slow course unless modified by specific treatment. There is not 
 apt to be much involvement of the soft parts ; the integument will be reddish 
 and inflamed, but there is little tendency to suppuration and ulceration. These 
 swellings usually present a fusiform shape, with a hard, firm sensation to the touch. 
 
 Teeth. — The appearance of the deciduous teeth is delayed in hereditary 
 syphilis, as in rachitis. The first teeth may not appear until the tenth or 
 twelfth month, or even later. These teeth are poorly developed and apt to 
 undergo early decay. There is usually a similar delay in the appearance of 
 the second teeth, which present more pathognomonic changes, which will be 
 noted in connection with late hereditary syphilis. 
 
 Nervous Disturbances. — Lesions of the nerve-centres do not often appear 
 in hereditary syphilis ; there may be, however, an occasional palsy due to a 
 peripheral cause. One form in connection with bony lesions has already been 
 mentioned. There may be contractures and paresis, however, where no bony 
 lesion can be noted. Henoch questions whether such affections may not be 
 myopathic in their origin and independent of the nervous system. 
 
 The following case coming under my observation illustrates a case of 
 paralysis evidently caused by interstitial syphilitic myositis: An infant four 
 weeks old, whose mother presented syphilitic lesions, was born healthy at full 
 term. When seven days old it was noticed that the right leg was drawn up 
 and apparently did not move ; also the right arm. There was complete loss 
 of power in these members ; there was wrist-drop, and a loss of faradic and 
 galvanic irritability in the extensors of the left wrist. The muscles affected 
 were rather hard and painful to the touch. There was an enlargement at 
 the epiphyseal end of the left humerus. The paralysis completely disappeared 
 in about two months under specific treatment. 
 
 Dr. Eustace Smith states that a form of real paralysis has been occasionally 
 seen affecting the branches of the brachial plexus, causing more or less com- 
 plete loss of power in the arm. 
 
112 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Onychia. — Two kinds of onychia are noted in hereditary syphilis — the 
 ulcerative and the nutritive. In the ulcerative form the pustule appears at 
 the margin of the nail, which soon breaks down, leaving a sloughy surface, 
 which may destroy the matrix. The surrounding skin presents a coppery 
 discoloration. In the nutritive form, which is apt to appear later, the ulcer 
 has a sloughy base, and presents a swelling around the periphery of the nail, 
 which becomes thickened and brittle. Swelling and deformity of the phalanx 
 may ensue. In a case recently observed, a child of two years, whose father 
 had a specific history, presented immense bulbous masses upon the extremities 
 of the thumb and middle finger of the right hand and the thumb and fore 
 finger of the left hand. These were granular, warty masses about the size of 
 hickory-nuts, with the nail protruding backward. When the infant was eight 
 months old it appeared healthy, except that the finger-nails now involved were 
 like claws and were reddened as if scalded. The trouble had continued until 
 the nutritive changes produced the enlarged mass here noted. There had 
 been a history of "snuffles," abscesses on the buttocks, sore lips and gums, 
 but at the time of the examination the only other manifestation of the disease 
 was a large mucous patch in front of the scrotum. In the nutritive form of 
 onychia the hypersemia of the matrix and the deformity of the phalanx, if not 
 extreme, may disappear under specific treatment. 
 
 Iritis. — This is an exceedingly rare affection in hereditary syphilis, but 
 cases have been reported by Mr. Hutchinson in infants varying in age from 
 six weeks to sixteen months. It does not differ from the same manifestation 
 in adults. 
 
 Alopecia. — There may be loss of hair in the scalp, eyebrows, or eyelashes. 
 The last form is the most pathognomonic, as there may be a deficiency in the 
 nourishment of the hair of the scalp in rickets or any condition of cachexia 
 in infants. 
 
 General Irritability. — Syphilitic infants are very fretful, and the cry is of 
 a peculiar high-pitched character. This fretfulness is particularly apt to be 
 present at night, at which time the child is extremely wakeful. In this, how- 
 ever, it does not differ much from rickets. 
 
 Diagnosis. — A difficulty in the diagnosis of hereditary syphilis may 
 obtain where typical lesions are not well marked, or where it is a question 
 between syphilis and scrofulous or tubercular lesions. In cases of marasmus, 
 if there is no history of chronic indigestion, particularly if the infant have 
 been fed at the breast, 'there is strong rnspicion of syphilis. A careful 
 examination for mucous patches will often throw light on such a case. 
 Chronic coryza is likewise a valuable sign in diagnosis. 
 
 The following points of distinction between syphilitic and scrofulous lesions 
 of the skin have been given by Dr. P. A. Morrow : (1) Syphilitic lesions are 
 general in their distribution ; they may occur upon any region of the body. 
 Scrofulous lesions are more limited in their localization; they have a special 
 predilection for the neck or regions rich in lymphatic glands. (2) Syphilitic 
 lesions are ambulatory and changing ; they disappear and reappear elsewhere. 
 Scrofulous lesions are fixed and permanent. (3) The color of syphilitic 
 lesions is reddish-brown or "lean-ham" tint. The color of scrofulous lesions 
 is brighter and more violaceous in hue. (4) Syphilis is distinct from scrofula 
 in its objective appearances and mode of evolution. In the initial stage the 
 syphilitic neoplasms are firm and hard ; the scrofulous infiltrations are softer 
 and more compressible. In the ulcerative stage the differences are more 
 pronounced ; the ulcers of syphilis are cleaner cut, regular in contour, with 
 perpendicular, firmly-infiltrated borders encircled by a pigmented areola; 
 
HEREDITARY SYPHILIS. 113 
 
 scrofulous ulcers are irregular, with soft, undermined borders ; they are 
 painless, bleed easily, and show slight tendency to spread. (5) The crusts of 
 syphilis are bulkier, thicker, with a tendency to accumulate in layers, and 
 darker in color ; the cicatrices are smooth and remain long surrounded by a 
 pigmented areola. The crusts of scrofula are softer, more adherent; the 
 cicatrices are elevated, irregular, bridled ; they retain their violaceous color 
 for a long time. (6) The course of a syphilitic ulcer, though sluggish and 
 chronic, is much more rapid than that of scrofula. (7) Absence of pain and 
 local reaction characterize both syphilitic and scrofulous ulcers ; they are 
 essentially lesions without symptoms. 
 
 In connection with the bony lesions it is important to diagnose between 
 syphilis and tubercular and rachitic affections. The following points in diagnosis 
 between syphilis and tuberculosis are given by Dr. Morrow : (1) Syphilis ex- 
 hibits a marked predilection for the long bones ; its habitual localization is in 
 the diaphysis, and almost always at its terminal extremity. Tuberculosis 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 volumin- 
 ous osseous tumors or hyperostoses, with little or no involvement of the soft parts ; 
 and in tuberculosis the tumefaction is due less to increase in the size of the 
 bone than to oedematous infiltration of the soft structures. (3) In syphilis 
 there is little tendency to suppuration and necrosis ; in tuberculosis the pyogenic 
 tendency is marked. (4) In syphilis osteocopic pains, with tendency to noc- 
 turnal exacerbation, are a pronounced feature ; in tuberculosis the pain is dull 
 and heavy, not aggravated at night ; sometimes there is entire absence of acute 
 painful symptoms. (5) The osseous lesions of syphilis rarely react upon the 
 general system, while those of tuberculosis often determine a marked impair- 
 ment of the general health, grave complications, hectic fever, cachexia, etc. 
 
 In syphilitic dactylitis there is little involvement of the soft parts, the 
 swelling being caused by the enlargement in the size of the bone. In tuber- 
 cular dactylitis the swelling is due more to an oedematous infiltrated condition of 
 the soft tissues than to enlargemtTi t of the bone. In the latter cases breaking 
 down of the tissues and ulceration are more apt to ensue. 
 
 The diagnosis between syphilis and rickety bone-lesions may be of great 
 importance. Epiphyseal swellings occurring under six months are very apt to 
 be syphilitic. In syphilis the epiphyseal swelling may be unilateral, but it is 
 always symmetrical in rachitis. In doubtful cases the swelling must be sub- 
 jected to specific treatment. It is well to remember, however, that rickets and 
 syphilis may coexist in the same case. There is almost invariably enlargement 
 at the costo-chondral articulations in all cases of rickets, which is absent in 
 syphilis. 
 
 Prognosis. — According to Kassowitz, one-third of all syphilitic children 
 die before their birth, and among those who are born 34 per cent, die in the 
 first six months of life. Fournier places the mortality, when derived from the 
 father alone, at 28 per cent. • from the mother alone, 60 per cent. ; when from 
 both parents, 68J- per cent. The earlier the symptoms appear after birth, 
 the severer will be the type of the disease and the worse the prognosis. Involve- 
 ment of the bones and viscera means a severe type of the disease. Infants 
 fed upon the breast will have a much better chance than those artificially fed. 
 In bottle-fed infants, particularly when the disease appears early, the prognosis 
 is almost always fatal ; it is invariably so in hospitals and lying-in institutions. 
 Any interference with digestion and assimilation, no matter from what cause, 
 will necessitate a guarded prognosis. If the coryza is extreme and breathing 
 much disturbed, the prognosis must be altered in proportion to the amount of 
 
114 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 such disturbance, which interferes with rest and the taking of food. If the 
 digestion remains good, and particularly when the manifestations of the disease 
 are not severe, complete recovery takes place, and the infant may grow up 
 healthy and strong. 
 
 Late Hereditary Syphilis. 
 
 In some cases of hereditary syphilis the manifestations of the disease during 
 infancy may be exceedingly mild, and, in fact, overlooked. It is possible in 
 such a case that the poison may show itself in various ways during the period 
 of childhood. " Syphilis tarda " is a term applied to those cases in which the 
 first manifestations of hereditary syphilis appear in childhood. The existence 
 of such a condition without any earlier evidence of the disease has been dis- 
 puted. It is analogous to the discussion as to whether syphilis in the adult 
 may present late secondary or tertiary symptoms without being preceded by 
 earlier lesions. 
 
 Late hereditary syphilis may manifest itself either in certain active lesions 
 plainly to be attributed to this condition, or by certain developmental defects 
 that may easily be confused with scrofula, tuberculosis, or rickets. It may be 
 well for us to note some of the more characteristic lesions. 
 
 Bone Affections. — One of the commonest manifestations is a periostitis 
 involving various long bones, especially the tibia, the ulna, the radius, and 
 the humerus. Accompanying this periostitis there may be considerable thick- 
 ening upon the surface of the bone, sufficient to induce a change in its form. 
 The lesion may be multiple and symmetrical, although occasionally unilateral. 
 It is attended often with little discomfort aside from occasional nocturnal 
 pains. The nasal bones may be affected, producing much deformity by destruc- 
 tion of the bony arch of the nose. In many cases not so severe there is marked 
 flattening of the bridge of the nose and a wide separation of the eyes. The 
 frontal bone is apt to be large and flat, with prominences somewhat exagger- 
 ated. There is also usually a very high palate arch. Dactylitis may be 
 seen in this late stage of the disease, and sluggish swellings of the meta- 
 carpal and metatarsal bones. The secondary teeth are affected in a way 
 that has been considered pathognomonic. As is well known, Mr. Jonathan 
 Hutchinson first called attention to this condition. The principal change is 
 noted in the two superior middle incisors, which are small, peg-shaped, and 
 placed at such an angle that the cutting borders, if continued, would meet. 
 They may occasionally be deflected outward, as in the accompanying illustration. 
 (Plate IV.) The cause of this maldevelopment has been explained by Four- 
 nier as due to defective growth within the alveolus, while Hutchinson refers 
 it rather to an early stomatitis or an alveolar periostitis often present during 
 infancy. The incisors are apt to be notched at the lower edge, as is well 
 shown in the plate, which is taken from a case under the care of Dr. 
 Stowell. The enamel is usually eaten away in this portion of the teeth. 
 Dr. John N. Mackenzie has called attention to ulceration of the palate, which 
 is apt to take place in the centre, and be followed by caries or necrosis of the 
 bone. There may be simultaneous or consecutive deep ulceration of the palate, 
 pharynx, and naso-pharynx at any time previous to the age of puberty. Large 
 and indolent mucous patches may be present upon the cheek, tongue, gums, 
 and especially about the corners of the mouth. The ulceration about the lips 
 may leave long scars, particularly to be seen at the commissures of the lips. 
 This is most beautifully shown in the accompanying illustration of Dr. Sto- 
 well' s case. (Plate V.) 
 

HEREDITARY SYPHILIS. 115 
 
 Kidneys. — Fournier considers that chronic degenerative changes may take 
 place in the kidneys, usually in the form of a parenchymatous nephritis and 
 amyloid degeneration. 
 
 Interstitial Keratitis. — There is frequently noticed an opacity of the cornea 
 without much congestion of the conjunctiva. The opaque areas may, in severe 
 cases, coalesce, and cover the whole cornea. Although primarily attacking 
 one eye, it soon involves the other. There may coexist an iritis, presenting 
 symptoms which are indolent in character without the severe pain and photo- 
 phobia so often seen in many cases of iritis. It may be difficult to recognize 
 the existence of iritis when the cornea is opaque from the presence of abun- 
 dant interstitial keratitis. Deeper-seated troubles, such as choroiditis and reti- 
 nitis, may occasionally occur. 
 
 The Genitalia. — Occasionally a painless enlargement of one or both testi- 
 cles may be noticed, accompanied by a slight degree of hydrocele. This con- 
 dition may sometimes involve the epididymis and the cord. When the testicle 
 is thus involved, there are apt to be syphilitic lesions in other parts of the 
 body, which will aid in diagnosis. In many cases all the evidence of syphilitic 
 taint in childhood will be seen in arrested and perverted development. Such 
 a child exhibits in its growth much retardation of development in comparison 
 with other children of the same age. This may be particularly seen in the 
 genital organs, the testicles at puberty being the size seen in very early child- 
 hood, and in girls an absence of mammary development, delayed menstruation, 
 and a non-appearance of hairs on the genital and axillary regions. Fournier 
 has given the name " infantilism " to this defective physical and mental devel- 
 opment. Such cases not infrequently develop epilepsy. 
 
 The Treatment of Syphilis. 
 
 The dictum of Dr. Holmes that the proper treatment of some diseases 
 should be begun one hundred years before birth may be modified, in syphilis, 
 to a treatment existing several months before birth. There is no doubt that 
 parents who exhibit any specific symptoms or who have had syphilitic children 
 should be subjected to constant specific treatment and oversight. Such treat- 
 ment may avoid miscarriage, and possibly prevent the development of syphilitic 
 disease in the infant. The treatment of the syphilitic infant resolves itself 
 into specific medication directed to the actual poison of the disease and to 
 rreans aimed to prevent the collateral loss of nutrition which is so common and 
 so grave in these cases. Mercurial treatment may be applied by external or 
 internal medication. The former is particularly adapted to cases where infan- 
 tile diarrhoea and indigestion may, to a certain extent, contraindicate the inter- 
 nal use of mercury. Daily inunctions of mercurial ointment mixed with from 
 four to eight times its quantity of vaseline or rose ointment are efficacious. It 
 may be rubbed on the inside of the thighs or in the axillae, using a portion 
 about the size of a small hickory-nut. Or the ointment may be applied on a 
 flannel roller and bandaged about the child once a day. Before applying the 
 ointment in this way the skin must be cleansed thoroughly with soap and tepid 
 water. A little more cleanly method of local medication consists in applying 
 five drops of a 10 per cent, solution of the oleate of mercury three times daily. 
 It is certain that under external applications the specific lesions will frequently 
 disappear. 
 
 It is probable, however, that it will be found, as a rule, more satisfactory to 
 employ internal medication. Mercury with chalk is one of the best prepara- 
 tions, in doses of one-fourth of a grain to one or two grains twice a day. Dr. 
 
116 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Jacobi prefers calomel, on account of the rapidity of its action, in doses of from 
 ■JL- to \ grain three times a day. Bichloride of mercury has many adherents. 
 The liquor of Van Swieten is the form recommended by Parrot for internal 
 administration. The formula is as follows : 
 
 ~Bf. Bichloride of mercury 1 part. 
 
 Water 950 parts. 
 
 Rectified spirits 100 parts. 
 
 Sig. 5 to 20 drops in milk three times a day. 
 
 The bichloride of mercury may be given in simple watery solution, which 
 may be combined with milk, and hence readily taken by the infant. The dose 
 varies from -^-q to ^ of a grain, according to the age and condition of the 
 infant. If intestinal irritation be caused by the drug, a mixture of wine of 
 pepsin and elixir of bismuth may be used as a menstruum. 
 
 An important element in the management of these cases will be the local 
 treatment, applied to mucous patches, excoriations, and especially to the coryza. 
 Ulcerations and destructive processes in the nose may be largely avoided by 
 keeping the nasal passages clean by tepid water or bland oil. A 2 per cent, 
 solution of the oleate of mercury will be efficacious in the nose. Mucous 
 patches or condylomata should be kept clean, and may be dusted with calomel 
 and bismuth. Nitrate of silver may be applied to patches appearing in the 
 mouth that are intractable to internal treatment. 
 
 Where the bones are involved and evidence of gumma in any portion of the 
 body is present, iodide of potash should be employed. In the visceral lesions 
 this remedy likewise acts well ; and if the indications arise, mixed treatment, 
 by combining the binioclide of mercury with iodide of potassium, may be em- 
 ployed. The iodide of potassium is most efficacious, although the iodide of 
 sodium may be administered with good results. The dose should be moderate, 
 not averaging more than a few grains. 
 
 The general care of the nutrition of the syphilitic infant is most important. 
 The chances for maintaining good nutrition are much improved by keeping the 
 baby on its mother's breast. If the mother is unable to entirely supply the 
 infant with nourishment, the bottle may be employed, but never to the com- 
 plete exclusion of the breast. The well-known fact that an infant cannot infect 
 the mother, although the latter shows no evidences of syphilis, justifies us in 
 insisting upon her nursing her own infant. The employment of a healthy wet- 
 nurse, although of advantage to the infant, is not justifiable, as the former will 
 almost surely be infected by the latter. After nursing, the nipple should 
 always be carefully cleansed, as well as the infant's mouth, by the use of some 
 bland disinfectant solution. In cases in which the infant is deprived of the 
 breast the most scrupulous care and cleanliness must be exercised in artificial 
 feeding. A mild form of indigestion will severely handicap the syphilitic infant, 
 and may eventuate in its death. General tonic treatment and stimulation may 
 be employed in connection with specific treatment. 
 
 The treatment of the later forms of syphilis will depend upon the activity 
 of the morbid process. Mercury should always be exhibited in some form 
 when there is any evidence of active syphilitic disease. It has been proven 
 that small and proper doses of mercury are tonic in syphilis, and actually 
 relieve the hydremia and defective nutrition so often seen in this disease. 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, change of air when possible, are all of value in aiding 
 healthy growth and development in these retarded cases. 
 
PART III. 
 THE INFECTIOUS DISEASES. 
 
 MEASLES. 
 
 By LOUIS STARR, M. D., 
 
 Philadelphia. 
 
 Rubeola is an acute, infectious disease, characterized by coryza and 
 other catarrhal symptoms, by continued fever, and by an eruption of slightly 
 elevated, crimson papules upon the face and body, followed by furfuraceous 
 desquamation. 
 
 It is perhaps the commonest of the infectious diseases of childhood, and 
 very few individuals arrive at adult age without having suffered from an 
 attack. One attack usually protects against a second, though instances in 
 which there have been two, or even three, attacks are not rare. 
 
 In large cities scattered cases of measles may be encountered at almost 
 any time, but at certain recurring intervals, varying from eighteen months to 
 two years, the disorder becomes epidemic. These epidemics are alike in the 
 fact that young children, being unprotected by a previous attack, uniformly 
 suifer most ; unlike, in the extent of their prevalence, in fatality, and in the 
 accentuation of particular symptoms. In isolated localities, having infrequent 
 communication with large centres of population, and where measles has pre- 
 vailed only at long intervals, the disease when it does arise finds a greater num- 
 ber of victims, attacks a larger proportion of adults, and is more fatal. When 
 introduced to a virgin soil the virulence is extreme. As an instance of this 
 the four months' epidemic of 1875 in the Fiji Islands may be cited: during it 
 40,000 natives died out of a population of 150,000 — upward of 1 to every 4 
 souls. By contrast, the mortality in London in 1886 — an average year — was 
 1 to each 2000 of the population. 
 
 Etiology. — The prime cause of the disease is a specific poison, the nature 
 of which has not been determined, though A. Ransome and Braidworth and 
 Yacher have discovered, in the breath and secretions of measles patients, 
 certain peculiar organisms identical with those to be described as existing 
 in the skin, the lungs, and the liver. It is certain, however, that the poison 
 spreads by contagion, and most probable that, whether or no these micro-organ- 
 isms carry it, it is given off in the breath and secretions. The contagion is 
 usually conveyed directly from the sick to the well, and is so virulent that 
 when once introduced to a dwelling or hospital ward its spread is rarely 
 stopped until all unprotected inmates suffer. It may be carried from place to 
 place by fomites, but simple airing of the clothing is usually sufficient to dis- 
 infect it. When such instances of infection occur close connection is shown, 
 the medium being a child or nurse coming directly from an infected house. 
 Experimentally, the disease has been propagated by inoculation with the 
 blood, the nasal and bronchial mucus, and the tears of a patient, and also 
 
 117 
 
118 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 with the serum taken from the vesicles which occasionally accompany the 
 eruption. Infection begins in the incubative stage, is most active during the 
 pre-eruptive period of coryza and fever, continues throughout the eruption, 
 and thereafter rapidly subsides, to disappear at the end of the third week. 
 
 No age of infancy or childhood is exempt from measles. It may occur 
 in sucklings a few weeks old, but is uncommon during the first six months 
 of life. The period of greatest susceptibility is between the second and sixth 
 years. 
 
 According to some authorities, males are more prone to be attacked than 
 females, but the disproportion between the two sexes is insignificant. Season, 
 too, seems to have little influence in furthering the onset of the disease. If 
 there be any difference, it is in favor of the damp, changeable, depressing 
 weather of March, April, and early May. In the Children's Hospital of 
 Philadelphia, for example, scarcely a year passes in which there is not a more 
 or less extended epidemic during these months. Apart from unknown atmo- 
 spheric causes, the explanation may be found in the fact that at this season 
 children are below par, or impaired in health by the disorders and confine- 
 ment incident to the winter months, and therefore less able to resist the 
 contagion which is always latent in large cities. 
 
 Pathology. — When death comes early in the course of the disease from 
 the force of the poison itself, an autopsy reveals hypostatic congestion of the 
 lungs, hyperaemia of the mucous membranes, and congestion of the organs 
 generally, with extravasation into their substance, and softening. The blood 
 is fluid, dark-colored, and deficient in fibrin. 
 
 During an epidemic at the Philadelphia Hospital, Drs. Keating and 
 Formad detected large numbers of microbes in the liquor sanguinis and white 
 corpuscles of blood taken from malignant cases, and the author has since 
 made the same observation. Quite recently, too, a bacillus has been discovered 
 in the urine of rubeolous patients. What relation these organisms bear to 
 the disease cannot yet be definitely asserted. In sections of skin made on 
 the sixth day of the eruption Braidworth and Vacher found swelling of the 
 chorium and thickening of the rete Malpighii, due to great proliferation of 
 cells which extended along the hair and sweat-ducts into the glands. Spark- 
 ling, colorless, spheroidal, and elongated bodies were also present in the true 
 skin next to the rete, in the lungs, and in the liver. In each situation these 
 bodies were mixed with others, spindle-shaped, staff-shaped, and canoe-shaped ; 
 all appeared to be albuminoid in character. 
 
 Other morbid appearances vary with the complications upon which death so 
 frequently depends. The most common lesions are those of diffuse broncho- 
 pneumonia and of structural alterations of the mucous membrane of the 
 gastro- intestinal tract, either catarrhal inflammation, follicular entero-colitis, 
 ulcerative inflammation, especially of the colon, or softening. Less frequent 
 are caseation of the bronchial glands, miliary tuberculosis of the lungs, 
 pulmonary collapse, membranous laryngitis, diphtheria of the pharynx, and 
 effusions into the pleurae and other serous cavities. 
 
 Incubation. — The interval between the actual introduction of the poison 
 and the appearance of the first symptoms of illness has been quite accu- 
 rately determined — first, by experiment, measles having been introduced by 
 inoculation in Edinburgh, Italy, and Germany ; second, by the careful study 
 of outbreaks in virgin soil, such as that in the Faroe Islands, by Panum ; 
 and third, by ordinary clinical observation. From all these sources the period 
 may be fixed at from ten to twelve days. 
 
 Adults and older children may complain of distaste for food, slight head- 
 
MEASLES. 
 
 119 
 
 ache, and lassitude for several days before the actual beginning of the disease, 
 but younger children appear to be perfectly well, and practically there are 
 no symptoms during incubation. 
 
 Symptoms. — The course of rubeola may be divided into several stages. 
 
 Prodromal Stage. — This lasts about four days, and is characterized by the 
 following group of symptoms : lassitude, irritability, at times chilliness, pain 
 in the back and limbs, headache, loss of appetite, thirst and other indications 
 of gastro-intestinal disturbance, and, more important, fever, with the various 
 signs of catarrhal irritation of the mucous membrane of the eyes, nose, fauces, 
 and larynx. The chilliness is not marked, rarely amounting to more than a 
 disposition on the part of the patient to keep near a fire or a desire for more 
 clothing, and a degree of coolness in the extremities appreciable to the nurse's 
 hand. The same may be said of pain in the back and limbs, its presence in 
 older children being established only by close questioning, and in younger by 
 their showing indications of suffering when moved. 
 
 Pyrexia is uniformly present. It may be postponed until the second day 
 of the prodromal stage, but usually begins on the first. The fever is contin- 
 ued in type, the ascent of temperature being marked by evening exacerbations 
 
 Fig. 1. 
 
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 Chart of Temperature in Measles, showing Pre-eruptive Rise. 
 
 This chart was taken from a negro boy set. eight years, a patient at the Children's Hospital, Philadelphia. 
 The attack of measles began on the day marked 1 ; the eruption was detected on that marked 5, and was at 
 its height on 5 and 6. 
 
 (about 2°) and morning remissions (about 1°), which show a tendency to become 
 less decided and shorter as the day of eruption is approached. Sometimes there 
 is a marked remission or complete intermission on the second or third day, after 
 which the temperature curve pursues the ordinary course. (See Figs. 1 and 2.) 
 
120 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 With the rise in temperature the pulse becomes increased in frequency, 
 force, and volume, though it is rarely as frequent as in scarlet fever. The 
 skin, while moist, feels hot ; complaints are made of frontal headache ; and 
 the child, at first irritable and restless, gradually passes into a condition of 
 quiet and drowsiness, when it is said to "sleep for the measles." 
 
 The pathognomonic catarrhal symptoms begin with, or even precede, the 
 pyrexia. These are inflammation and redness of the conjunctivae — the pal- 
 pebral portions especially — injection of the whites of the eyes, photophobia, 
 lachrymation, stuffing of the nose, sneezing, and an abundant discharge of 
 muco-purulent fluid from the anterior nares. The secretions from the eyes 
 and nose are irritating and excoriate the skin over which they flow; the red- 
 ness thus produced, with the injection of the eyeballs, the swelling of the lids 
 and face generally, make up a heavy, almost characteristic, physiognomy. 
 
 Cough is usually present from the first day. Slight and infrequent in the 
 beginning, it gradually increases, until on the third or fourth day it assumes a 
 peculiar character. It is laryngeal, hard, dry, rather hoarse, and occurs in 
 short paroxysms. Expectoration, when present, is slight and consists of clear, 
 viscid mucus. The voice is hoarse. 
 
 The tongue is covered with a light white coating ; the tonsils are moder- 
 ately enlarged ; the mucous membrane of the soft palate, fauces, and pharynx 
 is uniformly swollen and reddened, and from twelve to twenty-four hours before 
 the close of the prodromal period often becomes maculated with darker red, 
 slightly-elevated spots closely resembling those of the cutaneous eruption ; 
 the latter appearance is most noticeable upon, and may be confined to, the 
 soft palate. 
 
 Koplik recently called attention to a peculiar eruption upon the buccal 
 and labial mucous membrane which he claims to be pathognomonic of 
 measles. This eruption appears on the first day of invasion as a variable 
 number of "small, irregular spots of a bright-red color," each having in its 
 centre a "bluish-white speck." As the skin-rash appears the eruption on 
 the mucous membrane grows diffuse, and when the former is at the efflores- 
 cence the latter has but the characters of a discrete spotting, and has become 
 a diffuse redness with innumerable bluish-white maculae scattered over its sur- 
 face. This symptom must not be confounded with the pharyngeal eruption 
 already mentioned, and, if as constantly present as Koplik asserts, will prove 
 of great diagnostic value in the early stage of the disease. 
 
 Moderate enlargement of the glands behind the angle of the jaw is an ordi- 
 nary feature, and the same condition of the cervical lymphatics may sometimes 
 be observed. 
 
 There are anorexia, thirst, slight difficulty in deglutition, sometimes vomit- 
 ing, and at first constipation, later diarrhoea. 
 
 Of nervous manifestations, irritability and drowsiness have been already 
 mentioned. The latter symptom is often very marked, the child sleeping for 
 the greater part of one or even two days before the rash appears, waking only 
 to ask for drink or to have its urgent wants attended to, and then drowsing 
 off again. There is no danger in this condition, unless it be associated with 
 indications of cerebral disease or deepen into coma or alternate with decided 
 delirium. Restlessness with mild delirium at night may take the place of 
 drowsiness, and, in exceptional cases, convulsions occur. 
 
 Eruptive Stage. — The eruption usually appears in the evening of the 
 fourth day. For a few hours immediately preceding its outbreak the nervous 
 symptoms are increased, or, if absent before, are developed, and it is at this 
 time that convulsions are most liable to take place. The rash shows itself first 
 
MEASLES. 
 
 121 
 
 on the skin immediately behind, beneath, and in front of the ears ; thence it 
 spreads to the rest of the face, the neck, the trunk, and the limbs, completing 
 its extension over the entire body in from twenty-four to forty-eight hours. It 
 begins in the form of distinct maculae, more or less deep crimson in color, 
 rounded in shape, with irregular edges, and varying from half a line to three 
 lines in diameter. These soon develop into slightly elevated papules with hard, 
 flat summits, which feel firm to the touch and temporarily lose their color under 
 pressure. Isolated and few in number in the beginning, the papules rapidly 
 become more abundant, and show a teDdency to arrange themselves into irreg- 
 ular clusters, the unaffected portions of the skin preserving the normal appear- 
 ance. The intensity of the eruption varies greatly ; sometimes the papules are 
 
 Fig. 2. 
 
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 Chart of Temperature and Pulse in Measles. 
 
 quite scattered and the few clusters are separated by large areas of healthy skin ; 
 at others they are so numerous and coalesce so closely that extended portions 
 of the surface assume a dark-red tint. This coalescing is most frequently 
 observed on the face, on the neck and back, and near the flexures of the joints. 
 Occasionally, in very severe cases, minute vesicles form on the summits of the 
 papules. After full development the rash shows little change for one or two 
 days. It then begins to fade in the order of its appearance, assuming a lighter 
 or yellowish-red color, and in a day or two later disappears, leaving only faint 
 reddish stains which mottle the skin for several days longer. The subsidence 
 of the rash is followed by desquamation, the epithelium falling in very fine 
 bran-like scales. This process is most noticeable on the nice, but even in this 
 position may readily escape observation. 
 
 The rash may vary in other characters as well as in its intensity. Some- 
 
122 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 times the papules on their first appearance are hard and prominent, resembling 
 closely those of variola. Again, their crimson color may not entirely disap- 
 pear on pressure — a condition due to great hyperemia of the skin. Finally, 
 the eruption may steadily grow darker until a deep-purple color is acquired ; 
 this is also due to intense hyperemia with rupture of distended cutaneous 
 capillaries. Such a rash does not disappear on pressure : it remains at its 
 height much longer than the ordinary eruption, and is slow in fading. 
 
 The fever does not abate on the appearance of the eruption ; on the con- 
 trary, it often attains a higher marking (103°-105° F. in the axilla) on the 
 first and second day ; after that, as the rash fades, it rapidly falls to the 
 normal line. 
 
 The preceding chart (Fig. 2) presents a fair picture of the temperature 
 curve of measles of average severity. The patient who furnished the record 
 was a boy five years old, an inmate of the Children's Hospital, Philadelphia. 
 Having been directly exposed to contagion, the symptoms of coryza were 
 noticed on the day marked 1 : the eruption appeared on the evening of that 
 marked 4, and was at its height on 5 and 6. Afterward the eruption rapidly 
 faded, and with it the temperature fell almost to the normal line on 8, though 
 complete lysis was delayed for forty-eight hours by a trifling secondary laryn- 
 geal catarrh. 
 
 The pulse increases in frequency as the temperature rises, and follows its 
 curve moderately closely. The maximum ratio is usually about 120 beats per 
 minute, though it occasionally rises higher, as in the case just referred to. 
 
 During the acme of the eruption and pyrexia the catarrhal symptoms 
 become more severe. The conjunctivae are red, the eyelids are much swollen, 
 photophobia is extreme, and there is a copious flow of irritating tears ; the 
 nasal passages are dry and encrusted, or there is a free discharge of acrid 
 mucus, and crusts of dried blood may often be seen about the nostrils, for 
 epistaxis is common. The upper lip is tumid and excoriated, the cheeks are 
 swollen and deeply reddened, and the characteristic physiognomy, already 
 mentioned as existing in the prodromal stage, is more strikingly marked. The 
 tongue is usually moist, with a thick, yellowish-white central coating and 
 red tip and edges ; the soft palate, tonsils, and pharynx are red ; and the 
 throat feels sore. Thirst and anorexia continue ; there may be some tume- 
 faction and tenderness of the abdomen ; moderate diarrhoea is the rule ; and 
 in some cases there are violent vomiting and purging. The respiratory 
 movements are somewhat quickened : the voice is husky, the cough is parox- 
 ysmal, dry, hoarse, and troublesome, and attacks of spasmodic croup are apt 
 to occur. Physical examination of the chest reveals the signs of catarrh of the 
 larger bronchial tubes, and as a rule — especially in scrofulous children — of 
 enlargement of the bronchial glands. The probability of a similar enlarge- 
 ment of the glands at the angles of the jaw and sides of the neck must also 
 be remembered. The urine is scanty, dark yellow in color, with abundant 
 urates, and, while the temperature remains elevated, may contain a trace of 
 albumin. Prostration of the general strength is not decided in the majority 
 of cases. 
 
 Stage of Decline. — So soon as the rash begins to fade — fourth day of 
 eruption, eighth of disease — the other symptoms rapidly abate. The pulse 
 loses its rapidity, though it is somewhat weaker than normal ; the temperature 
 steadily falls, often with considerable sweating ; the coryzal symptoms subside ; 
 the voice becomes less hoarse ; the cough grows looser and less frequent ; and, 
 if the child be old enough, nummular masses of muco-purulent matter are 
 freely expectorated. The tongue cleans off; appetite returns; there is no 
 
JIUASLUS. 123 
 
 longer thirst, irritability, or restlessness ; the bowels return to their normal 
 condition, and ordinary health is soon regained. 
 
 Modified Forms. — Measles without eruption and measles without catarrh 
 have been described by different authorities. In regard to the first modification, 
 it is difficult to doubt the records of certain isolated cases that have occurred 
 during epidemics of the disease, though the author has never met with any 
 examples. On the other hand, cases reported as "rubeola sine catarrho" 
 must be classed under rubella rather than modified rubeola. 
 
 There is, however, a form of measles which is distinguished from its outset 
 by typhoid symptoms, and is very fatal. Malignant, ataxic, or black measles, 
 as this variety is called, may occur as an epidemic or sporadic affection, but it 
 is usually the former. There is great prostration ; the patient is dull and stupid ; 
 the pulse is small, feeble, and frequent ; the respiratory movements are diffi- 
 cult and rapid; the rectal temperature is high, often reaching 107° or 108° 
 F.. while the hands and feet feel cold: the tongue is dry, brown, and thickly 
 coated ; epistaxis is often obstinate, and hematuria may occur. The rash 
 appears slowly, imperfectly, and irregularly, assumes a livid, purplish, or 
 blackish hue, and may quickly retrocede ; at the same time, the skin is 
 thickly mottled with petechia. The attack progressing, the pulse becomes 
 so rapid that it can scarcely be counted; there is muscular tremor with 
 muttering delirium, and life terminates in coma or convulsions. After death 
 ecchymoses may be found in the viscera. 
 
 Complications. — The conditions which disturb the regular course and 
 threaten the ordinarily favorable result of measles are mainly furnished by an 
 undue development of certain of the usual or unusual features — an exaggera- 
 tion determined either by the nature of the special epidemic or by certain 
 constitutional peculiarities of the individual affected. These complications 
 may be described in the order of their frequency and importance. 
 
 Bronchial catarrh may spread from its ordinary position, the larger tubes, 
 to those of smaller calibre, and become a grave complication. The extension 
 is most common in infants under one year, and in them usually proves fatal 
 through collapse of the lung — a condition readily produced at this early age. 
 The indicative symptoms are dyspnoea and rapid breathing, lividity of the 
 face and extremities, a haggard and anxious expression of the countenance, 
 and the detection, on auscultation, of fine sub crepitant rales distributed 
 throughout both lungs. 
 
 After the age of twelve months catarrhal pneumonia is more frequent than 
 extended bronchitis. It is, in fact, the most common complication of the dis- 
 ease, and may occur at any time during its course. When it arises early, the 
 eruption is often delayed, or, if already present, may retrocede, and there is con- 
 siderable aggravation of the general symptoms. If later — at about the time of 
 the disappearance of the rash, for example — the temperature, instead of falling, 
 remains high, ranging in the neighborhood of 102° F. : in place of the usual 
 general improvement, there are greater weakness and more manifest illness ; 
 the patient is listless and takes little interest in his toys or in what is going on 
 about him ; there is increased thirst and anorexia ; the face is pinched and 
 distressed-looking ; the lips are livid, and the alae nasi move to and fro with 
 the breathing, which is labored and quickened. On physical examination of 
 the chest the ordinary signs of broncho-pneumonia can be detected. This compli- 
 eation varies greatly in degree of severity. It often runs a prolonged, subacute 
 course, and may terminate in complete recovery, in death, or, becoming 
 chronic, may merge into one of the varieties of pulmonary phthisis. 
 
 Intestinal catarrh, which is usually productive of nothing more than a 
 
124 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 trifling, readily-controlled diarrhoea, may be aggravated into an entero-colitis, 
 or even an ulcerative inflammation of the mucous membrane of the colon. 
 These complications are excited by improper food, by injudicious use of purga- 
 tive medicines, and by careless exposure to cold and dampness. They some- 
 times appear during the initial stage, but are usually developed later in the 
 disease. The symptoms are tumidity and tenderness of the abdomen, colic, 
 tenesmus, and more or less frequent purgation, the evacuations being green in 
 color and containing glairy or bloody mucus. The regular course of the 
 disease is little affected, though in nervous, sensitive children the intestinal 
 lesions may maintain a temperature of 104° or 105° F. for several days after 
 the subsidence of the rash. In such cases convalescence is prolonged, though 
 the ultimate outlook is favorable unless catarrhal pneumonia coexists ; then the 
 danger inherent to the latter condition is greatly increased. 
 
 Laryngitis often complicates measles. It is most likely to occur during 
 the decline of the eruption. Ordinarily the spasmodic form — false croup — is 
 assumed, with symptoms that are alarming to the uninitiated, but really devoid 
 of actual danger and without effect upon the regular course of the disease. 
 Sometimes, on the contrary, a pseudo-membranous exudation forms in the 
 larynx, and the case at once becomes extremely grave. The symptoms are the 
 same as in idiopathic cases. Thickening, softening, and ulceration of the 
 mucous membrane occasionally occur, and Rilliet and Barthez record a case 
 in which suppuration about the larynx followed an attack of measles. 
 
 Convulsions happening during the eruptive stage are of grave import ; 
 preceding it, they are seldom serious. 
 
 Epistaxis, when it becomes profuse and exhausting, always tends to post- 
 pone the restoration to health, and may determine death in weak subjects or 
 when the disorder is severe and ataxic in type. 
 
 Ophthalmia and otitis are infrequent complications, and are almost entirely 
 limited to patients having tuberculous tendencies. Both yield sluggishly to 
 treatment, and otitis may prove fatal by an extension of the inflammatory 
 process to the membranes of the brain. 
 
 Paralysis should be mentioned as a rare accident that may be associated 
 with measles. Drs. Barlow and Ormerod have recorded cases in point. 
 
 Sequelae. — Many of the conditions referred to as complications may also 
 occur as sequels of the disease. Thus catarrhal pneumonia, laryngitis, and bron- 
 chitis in chronic form, and chronic gastro-intestinal catarrh are frequent results. 
 Enlargement of the bronchial glands is another common sequence, and acute 
 tuberculosis so often follows that the physician must suspect its development 
 whenever a patient remains feeble and feverish after an attack of measles. In 
 children having a tuberculous diathesis the disease is very prone to light up 
 any or all of the troubles which are characteristic of their constitutional taint. 
 Other less common sequelae are "marasmus," or a condition of general wast- 
 ing and debility ; diseases of the eyes and ears ; ulcerative stomatitis, with 
 necrosis of the jaw; gangrene of the cheek and vulva; necrosis of the nasal 
 cartilages ; and, rarest of all, renal disease. 
 
 Whooping-cough is generally supposed to bear an intimate relation to 
 measles. Epidemics of the two diseases undoubtedly often follow close upon 
 each other without any uniformity of precedence. What the actual connec- 
 tion may be is uncertain, but it is probable that the presence of one exanthem 
 merely lessens the resistance which a healthy body manifests to the infective 
 power of the other. 
 
 Diagnosis. — The distinguishing features of rubeola are the long prodromal 
 stage with its marked catarrhal symptoms ; the course of the fever-curve, espe- 
 
MEASLES. 1*5 
 
 dally the continuance of high temperature for two days after the appearance 
 of the eruption ; and the peculiarities of the rash. It should be remembered, 
 however, that the rash, though quite characteristic in typical cases, is more apt 
 to be misleading, through its variations, than any of the other pathognomonic 
 signs ; and it may be said of measles, as indeed of all other exanthemata, that 
 a diagnosis must never be based exclusively upon the eruption. 
 
 In the initial stage it is often difficult to differentiate between measles and 
 an ordinary acute catarrh — a "severe cold." The coryzal symptoms are 
 identical : hoarseness and cough are present in both, and both are attended by 
 fever. If such symptoms are developed at a time when measles is epidemic, 
 the probabilities are strongly in favor of an attack of the disease. On the 
 other hand, if the history of exposure to contagion is uncertain, it is best to 
 withhold a decided opinion and wait for the appearance of the rash, which, it 
 is well to recollect, shows upon the soft palate from twenty-four to forty-eight 
 hours before it can be detected upon the skin. In this connection the buccal 
 eruption described by Koplik, and already mentioned, may be of great 
 assistance in establishing an opinion. It may be stated here that this 
 element of uncertainty in the early diagnosis is much to blame for the ready 
 and wide extension of the disease ; for, while contagion is freely given off by 
 patients in the catarrhal stage, isolation is rarely practised until all doubt as to 
 the nature of the attack is cleared up by the eruption. 
 
 Sore throat, which is sometimes present, combined with fever, may suggest 
 scarlatina, but the latter disease has a sudden onset, with vomiting, rapid and 
 extreme elevation of temperature, and very frequent pulse, and without catar- 
 rhal symptoms ; further, the characteristic eruption appears not later than 
 twenty-four hours from the commencement of the attack. 
 
 In the eruptive stage, when the color and grouping of the papules are 
 typical, and the fever, coryza and cough marked, there is little room for error. 
 
 When the rash appears in hard, isolated papules, variola may be suspected, 
 a mistake not uncommonly made. In small-pox, hoAvever, the pre-eruptive 
 stage is characterized by obstinate vomiting and severe pain in the back. 
 When the eruption appears, the temperature abruptly falls and the active 
 symptoms abate ; the papules themselves are harder than ever noticed in 
 measles, feeling like pellets of shot under the skin, and by the second day 
 those first appearing on the face are changed into vesicles. 
 
 There is more difficulty in distinguishing the rubeolous eruption from the 
 rash of rubella than from that of any other of the exanthemata. The points 
 of distinction are the short, often featureless, prodromal stage of rubella, the 
 comparative absence of catarrhal symptoms, and the fact that the papules are 
 smaller and lighter in color, appear almost simultaneously on the face, the 
 wrists, and the ankles, and thence extend over the body, showing no tendency 
 to irregular grouping. 
 
 Various skin eruptions, notably the early stages of acute and general eczema 
 and syphilitic roseola, resemble the rash of measles, but the differences in clin- 
 ical history and the entire absence of general symptoms render the distinc- 
 tion easy. 
 
 Prognosis. — Generally speaking, the percentage of fatality in rubeola is 
 small. Nevertheless, in individual cases the prognosis depends upon the type 
 of the epidemic, the age and previous condition of health of the patient, the 
 nature of the hygienic surroundings, and the character aud severity of the 
 complications. 
 
 . An attack, of whatever severity short of malignancy, occurring in a pre- 
 viously healthy child over the age of two years, who is surrounded by the usual 
 
126 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 comforts of life and treated with ordinary skill, should almost invariably ter- 
 minate in recovery ; and in such cases even the onset of so serious a comply 
 cation as catarrhal pneumonia is rarely fatal. Quite the reverse is true when 
 the disease attacks children who are constitutionally feeble or debilitated by 
 some antecedent acute disease, who are suffering from rickets or suppurative 
 bone disease, who have chronic pulmonary lesions, who are subjects of the 
 tuberculous diathesis, and who live in crowded and filthy houses or unhealthy 
 localities. These patients, when they survive the force of the disease itself, 
 are often carried away by one of the complications or sequelae, to the devel- 
 opment of which they are very prone. 
 
 In children under two years of age measles is more serious, and the younger 
 the infant the greater is the danger of an unfavorable termination. Here death 
 is due to the readiness with which bronchial catarrh extends to the finer tubes, 
 producing catarrhal pneumonia or pulmonary collapse — a tendency inherent to 
 every catarrh in the very young, but most marked in that attending measles, 
 and very apt to be exhibited in weakly or rachitic infants. 
 
 The gravity of the different complications and the fatality of epidemics 
 of malignant type have already been referred to. In ordinary epidemics the 
 prognosis becomes unfavorable under the following conditions : When the 
 prodromal stage is more prolonged than usual and attended by violent 
 symptoms of any kind, as great jactitation, irritability, dyspnoea, stupor, and 
 coma or convulsions ; when the eruption is irregular in development or course ; 
 when the pyrexia continues after the subsidence of the rash ; when in the later 
 stages of the disease the face remains deeply flushed or grows pale ; when 
 cough, dyspnoea, or diarrhoea persist, and when the child is left weak, languid, 
 dispirited, or irritable. 
 
 Dr. Ellis places the mortality of measles at 1 in 15 cases. My own experi- 
 ence has been much more fortunate. In private practice all of my cases have 
 recovered save one, and that, an infant of nine months, died of meningitis 
 directly due to the active lighting up, by the measles, of a long-standing disease 
 of the middle ear. Even in my hospital wards the mortality has been less 
 than that given by the author quoted, and the deaths, while occasionally due 
 to the force of the poison on enfeebled bodies, have mainly occurred in patients 
 previously affected with spinal caries or suppurating joints or having badly 
 deformed rachitic chests. 
 
 Before leaving this division of the subject some attention should be given 
 to the question of the liability of the return of measles. The fact is, that, 
 next to typhoid fever, measles is the most liable of all the exanthemata to 
 return. A number of cases are on record in which patients have had a second 
 attack after a short interval, and sometimes so soon after the first as to consti- 
 tute a true relapse, both attacks running their course within a period of four 
 or five weeks. 
 
 Treatment. — Attention must be directed first to the hygienic manage- 
 ment of the disease, as this is of vast importance in all cases, and in those of 
 ordinary severity suffices, with a very little aid from simple drugs, to ensure 
 a favorable ending. 
 
 As early as the nature of the attack can be decided upon the patient 
 must be put to bed, and confined there until not only the rash -itself, but all 
 traces of the remaining yellowish-red stains, have "disappeared — about the 
 eighth or tenth day of the disease. Young infants, with whom it is difficult 
 to enforce complete rest in bed, must, when taken up, be held upon the nurse's 
 lap and be properly protected by some light wrap. If it be possible to have two 
 cots, one for day and the other for night use, the patient's comfort is greatly 
 
MEASLES. 127 
 
 increased. Care must be taken to provide only sufficient bed-covering to 
 maintain warmth ; the mattress should be of hair, and, when only one bed 
 is at command, the sheets ought to be changed at least once each day, though 
 accidental soiling may render more frequent renewal necessary. A large, airy, 
 and. if possible, isolated chamber is to be selected for the sick-room, and an 
 open fireplace for wood or coal is the best method of heating, at the same time 
 securing free ventilation without draughts. When heat is supplied from a 
 furnace, change of air must be effected by a window or door, the patient 
 being protected from chilling currents by a carefully placed screen. The 
 proper temperature is 65° to 68° F. During the continuance of photophobia 
 and conjunctival irritation the room must be moderately darkened, and it is 
 always well to see that the bed is so placed that the patient's face will not 
 be turned directly toward a window. All superfluous hangings and furniture 
 should "be dispensed with, though it is unnecessary to strip the apartment so 
 completely as in case of scarlet fever. 
 
 After the child is well enough to leave his bed he should be kept in 
 the sick-room for three or four days ; then, so far as his own safety is 
 concerned, he may be allowed the range of the house, but not permitted to 
 go out doors for a week longer, and then only in favorable weather. If, however, 
 there are other susceptible subjects in the house, and the question is one of 
 isolation, he must not quit his chamber until the end of the third week from 
 the beginning of the attack. 
 
 The diet requires careful regulation. Nursing infants must be fed, during 
 the febrile stage of the disease, at somewhat shorter intervals than in health, 
 but if, on account of increased thirst, they suck very greedily, the time of 
 lying at the breast must be curtailed, the object being to secure sufficient 
 nourishment without at any time overloading the alimentary canal and over- 
 working the digestive powers, which are enfeebled by the catarrhal condition 
 of the mucous membrane. With bottle-fed babies it is even more essential to 
 carefully regulate the administration and preparation of the artificial food. 
 For example, a child of nine months, who in health would be fed five times 
 daily and take in all about forty fluidounces of appropriately strong food, must 
 during measles be placed nearly on the plane of a child six months old, the 
 feedings being increased to six or eight a day, the total quantity reduced 
 to thirty or thirty-four fluidounces, and the strength proportionally lessened. 
 For the purpose of dilution lime-water or barley-water may be employed 
 with advantage, on account of its power of preventing rapid coagulation and 
 the formation of large, tough curds in the stomach. 
 
 Should ordinary milk mixtures disagree, it is well to resort to Pasteuriza- 
 tion or partial predigestion, and if it be impossible for the infant to retain any 
 form of milk food, as is sometimes the case, raw beef juice in doses of two 
 teaspoonfuls every two hours, or veal broth and barley-water may be resorted 
 to as temporary substitutes. 
 
 Patients who are old enough to take a mixed diet when well should at once 
 be placed upon liquid food. 
 
 To relieve thirst, pure water, carbonic-acid water, and Vichy are prefer- 
 able to any of the old-fashioned sweetened or acidulated drinks. They are to 
 be given cool (not iced), and in moderate quantities at short intervals. In 
 administering drink a good plan is to use a small glass — holding a fluidounce, 
 for example ; to drain this gives the child more satisfaction than the same 
 draught from a larger vessel which he is not allowed to empty, and there is 
 much less danger of an excessive quantity being taken. 
 
 With the decline of the temperature and the abatement of symptoms denot- 
 
128 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ing gastrointestinal disturbance, additions may gradually be made to the diet 
 until the full feeding of health is resumed. 
 
 Due attention must be paid to keeping the patient's person clean. To 
 this end the face, hands, portions of the body liable to become soiled, and 
 even the whole surface, should be sponged with tepid water every morning, 
 each part being washed and dried separately, so as to avoid exposure and 
 chilling. 
 
 When the patient is well enough to go into the open air, it is essential to 
 see that he is properly dressed with warm woollen under-clothing ; morning 
 spongings with salt water may also be ordered now, and complete restoration 
 to health will be greatly hastened by a change of air. So the atmosphere be 
 dry and bracing, it makes little difference, in ordinary cases, whether the resort 
 selected be at the sea-coast or inland, though the former is to be preferred when 
 the disease leaves the subject with marked glandular enlargements or develops 
 other manifestations of the tuberculous diathesis. 
 
 The medicinal treatment of ordinary cases of measles is very simple. 
 Early in the attack, while the temperature is elevated and the cough hoarse, 
 citrate of potassium is useful as a febrifuge and relaxing expectorant. To a 
 child six years old from one to two fluidrachms of liquor potassii citratis 
 should be given every two hours, and to this may be added 20 drops of pare- 
 goric and 5 or 10 drops of syrup of ipecacuanha if the cough becomes very 
 troublesome and croupy — a tendency often exhibited during the first two or 
 three nights of the attack. Later, as the cough grows loose, a stimulating 
 expectorant should be substituted. The best of this class of drugs is chloride 
 of ammonium, which must be given in solution and in doses of 1 to 2 grains 
 every second hour. As convalescence approaches the expectorant may be 
 gradually discontinued, and 1 grain of quinine may be given three times daily, 
 either in solution or in chocolate tablets ; sometimes, too, there is sufficient 
 debility to warrant the administration of moderate doses of whiskey. Finally, 
 a course of iron or of cod-liver oil — in tuberculous cases — is often necessary. 
 
 While pursuing these general measures the eyes need careful attention. 
 Four times daily the lids should be washed with water as hot as can be borne, 
 and afterward a few drops of a solution of borax (gr. v to f§j) gently applied 
 to the conjunctivae. In case of great photophobia and conjunctival irritation 
 a weak solution of cocaine (gr. j to f^ss) may be dropped into the eye twice 
 daily. It is well also to spray the nares and pharynx at frequent intervals 
 with Dobell's solution or Listerine diluted with water (1 part to 6), or, if the 
 patient be old enough, the throat may be gargled every three hours with one 
 teaspoonful of chlorate of potassium dissolved in 4 fluidounces each of claret 
 and water. Mild counter-irritation of the skin of the throat is often of serv- 
 ice in relieving pain and hoarseness ; for this purpose a combination of tur- 
 pentine and olive oil (1 part to 2 or 3) may be employed several times in 
 the twenty-four hours. 
 
 Malignant measles demands a stimulant and tonic treatment. Whiskey or 
 brandy in properly proportioned quantities must be added to the milk, or 
 brandy-and-egg mixture may be employed, and raw beef juice and concen- 
 trated meat broth must form an element in the diet. Of drugs, quinine, 
 carbonate of ammonium, and digitalis are called for, and must be used in 
 sufficient doses to meet the urgency of the indications. In this form mustard 
 baths and hot packs are of great service. For the mustard bath, which is 
 more suitable for children under three years of age, the water should be at a 
 temperature of 100°, and contain about one tablespoonful of mustard to the 
 gallon ; the patient is immersed up to the neck for three minutes, then quickly 
 
MEASLES. 129 
 
 dried and placed in bed between blankets or wrapped in a blanket and dried 
 later. The bath may be repeated in two hours if necessary. In hot packing 
 the child is placed between blankets, and then a blanket wrung out as dry as 
 possible, after being wet with hot water or mustard and water (two teaspoonfuls 
 to the gallon), is quickly wrapped about the body, care being taken lest it be 
 too hot : it may be renewed in half an hour. 
 
 At times one or more of the symptoms of the disease may be so modified 
 or exaggerated as to require special treatment. 
 
 Headache, when violent, is usually attended by constipation, and can be 
 relieved by unloading the bowels and by putting the feet in hot mustard- 
 water (one tablespoonful to the bath) or applying a mustard plaster ( 1 part to 
 4 or 6 of flour) to the nape of the neck. For the purpose of evacuating the 
 bowels enemata or glycerin suppositories should first be tried, and if these 
 fail, a mild laxative, as calomel in broken doses or milk of magnesia with 
 aromatic syrup of rhubarb, may be administered. Active purgatives should 
 never be employed, on account of the decided diarrhoeal tendency of the 
 disease. Should these measures fail to relieve the headache, resort must be 
 had to bromide of potassium or elixir of the valerianate of ammonium. 
 
 Moderate looseness of the bowels need not be interfered with, but if the 
 purging be sufficiently violent and continuous to threaten the strength of the 
 patient, a combination of rhubarb, bismuth, and chalk mixture may be 
 prescribed, or, if the evacuations be very watery, it may be necessary to use 
 a more powerful astringent, as oxide of zinc in doses of gr. J-J every three 
 or four hours. 
 
 Distressing vomiting is best treated by causing the patient to drink tepid 
 water, and, when the stomach has been relieved of altered food and irritating 
 secretions, applying weak mustard plasters to the epigastrium. In this condi- 
 tion, however, it is most important to pay careful attention to the feeding. 
 
 When the eruption is delayed, appears irregularly, or retrocedes, it must 
 be remembered that the condition depends upon some complication — broncho- 
 pneumonia, for example — and that the true mode of relief is to relieve the 
 internal inflammation which is the cause of the difficulty : hot mustard foot- 
 baths or full baths, hot packs, mustard sinapisms, and stimulants are required. 
 Liquor ammonii acetatis is a useful preparation in these cases ; it may be 
 given in doses of one to two teaspoonfuls every two hours. When the rash 
 itches or burns, frequent applications of fresh lard or vaseline will afford 
 relief. 
 
 At the acme of the eruption the temperature often runs up to 104° or 
 105° F. for a few hours, without corresponding severity of the other symp- 
 toms. No interference is necessary for a temporary elevation of this sort, but 
 for a persistently high temperature of twelve hours or more some antipyretic 
 must be given or cooling baths resorted to. Antipyretics are still on trial, but 
 the safest is phenacetin. This may be administered in an initial dose of 1 
 grain for any age between two and six years. If the temperature falls after- 
 ward, wait and observe the extent of the depression; if not, repeat the dose 
 after the lapse of an hour ; should this fail, gradually increase the amount to 
 2 or 3 grains. The first dose may be given when the temperature ranges 
 above 103°, and the drug may be repeated as often as necessary to keep it 
 below this point, the cardiac condition being carefully watched in the mean 
 time. 
 
 When baths are employed to reduce the pyrexia, water at a temperature 
 of 95° to 98° F. should first be used ; if this fail, tepid or cold spongings 
 may next be resorted to, and as a final resort the tepid or cooled bath may 
 
130 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 be tried. In giving the latter the child should be undressed as quickly as 
 possible, and then immersed in a bath of 90° F. ; cold water is now rapidly 
 added until the temperature of the bath is reduced to 80°. After a sufficient 
 intermission — usually five or six minutes — the body is quickly dried with a 
 soft towel and the patient put back to bed between sheets. The effect of the 
 bath is sometimes very powerful, and the child remains livid-looking and 
 collapsed for some time. In such case small doses of brandy must be given 
 in warm milk at short intervals and artificial heat applied to the feet. 
 
 It is stated by some authorities that antipyretics ought to be employed 
 whenever the temperature reaches 102° F. Such a rule is dangerous. There 
 are many instances in which, with a temperature of 102°, the child is very ill, 
 and this degree of fever may be judged to be more than usually detrimental. 
 For these a bath, either tepid or cold, cold sponging, or phenacetin, may be 
 recommended, but for one such case there are many others that run a perfectly 
 favorable course with a temperature even higher than this, and in which it is 
 difficult to see what benefit could have accrued from antipyretics. Each case 
 must be treated upon its own merits. 
 
 When in doubt as to the propriety of using antipyretic drugs or baths, it 
 is well to try the effect of moderately full doses of sulphate of quinine. It has 
 been my own experience that this agent given by the mouth, or, better still, 
 by the rectum, in suppositories of two to four grains every three or four hours, 
 frequently reduces temperature, and, should there be much associated restless- 
 ness, produces sleep. 
 
 The treatment of convulsions, broncho-pneumonia, and other disorders 
 which may be associated with or follow after measles does not differ from that 
 employed when these affections occur idiopathically, and therefore requires no 
 especial consideration here. 
 
 Quarantine. — The rubeolous patient should keep his bed for eight or ten 
 days and his room for three weeks ; then, if he be quite well in every respect, 
 there is little danger in his mixing with his- playmates. When one member 
 of a household is attacked, it is necessary for the other children of the family 
 who have not had the disease to stop going to school or associating with other 
 children, as it is probable that they also have contracted the malady, and, as 
 it is infectious in its early stages, they may readily be the means of giving it 
 to others. For the same reason it is unwise to send them away from home ; at 
 the same time they must not come in contact with the case already developed. 
 
 The convalescent should have a warm bath and fresh clothing before ming- 
 ling with his associates. Scalding of the bed- and body-clothing and thorough 
 airing and cleaniDg of the sick-room are all that is necessary in ordinary cases, 
 though in malignant epidemics disinfection of the bedding and thorough fumi- 
 gation of the chamber with sulphur should be insisted upon. 
 
SCARLET FEVER. 
 
 By MARCUS P. HATFIELD, M. D., 
 
 Chicago. 
 
 Scarlet fever, or scarlatina, is a self-limited, contagious, microbic disease, 
 characterized by fever, angina, and a typical eruption, and followed by des- 
 quamation and recovery in about three weeks if the disease be uncomplicated. 
 
 The health reports of all of our large cities show that scarlet fever is an 
 endemic disease of childhood, never being entirely stamped out, and affecting 
 now only a trivial percentage of the population, and then increasing into epi- 
 demics of frightful mortality, often from causes as yet unknown to modern 
 science. 
 
 According to Busey, it is the most widely disseminated of the exanthemata 
 of childhood, and, perhaps rightly, the most dreaded of all the diseases of 
 children, whose susceptibility varies not a little with their age. Infants under 
 six months, as a rule, escape ; 64 per cent, of all cases occur in children under 
 six years of age (Murchison), after which susceptibility diminishes, though liable 
 to as yet inexplicable variations, for children and nurses who have escaped 
 half a dozen epidemics may succumb to the seventh after exposure apparently 
 in no wise different from that which preceded it. 
 
 One attack, as a rule, protects from a second, though well-attested returns 
 are on record. The majority of those cases popularly reported as second 
 attacks are usually due to errors in diagnosis. But it must also be remembered 
 that frequent abortive attacks of sore throat are well known to occur in nurses 
 or physicians attending cases of this disease. 
 
 Scarlet fever may be complicated with other of the exanthemata, especially 
 varicella. Cases of coincident scarlatina, variola, and measles are reported 
 by Vogel. 
 
 While the disease is not so infectious as measles, as shown by the fact 
 that 42 per cent, of Budert's unprotected children escaped infection during 
 an epidemic in the isolated German village of Neundorf, it should be remem- 
 bered that the contagiousness of scarlet fever varies greatly with the epidemic. 
 
 Brush's statement that the colored race possesses an immunity from this 
 disease is erroneous, for the writer has seen scarlet — or rather royal purple — 
 fever in a coal-black pickaninny, and in Chicago, at least, colored children enjoy 
 like privileges in this respect with those of lighter skin. 
 
 History. — It is more than probable that scarlet fever must have existed as 
 far back as there have been masses of people crowded together in great cities ; 
 but there are no earlier accounts of the disease than those of the seventeenth 
 century (1610-18), when epidemics occurring in Spain and Italy were described 
 by Mercatus, Heredia, and Syambatus (Bohn). About the year 1625 both 
 sporadic and epidemic cases were met with in Breslau and described by a Dr. 
 Doring, who is probably entitled to the honor of being the first German author 
 to write on this subject. He was closely followed by Sennert's description of 
 
 131 
 
132 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the disease at Wittenberg, later followed by like outbreaks at Brieg (1642), 
 Schweinfurt (1652), and in Poland (1664). 
 
 Up to the time of Sydenham scarlet fever was supposed to be a variety of 
 measles, being known by such fanciful terms as " ingrassius, rosalia, rubeolas, 
 morbilli ignei," etc. During the years 1670-75, Sydenham had ample oppor- 
 tunity to study the epidemics raging in the city of London, and differentiated 
 the disease from measles. The origin of the name is yet uncertain (Bohn). 
 
 To Fothergill (1750) justly belongs the credit of establishing the con- 
 tagiousness of scarlatina, and the facts upon which depend all modern theories 
 of its prophylaxis. But many writers believe that the disease has steadily in- 
 creased in virulence, until to-day it is the most prevalent and dangerous of all 
 the diseases of childhood. 
 
 Scarlet fever is supposed to have been brought to North America in 1735, 
 spreading slowly from the coast inland, and so infrequently met with that Dr. 
 Rush, as late as the beginning of the present century, wrote : " No physician 
 would be likely to see it more than once in his lifetime." At first it was 
 regarded as rather a trivial affection, but malignant epidemics swept through 
 Kentucky and Ohio when the country was almost an unbroken forest. Then 
 came a period of slight malignity, so that Professor Chapman of the University 
 of Pennsylvania so late as 1833-36 positively denied the contagiousness of 
 this disease. 
 
 Etiology. — He would be a purblind physician who, in these latter days, 
 would attempt to deny the microbic origin of scarlet fever, but it must as 
 frankly be admitted that our knowledge concerning its exact etiology is as 
 yet indefinite and conflicting. Klebs figures the peccant microbe and names 
 it Monas scarlatinosum. Ecklund of Stockholm minutely describes another, 
 which he is certain is the cause of scarlet fever, and proposes the name Plox 
 scindens, a fuller description of which may be found under the heading of 
 Pathology. Edington of Edinburgh later isolated from the blood and epi- 
 dermic scales of scarlet-fever patients another microbe, which he and Dr. 
 Shakespeare of Philadelphia unite in declaring to be the specific cause. 
 
 But, while it is disheartening that as yet we know so little accurately con- 
 cerning the bacteriology of scarlatina, there is much that is well known and 
 proven beyond dispute in regard to the spread of the disease and the nature 
 of its contagion. First of all, it can be insisted upon that its contagium vivum 
 is easily portable, tenacious in its power to do evil for years, and with great 
 probability originating in some of the lower animals. The horse, the dog, 
 and the cow all have had their claims advanced as first owners of the scarla- 
 tinal microbe, and during the Hendon epidemic some years since it seemed as 
 if the question had been decided in favor of the cow. Later and more accu- 
 rate investigations, however, seemed to show that the disease carried from the 
 diseased teats of the infected cows was scarlatinal only in the form of the rash 
 communicated to human beings. 
 
 There is also considerable dispute as to which of the secretions may carry 
 the scarlatinal virus. Some writers insist that the patient is a source of infec- 
 tion from the initial sore throat until the last branny scales have dropped 
 away from between the fingers and toes ; others, that infection may be carried 
 so long as there is a specific otorrhcea. Undoubtedly, the micro-organism 
 usually enters the system by inhalation, but there seems to be good reason 
 for believing that it may be taken in with food (Smith), or carried from 
 person to person by inoculation of scarlatinal blood or blood-serum. It is, 
 however, generally conceded that a scarlet-fever patient is most dangerous 
 during the stage of desquamation, and that the branny scales of this period 
 
PE V 
 
 Original impure cultures from skin. 
 X 1500. 
 
 al impure eultun 
 X 1000- 
 
 Original impure cultures from skin. 
 X 1000. 
 
 Bacillus Fulvus. "* s us. Diplococcus 
 
 guinis 
 
 < 1000. 
 
 Plates illustrating the cultivation of the bacillus scarlatina according 
 
 Taken from British 
 
PLATE VI 
 
 Bacillus Arborescens. 
 
 Bacillus Scarlatina; 
 
 x 1000. 
 
 Original impure tube, taken from the skin, but which 
 was a nearly pure culture of Bacillus Scarlatina:. 
 
 Bacillus Arborescens icillus Scarlatina: 
 
 after a week's growth. after 12 days* growth. 
 
 to the methods of Drs. W. Allan Jamieson and Alexander Edington. 
 

SCARLET FEVER. 133 
 
 are the most frequent carriers of the contagion, though others claim like 
 dangerous properties for mucus, urine, and the faeces. It is certainly true that the 
 contagion of scarlet fever may be carried by almost every conceivable article 
 of apparel or material used about the sick, for next to the variolous microbe 
 the scarlet-fever contagion preserves its vitality for a longer time than any 
 other of the exanthematous poisons. Dr. Holland relates an extraordinary 
 case where the virus survived two generations, being packed away in clothing 
 in a chest for thirty-five years, at the end of which time it communicated the 
 disease to a grandchild for whom some of his grandfather's clothing was made 
 over. To the writer's knowledge, the disease remained hidden in a fur cloak 
 packed away for more than a year, and then communicated the disease to an 
 entire logging community isolated for the winter in the wilds of Northern 
 Michigan. Hence the exact origin of any given case of scarlet fever is often 
 most difficult to accurately settle, especially when we remember the possibility 
 of the disease being carried by books, letters, or toys from some previous 
 case. 
 
 Next to library-books, letters, clothing, and toys, milk seems frequently to 
 be the medium of contagion. In one instance milk is known to have carried 
 scarlatina to one-half of the families to which it had been delivered, although it 
 had not been touched by the milkman or other members of the infected family 
 (Taylor) ; and in another the disease was carried to all the families served save 
 one, which consisted only of elderly people (Bell). Powers and Klein still 
 teach that the disease originates from the sore teats of infected cattle suffering 
 from bovine fever, but, after much heated discussion on the subject, it appears 
 that the disease thus communicated is modified cow-pox rather than true 
 scarlet fever (Hendon epidemic, 1885). The persistence of the scarlatinal 
 virus in clothing and apartments after ordinary methods of disinfection is 
 sometimes amazing. J. Lewis Smith relates the case of a Sunday-school 
 librarian who contracted the disease from books returned from an infected 
 tenement-house. One month after his recovery the room in which he had 
 been sick and his clothing were disinfected with burning sulphur, and yet he 
 succeeded in carrying the disease personally to his sisters after a journey of 
 three hundred miles to an isolated country town, to which they had been 
 quarantined. These sisters infected the room in which they were confined, so 
 that children visiting it, after its disinfection, in turn contracted the disease. 
 The writer knows of a building in the city of Chicago in which, in three 
 successive years, the children of the families moving into the house con- 
 tracted scarlet fever in spite of yearly domestic disinfections. 
 
 Mode of Transmission. — Although it is usually believed that the scarlet- 
 fever poison is not volatile and cannot be carried by the atmosphere solely, 
 the case sketched in the description of Fig. 1, contributed by an intelligent 
 medical student, apparently contradicts previous statements on this subject. 
 
 Bacteriology. — Illingworth still claims, I believe, that the germs of scarlet 
 fever are set free during the fermentation of animal and vegetable refuse. The 
 inhalation of these causes them to lodge upon the mucous membrane of the 
 throat, where they propagate, and, by the reabsorption of their products, pro- 
 duce the other lesions of scarlet fever. Almost all other authorities believe 
 that there is a specific scarlet-fever microbe, which requires a previous human 
 being for its host. Repeated efforts have been made to isolate this micro- 
 organism. As early as 1882, Ecklund of Stockholm thought he had discovered 
 it in the form of colorless discoid corpuscles, about one-tenth the size of the 
 red corpuscle, and found in immense numbers in the urine of scarlatinal 
 patients. These he named Plox seindens. He states that he had found them 
 
134 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 in vast numbers in the soil and ground-water of the island of Skeppsholm 
 during an epidemic of scarlet fever there. Their presence seems to be well 
 proven, but their relation to scarlet fever is by no means as definite. More 
 
 Fig. 1. 
 
 N 
 
 W 
 
 " The above rude map shows the relation of, and distance between, several houses in the township of Clare- 
 mont, Minn., one inch representing a mile. In the house A lived Win. Connell. During February of 
 1879 one of his children contracted scarlet fever through a letter tbat came from relatives in Toronto, 
 Canada. About three days later a second child came down with the disease and died on the ninth 
 day. The wind bad been'blowing from the north-east, and about this time my younger brother came 
 down with the disease in house No. 4. Young James Connell was buried on the day after his death; 
 and on that day the wind changed into the north-west, where it continued for some time. The bed- 
 ding and clothes of the Connells were hung on the clothes-line to air, and in about one week 
 from that time the children in house No. 3 were "taken with the disease. In house No. 2, thirty 
 rods north, there were five children, in house No. 6 there were four children, and in house No. 5, 
 two children. All of these escaped the disease. There was absolutely no communication between the 
 houses on account of the cold weather and fear of the disease. Two years later there came an epi- 
 demic of the disease in that vicinity of a severe type, and all the children in the neighborhood had the 
 disease, except those that had had it two years previously." 
 
 hopeful are the results of Dr. Edington of Edinburgh, who began in 1886 to 
 make investigations of the blood and epidermis in human scarlet fever. He 
 succeeded in isolating a diplococcus scarlatina sanguinis and a bacillus scarla- 
 tina. Inoculation of the bacilli produced in rabbits erythema and desquama- 
 tion ; in calves, fever and a rash, followed by desquamation. Dr. Edington says 
 "the bacilli measure 1.2 to 1.4 micro-millimetres in length and 0.4 micro- 
 millimetre in width, and are found in the blood during the first two days only, 
 in the desquamating epidermis only after the twenty-first day, and in the 
 eighteen intermediate days they cannot be demonstrated in any of the tissues." 
 His results have been confirmed by Dr. E. 0. Shakespeare, who proposes the 
 provisional name of bacillus scarlatina? for this micro-organism, and reports 
 that, " sown on gelatin-plates, it forms little points of liquefaction after 
 several days. Sown in test-tubes of Koch's jelly, it rapidly liquefies it, 
 but with no distinct growth-formation. The fluid thus formed is crowded 
 with the motile bacilli, but a pellicle is not formed until the liquefaction is well 
 advanced." This occurred in every case but one of the tubes made from the 
 desquamation if taken after the termination of the third week, but never before 
 this. It also occurred in every tube made from scarlatinal blood if taken before 
 the third day of the fever. Inoculation upon rabbits produced erythema, best 
 marked in the old, and in from two to five days a fine desquamation, which lasted 
 for a week to ten days. Temperature, 103°-106° F. Similar results were 
 obtained from guinea-pigs, except that the desquamation was more copious and 
 the hair fell out if pulled upon. 
 
 "A calf was then inoculated, and at the same time given some of the 
 
SCARLET FEVER. 135 
 
 culture in milk. The calf was in good health at the time, and had a tem- 
 perature of 99.5° F. Six hours from the inoculation the calf developed 
 great sickness, and the temperature taken in the axilla registered 103° F. 
 [This was at 10 p. M.] The calf was then left for the night, but in the morn- 
 ing was found dead. Small portions of the spleen and kidneys were taken 
 from the animal, placed in Koch's jelly, and allowed to incubate, and developed 
 the characteristic bacillus previously described. A second calf was inoculated, 
 when only one day old, with the bacillus, care being taken that the inocula- 
 tion was made with the absolutely pure material. Previous to the injection 
 the calf's blood was examined, and found to contain no organisms. The inocula- 
 tion was made in this case with a very carefully sterilized hypodermic syringe. 
 At 6.30 p. M. this was performed, the temperature per rectum then being 
 99.6° F. At 10 p. M. the animal took milk freely, and the temperature re- 
 mained practically the same. Next morning, temperature 104° ; sickness, 
 slight diarrhoea, and great prostration, and the throat inflamed. In the after- 
 noon the skin of the thorax, upper abdomen, and inner side of the foreleg pre- 
 sented a general redness, increasing toward evening (T. 102.8°). The next 
 morning the animal was better, but rash still vivid, throat and posterior part 
 of the tongue inflamed (T. 102°). From this time the beast steadily improved, 
 and on the sixth day desquamation set in." 
 
 The same bacillus, according to Dr. Shakespeare's report, may be obtained 
 from the blood of a scarlet-fever patient during the first two or three days of 
 the disease, and from the desquamating scales on the twenty-first day in an 
 ordinary case; if malignant, they may be obtained earlier. These bacilli 
 rapidly increase in warm milk, which they may thus infect. 
 
 " The rapidity of the growth of this organism — which is such if one in- 
 oculate a flask of broth the diameter of which is two inches and a half, and 
 if it be incubated, the pellicle will develop and cover it entirely over in the 
 course of four hours — suggests an explanation of the short incubation of 
 scarlet fever when furnished a proper pabulum." 
 
 Such, it seems to the writer, is a fair statement of our present knowledge 
 on the subject, to be confirmed or reversed by later investigations. 
 
 Pathology. — Aside from its bacteriology, still in dispute, there cannot be 
 said to be any pathological changes pathognomonic of scarlet fever. Autopsies 
 made upon those dying in the earlier days of the disease show only the local 
 lesion of the throat and engorgement of various internal organs, especially the 
 intestines and brain. Deaths occurring later are generally due to septicaemia 
 or nephritis. The former are apt to show secondary pneumonia and metastatic 
 abscesses, and the blood coagulates poorly and is prone to form clots in the 
 right ventricle. The characteristic changes of pleurisy, pericarditis, endo- 
 carditis, purulent meningitis, empyema, or pulmonary gangrene may be found 
 in these cases. 
 
 The kidney lesions are those of an acute exudative (Delafield) or glomerulo- 
 nephritis (Welsh), the latter being the true post-scarlatinal nephritis. In such 
 cases " the liquor sanguinis and the red and white blood-cells escape from the 
 renal vessels into the tubules. Swelling or necrosis of the renal epithelium, with 
 changes in the glomeruli, occurs." 
 
 Macroscopically, the kidneys are large and flabby, and the cortex is thick 
 and pale, with injected capillaries. The tubal epithelium is swollen and opaque. 
 Hyaline cylinders identical with the casts are found in the convoluted tubes, 
 and more abundantly in the straight tubes, along with irregular masses formed 
 from the exuded blood-plasma. In the tubes are also red and white blood- 
 cells. The glomeruli exhibit important changes. They become larger or more 
 
136 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 opaque, due to the swelling and growth of the cells on and in the capillaries, 
 " for the glomerular capillaries in their normal state are covered on their out- 
 side by nucleated cells, and flat cells line their inner surfaces in places, not 
 continuously. On account of these cellular changes, the individual capillaries 
 in the glomerulus become indistinct, but the main divisions of the tufts are 
 visible. In very severe cases the growth of the cells on the tufts is so con- 
 siderable that they form large masses of cells between the glomerulus and its 
 capsule. The walls of the arteries in the kidneys may be thickened by a 
 swelling of their muscular coats, and the Malpighian bodies may stand out like 
 grains of sand." 
 
 This connective-tissue growth Delafield considers characteristic, "involving 
 not the whole of the kidney, but symmetrical strips or wedges in the cortex, 
 which follow the line of the arteries. These wedges are small or large, few or 
 numerous, regular or irregular, in different kidneys, but in every wedge we 
 find the same general characters : one or more arteries, of which the walls are 
 thickened ; glomeruli belonging to these arteries, with a large growth of 
 capsule ; cells compressing the tufts ; a growth of new connective tissue in the 
 stroma around and parallel to the arteries. Between the wedges we find at 
 first only the changes of exudative nephritis ; later, a diffuse growth of con- 
 nective tissue. If the nephritis is of acute type and longer duration, the 
 tissue is denser and has more basement substance. Where the growth of the 
 new tissue is abundant the tubes become small and atrophied. The exudation 
 from the blood-vessels is very considerable, so that the urine contains large 
 quantities of albumin, many casts, and red and w T hite blood-cells" (Delafield 
 and Prudden). The irregular distribution of these kidney lesions, according 
 to Bartel, explains the contradictory results often obtained by successive 
 examinations of the urine. There may be parts of the kidney which entirely 
 retain their functions, and from these normal urine may be secreted. But that 
 a scarlatinal dropsy may exist from beginning to end without the presence, at 
 any time, in the urine of either blood, albumin, or casts, is as improbable as 
 that dropsy may occur without nephritis (Bohn). 
 
 Incubation. — Formerly a week or ten days was given as the usual length 
 of the stage of incubation ; later writers, however, fix it at two to five days, 
 and it may, in malignant cases, last not more than twenty-four hours. But 
 it is often difficult to say exactly when the stage of incubation ends and that 
 of the initial sore throat begins. Murchison's table (Smith, p. 275) shows that 
 in the great majority of the cases reported by him the stage of incubation was 
 within five days, and the latest writer on this subject says that if the initial 
 vomiting be taken as the conclusion of the stage of incubation, it will be 
 found to be under three days (Ashby, p. 248). 
 
 Symptoms. — The onset of scarlatina is usually so abrupt that its begin- 
 ning may be fixed with considerable definiteness. There is possibly a pre- 
 vious slight duskiness of the skin, chilliness and malaise, but usually the 
 first thing that attracts attention is vomiting, often without any relation to 
 a previous meal ; or there may be diarrhoea. Older children may not actually 
 vomit, but complain of nausea, languor, headache, and sore throat, and feel 
 chilly, although the face is flushed, and the thermometer may show a tem- 
 perature as high as 103°-105° F. If such children are also drowsy, they 
 may become delirious in their sleep. The pulse is full and strong (120-160), 
 the skin is hot and dry, and the throat feels stiff and uncomfortable, and, if 
 examined, will show a characteristic punctate redness. Such is the ordinary 
 onset of a typical case of scarlet fever, but there is no disease of childhood 
 that is liable to wider and more eccentric variations in its onset and course, 
 
PLATE VII. 
 
 . • ■■ . 
 
 s^&ft 
 
 f*> J 
 
 ^\ 
 
 SCARLET FEVER. 
 
SCARLET FEVER. 
 
 137 
 
 oscillating between the very slight abortive form and that frightful variety 
 called by the French foudroyanU or scarlatina fulminans, fortunately rarely 
 met with : for in such cases the child succumbs, mortally poisoned from the 
 verv first by the virulence of the scarlatinal virus, without any prodromal stage 
 or hardly any symptoms except those which may be referred to the nervous 
 svstem. These dreadful cases often run their entire course in from thirty-six 
 to forty-eight hours without eruption or sore throat, the only symptoms being 
 nausea, dizziness, loss of consciousness, coma, violent delirium, or convulsions 
 attended with abnormally high temperature (107°). 
 
 Scarlatina simplex may be differentiated in twenty -four hours by the ap- 
 pearance of the typical scarlatinal rash in the form of a scarcely perceptible 
 scarlet flush or pin-point eruption, very closely resembling in color and stip- 
 pling the shell of a freshly-boiled lobster. The eruption usually begins on the 
 neck or cheeks or small of the back, and ought in forty-eight hours to spread 
 nearly over the body, either as a well-defined blush or in scarlet patches — 
 scarlatina laevigata. Plethoric and blond children develop the rash most 
 promptly, and in all cases its color is heightened by the warmth of the bed, 
 by hot baths, or by crying. A characteristic white line remains for a few 
 seconds after drawing the edge of the nail or the point of a pencil over the 
 rash. This typical line is supposed to be due to a paralysis of the vaso-motor 
 
 
 
 
 
 
 
 
 
 
 
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 Temperature Chart in a Mild Case of Scarlatina. Patient 6 yrs. old. (After Ashby.) 
 
 nerves of the capillaries in these congestive areas. Until the eruption is well 
 marked the fever continues high, often dangerously so, as it is not unusual to 
 find the temperature in impressible children marking 105°-107° F. The pulse 
 is quick and sthenic, except in cases of scarlatina maligna, where there may be 
 general depression, delirium, and collapse from tfye very onset of the disease. 
 The pulse, as a rule, is faster than the temperature would apparently call for, 
 ranging from 130-150, its relation to the rash and temperature being well shown 
 in the accompanying chart, taken from Ashby (Fig. 1). Pharyngitis, with more 
 or less soreness of the throat, is always present, although it may not be sufficiently 
 painful to cause the child to complain {scarlatina sine angina). The respira- 
 tory organs, except the throat, are rarely involved, so that cough is generally 
 absent. When present, it is due to faucial irritation, except where pneumonia 
 occurs later as a dangerous complication. The tongue is the so-called straw- 
 berry tongue — that is, covered with a white fur with bright red tip and borders. 
 
138 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 When the papillae are greatly swollen, they cause the granular appearance 
 known as the raspberry tongue. Some writers speak of a pathognomonic 
 sweetish odor of the breath which may be detected at this time, but this is by 
 no means an invariable symptom nor one upon which much reliance should be 
 placed. 
 
 In a simple, uncomplicated case the fever and all threatening symptoms 
 moderate with the appearance of the rash, with the exception of a slight even- 
 ing febrile exacerbation, and any variation from this rule betokens malignancy 
 or some new complication. 
 
 From the fourth to the sixth day desquamation ordinarily begins. Those 
 areas which are first reddened fade in like order, and, as the color disappears, 
 
 Fig. 2. 
 
 Day of 
 Dtoease 
 
 
 
 L 2 
 
 
 
 L 2 
 
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 105° 
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 103° 
 102° 
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 96° 
 
 Pulse. 
 
 
 
 
 
 
 
 
 
 
 
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 nw 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 10 10 
 
 
 Temperature Chart of Malignant Scarlet 
 Fever. Death in 24 hrs. (After Ashby.) 
 
 Temperature Chart of Malignant Scarlet Fever. 
 Death on 7th day. Rash indicated by *. 
 
 the skin is found to be covered with loose branny scales. These scales drop 
 off imperceptibly, except when from itching, as is apt to happen on the face 
 and neck, they are scratched off, and the tender epidermis beneath becomes 
 cracked. In such cases the scales may be thrown off in shreds, or casts of the 
 entire lip, fingers, or palms of the hand may be shed. A like desquamation 
 occurs from the membranes of the throat, trachea, kidneys, and intestines, 
 though of course the epithelial scales in these localities are carried away in a 
 softened, macerated condition. 
 
 Out of 200 cases reported, 11 reached their highest temperature on the first 
 day, 76 on the second, 75 on the third, 36 on the fourth, and only 2 on the 
 fifth day. When the highest temperature is reached after the fifth day, or if 
 the temperature has not fallen considerably by that time, some complication is 
 certainly keeping it up, so that the thermometer and violence of the nervous 
 
SCARLET FEVER. 139 
 
 symptoms form a valuable criterion as to the danger of the child. A dull, apa- 
 thetic condition is, as a rule, more to be dreaded than the usual restlessness, 
 which is due to continued reflex irritation of the rash. In hypersesthetic chil- 
 dren this produces twitching, or even eclampsia, which is graver the later it 
 occurs in the disease. 
 
 Variations. — We have previously described what might be considered 
 a typical case of uncomplicated scarlet fever, but, unfortunately, uncompli- 
 cated cases are so rare that there is no disease of wider variations in every 
 symptom. 
 
 The eruption may be so light as to escape detection, or, on the other 
 hand, instead of the ordinary scarlatina laevigata, the eruption may appear 
 in the form of small nodules (scarlatina papulosa), in which the papillae 
 of the skin are swollen, and the whole body looks as if covered with goose- 
 skin. Or, again, these papillne may become covered with vesicles, and we have 
 that form of scarlatina which is known as scarlatina miliaria. Should these 
 vesicles become merged together, they give an eruption to which the name of 
 scarlatina pemphigoides seu bullosa is given. Such variations are found most 
 frequently on the face, and are usually of grave import. Vogel reports excep- 
 tional cases in which the eruption was intermittent in character, appearing only 
 at certain times of the day, and for this he proposes the name of scarlatina 
 intermittens. Lastly, we may find that fatal form to which the name of scar- 
 latina petechialis seu hcemorrhagica has been given, where there is an actual 
 extravasation of blood into the skin, and hence the popular name of " black 
 scarlet fever" by which it is sometimes known. In nervous children it is not 
 infrequent to find urticaria accompanying scarlet fever, masking the character- 
 istic rash. Vogel also reports a curious variation of scarlatinal rash in which 
 are found sharply-marked, isolated areas which remain milk-white in color, 
 or at least much whiter than normal integument, due to a temporary paralysis 
 of the arterioles similar in character to that which follows the thumb-nail mark 
 on the normal scarlatinal flush ; but they are more persistent in character and 
 are usually of unfavorable portent. Any intercurrent disease, as entero-colitis, 
 which produces a determination of blood from the surface of the body, may 
 greatly delay the appearance of the rash or render it so light that its dif- 
 ferentiation will be difficult. 
 
 Complications. — Throat. — The angina of scarlet fever may assume any 
 form, from simple catarrhal injection to extensive necrotic destruction of tissue. 
 Ordinarily, a bright red flush, with punctate marks, such as might have been 
 produced by a small brush dipped in red ink and dotted over the pillars of the 
 fauces, is the earliest and one of the most characteristic symptoms of scarla- 
 tina. This may proceed no further than to give slight difficulty in swallowing 
 and to impart a nasal tone to the voice. But, on the other hand, and more 
 frequently — especially if pharyngeal disinfection is not practised from the very 
 first — the swelling becomes so great as to make swallowing almost impossible. 
 In such cases fibrinous exudates appear on the tonsils and fauces, and should 
 the inflammation not be limited to the palate and fauces, the exudate may ex- 
 tend into the post-nasal cavities, the larynx, and even into the oesophagus and 
 stomach. More frequently it proceeds through the Eustachian tube into the 
 internal ear. (See Otitis Media.) The differentiation between the fibrinous 
 exudate of scarlatina and true diphtheritic membrane is by no means easy, the 
 more so since undoubtedly true diphtheria is not infrequently grafted upon the 
 necrosis of scarlatinal angina ; but it may be helpful to remember that the 
 exudate of scarlatina is yellowish and pultaceous, rather than the ashy-gray 
 membrane of true diphtheria. Should the presence of Loeffler's bacillus 
 
140 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 be finally accepted as pathognomonic of diphtheria, the differentiation may 
 then be made absolutely ; whereas at present we must frequently remain in 
 doubt, since the removal of the scarlatinal exudate leaves the superficial layers 
 of the pharyngeal mucous membrane denuded and bleeding exactly as in diph- 
 theria. A similar gangrenous process may proceed upward into the pharynx 
 or along the Eustachian tube into the cavity of the middle ear, with all the 
 perils of purulent meningitis which this implies. Similarly, as in true diph- 
 theria, the exudate may pass downward into the larynx, where its presence is 
 made known by a characteristic croupy metallic cough. If the exudate attacks 
 the nasal cavities, this is attended by a profuse excoriating discharge, which 
 soon grows purulent and offensive in odor. 
 
 Adenitis. — All forms of scarlet fever are attended with inflammation of the 
 lymphatic glands of the neck, and, as a rule, it will be found that the involve- 
 ment of these glands bears a direct relation to the severity of the throat lesions. 
 So we find all grades of adenitis, from the slight induration which may be 
 found accompanying all varieties of scarlatina, to a brawny swelling of the 
 glands and cellular tissue embracing the whole neck. Such extensive mischief 
 betokens like serious necrotic processes taking place within the pharynx, where 
 the poisonous debris clogs and inflames the lymphatic glands, their pres- 
 sure and morbid processes inflaming contiguous tissues. This cellulitis may 
 extend from ear to ear, until deglutition becomes difficult and wide opening of 
 the mouth impossible. If relief does not come early by resolution, the widely- 
 distended tissue gives way to suppuration or gangrene, and death from haemor- 
 rhage or septicaemia occurs. 
 
 Scarlatinal Arthritis is not infrequently met with in certain epidemics of 
 scarlet fever during both the eruptive and the desquamative stage. This form 
 of arthritis attacks by preference the knee- and elbow-joints, and scarcely can 
 be distinguished by its objective symptoms from ordinary articular rheumatism, 
 being, like it, excessively painful. But arthritis rheumatica rarely ends in 
 pyaemia or permanent articular osteitis, as arthritis scarlatinae is very prone 
 to do. 
 
 Diarrhoea and Dysentery are not at all infrequent complications after the 
 crisis of the disease, probably being caused by desquamation of the intestinal 
 epithelium, analogous to that which undoubtedly occurs in the tubuli uriniferi 
 at this time. 
 
 Scarlatinal Nephritis. — Last and, justly, the most dreaded of the com- 
 plications of scarlatina, is that form of nephritis which so frequently occurs 
 during the course of the disease that it may almost be considered pathognomonic ; 
 for a mild grade of renal catarrh is as constantly present as is desquamation 
 (Steiner). It is true this frequently escapes observation and passes on to re- 
 covery without special treatment, but its existence is always a potential cause 
 of morbus Brightii scarlatinosa, which should be considered not as a distinct 
 disease, but as an intensification of the previous catarrh of the tubules brought 
 about by chilling of the skin, etc. (Bohn). 
 
 Similar nephritic catarrh has been noted in measles, small-pox, pneumonia, 
 and other diseases, induced, as the writer believes, by the passage through the 
 kidneys of irritating ptomaines generated in the body by the specific microbes 
 of these diseases. The excretion of these or analogous compounds through the 
 skin very likely gives rise to the characteristic rash, hence analogous lesions 
 might be inferred for the kidneys. It is a well-known fact that the lighter the 
 cutaneous rash the more liable are the kidneys to be seriously implicated, pre- 
 sumably from increased excretion of various ptomaines through organs now 
 endeavoring to do the work of both skin and kidneys. Daily examination of 
 
SC ABLET FEVER. 141 
 
 the urine should be made for at least two weeks in even the mildest cases of 
 scarlet fever, and will show from the beginning of the eruption evidence of 
 renal catarrh (epithelial debris and albumin), although the kidneys are appar- 
 ently working normally. While the urine is high-colored and deposits copious 
 urates. Dr. Gee claims that urea is not necessarily diminished. The chloride of 
 sodium is lessened until the fourth to the sixth day, and phosphoric acid after 
 crisis ; while the urates or uric acid appear to excess during convalescence. 
 In other cases the urine is cloudy, and contains fatty renal epithelia, more 
 rarely hyaline casts, and red and white blood-corpuscles (only exceptionally 
 albumin), all of which disappear usually with the disappearance of the erup- 
 tion, but may progress to an actual catarrhal nephritis. This renal catarrh Bartel 
 believes is due to a specific poison — ptomaine (?) — circulating in the blood, which 
 poison irritates the tubules of the kidneys in its passage through the Mal- 
 pighian tufts, either directly or from irritating properties imparted to the urine 
 before its percolation through the tubuli uriniferi. Others claim that the source 
 of this irritation lies in certain specific micrococci circulating in the blood, being 
 analogous to diphtheritic nephritis, which Oertel thinks due to bacterial emboli. 
 
 A diminution in the quantity of the urine is often the first thing that 
 awakens the attention of the physician, if he makes it his duty, as he ought, 
 to keep himself posted daily until the end of the third week. The normal 
 amount of 800 to 900 c.c. per diem may fall suddenly to 100 or 50 c.c, or 
 even less. Its color is yellowish-red, sometimes almost yellowish-green when 
 cooled ; turbid, or clearing up on standing, depositing a cloudy precipitate made 
 up of kidney cells and casts, urates, and uric-acid crystals in varying propor- 
 tion. At times the urine is blood-red or smoky brown, from the blood it con- 
 tains. Under the microscope the precipitate is found to consist of varying 
 quantities of kidney epithelia, partly normal and partly swollen and distended, 
 cloudy, and undergoing fatty degeneration. Besides these there may be vari- 
 ous forms and phases of casts, lymph-corpuscles, red blood-corpuscles, and the 
 crystals of urate of sodium and uric acid. The quantity of albumin found in 
 urine is deceptive, since in certain epidemics of scarlatina, even where dropsy 
 suddenly appears, often only faint traces of albumin may be found in the urine. 
 Or albumin may be entirely absent during certain times in the day, or even for 
 several days at a time, or during the greater part of the disease. Or, again, 
 unmistakable albuminuria may be present while the urine is clear and free 
 from all other abnormal elements. It may even happen that frequent analysis 
 of the urine for days may fail to show either casts, epithelial cells, or crystals, 
 while all of these, together with albumin, may be found at a subsequent exami- 
 nation. 
 
 Scarlatinal dropsy is often the first warning of the existence of any kid- 
 ney lesion in mild cases which are supposed by parents, and even by the phy- 
 sician, to be well along in convalescence. As a rule, the chief danger of 
 scarlatinal nephritis lies about the end of the second week or during desquamation, 
 though dropsy may appear as late as the fifth or sixth week. The first symp- 
 toms noticed are slight oedema of the face and swelling of the eyelids. These 
 are followed by pufiiness of the backs of the hands and feet, sometimes uni- 
 lateral, with dropsical enlargement of the abdomen. In the case of children 
 who have not yet been allowed to rise from their beds the anasarca is often 
 most marked in the back and in the genitals, which may become frightfully 
 swollen and sensitive. As a rule, the kidney complication is ushered in with a 
 return of fever, or an increase in fever, if it still be present. But there is also a 
 feverless nephritis, without subjective symptoms, loss of appetite, or anything 
 abnormal that can be detected. In other cases there is only an evening 
 
142 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 increase of temperature and pulse. Generally the skin is dry and ceases to 
 desquamate. Pain over the kidneys is seldom complained of, unless questioned 
 about or obtained by pressure. If the disease in the kidney is limited, there 
 may be only a localized oedema, such as hydrothorax, hydrops pericardii, 
 oedema of the lungs, or dropsical effusions into joints. This localized oedema 
 may follow a brief apparent convalescence, during which children recover their 
 appetite, and exhibit no features of illness, unless it be the persistence of 
 slight lassitude and fever at night. After exposure to cold such cases develop 
 anorexia, depression, and pain over one or both kidneys. The amount of urine 
 is greatly diminished. It is concentrated, high-colored, and contains albumin 
 and casts, and may not measure more than an ounce for the entire day, or may 
 even be completely suppressed. About 6 per cent, of all scarlatina patients 
 suffer from post-scarlatinal nephritis, the course and duration of which depend 
 directly upon the extent of the anatomical lesions of the kidney. Very light 
 cases recover in a few days. Generally the anasarca and effusions increase for 
 several days — say a week and over — breathing being hindered by the ascites 
 and pleural effusions, and the nights are restless. (Edema of the lungs pro- 
 vokes incessant coughing. Swelling of the genitals is often painful, but does 
 not noticeably interfere with urination. Death may ensue suddenly from ure- 
 mic convulsions when danger is least expected. Ashby attempts — and it seems 
 wisely to the writer — to differentiate between septic and post-scarlatinal nephri- 
 tis, either of which may be met with during the course of scarlet fever. The 
 urine in the first contains no blood-corpuscles, but is highly albuminous, and is 
 not attended with dropsy nor uraemic convulsions. Autopsy in these cases 
 shows a distinctly softened, pyaemic kidney, which contains minute abscesses, 
 and is mottled in its cortex with injected blood-vessels and inspissated pus. 
 Death occurs from pyaemia, and not directly from the kidney lesions, which are 
 only a part of the more general process. In the second class of cases death 
 results from uraemia. The lesions of the post-scarlatinal kidney have been 
 fully described under Pathology. 
 
 Sequelae. — Chronic nasal catarrh, ozaena, pharyngitis, or hypertrophy 
 of the tonsils, with acute attacks of quinsy, or suppurative otitis, with chronic 
 otorrhoea and deafness, more or less complete, are among the dreaded reminders 
 left after scarlatina, especially where the angina has been malignant. In many 
 such cases the tonsils become deeply excavated, and the soft palate sloughs ; but 
 even under these circumstances recovery is possible. Or, as has previously been 
 noted, diphtheritic-like membrane may cover the fauces, palate, and even spread 
 on to the epiglottis and into the larynx. Death from exhaustion or haemorrhage 
 usually terminates such cases, or, if life is for a while prolonged, death comes 
 later from septicaemia, often terminated by septic pneumonia (seventh to four- 
 teenth day). But even septic pneumonia is not necessarily fatal, for recovery 
 took place in one of the writer's cases after the appearance of this sequel sub- 
 sequent to otorrhoea and cervical abscesses and sloughing. The amount of 
 damage sometimes inflicted by these cervical sloughs is frightful. Smith 
 speaks of one which laid bare the carotid and produced death by its per- 
 foration. Williams relates a still more remarkable case, in which superficial 
 ulceration of the fauces, palate, and tongue was conjoined with suppuration of 
 the lymphatics of the neck. This was followed by sloughing, exposing, in the 
 triangle of the neck, a space bounded by the edge of the sterno-mastoid, the 
 upper border of the thyroid cartilage, and the median line of the neck. Never- 
 theless, under antiseptic treatment, the boy made a good recovery, although he 
 was only six years of age and had previously been considered delicate. 
 
 Broncho-pneumonia, pleuro-pneumonia, empyema, and peritonitis are among 
 
SC ABLET FEVER. 143 
 
 the possible complications of scarlatinal nephritis. If the temperature runs 
 high, the tongue becomes dry and brown, the urine scanty and albuminous, 
 and death rapidly ensues. But milder cases are not hopeless if the urinary 
 secretion can be re-established. 
 
 Cardiac dilatation, endocarditis, and pericarditis are the more frequent 
 heart-lesions that should be guarded against in every scarlatinal nephritis, for, 
 conjoined with increased arterial tension and general malnutrition, they may 
 bring sudden death either from heart failure or embolism. The possibility of 
 such untoward termination to nephritis should never be forgotten, for no 
 sharper reproach can come to the physician than the thought that had he 
 allowed less work to be thrown upon a weakened heart he might have carried 
 his patient into safe convalescence. 
 
 Otitis, with perforation of the membrane, more than any other sequela, 
 has too often been left a lifelong reminder of scarlet fever. In many of these 
 cases little pain is complained of, although the fever remains suspiciously high 
 until a purulent discharge from the ear makes its appearance. Mastoiditis or 
 purulent meningitis may prove fatal, but in a majority of these cases no such 
 complications take place, and the child recovers, more or less deaf or afflicted 
 with a chronic otorrhoea. According to Batut, statistics in Belgium show that 
 out of 1892 cases of deafness, 216 followed scarlet fever. Another observer 
 found out of 400 cases 144 due to the same cause. 
 
 Synovitis has already been referred to under the head of Arthritis, as 
 liable to occur about the second week. Suppuration and pyaemia are the 
 chief dangers in these cases. 
 
 Cerebral lesions, such as paralyses, blindness, aphasia, loss of memory, 
 hemiplegia, etc., are among the sad sequelae of the uraemic convulsions of 
 scarlatinal nephritis. 
 
 Convalescence from severe cases of scarlatina is always protracted, the 
 subsequent anaemia lasting for months or years, especially in scrofulous chil- 
 dren, in whom the virulence of the poison is most lasting in its effects. Many 
 of the most discouraging cases that come into the hands of the physician deal- 
 ing largely with the diseases of children are those in which the child's vitality 
 has been undermined by malignant scarlatina. Such children frequently 
 suffer for years from the so-called mucous disease of Eustace Smith or from 
 renal incompetence. In other cases there is a chronic otorrhoea or offensive 
 ozaena, which renders their lives miserable, and so saps their vitality that they 
 succumb easily to intercurrent disease. This is especially true of those chil- 
 dren in whom the functions of the kidneys have been seriously crippled by 
 post-scarlatinal nephritis. Such a previous history always awakens serious 
 apprehensions in the presence of diphtheria, typhoid, or any septic disease. 
 
 Diagnosis. — The early diagnosis of a mild case of scarlet fever is often a 
 matter of great difficulty, but it is a matter of no little importance to the 
 patient, for such mild cases seem to be the ones most liable to nephritic com- 
 plications. Since mild cases may communicate dangerous attacks to those 
 more susceptible, it is always safe to give the well children the benefit of your 
 doubt by isolating all suspicious cases. Nausea, pain in swallowing, and fever 
 constitute a trio of symptoms sufficient to isolate a patient until a rash of some 
 kind appears. This may be so light and transient, especially if there be coin- 
 cident diarrhoea, that it may escape detection unless carefully watched for ; and 
 even then there is an erythema scarlatiniforme that without previous history 
 may deceive the very elect in paediatrics. In such cases, however, the throat 
 does not show the characteristic stippling of scarlet fever, and a brisk emetic 
 or purge brings the case to a speedy termination. The early differentiation of 
 
144 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 rubella from scarlatina is often puzzling, but Jamieson calls attention to the 
 fact that in rubella the characteristic tongue of scarlet fever is absent, while the 
 mild catarrhal symptoms of the former are not ordinarily present in the latter 
 disease. 
 
 The eruption of measles is most distinctly patchy, and is preceded by 
 several days of drowsiness and the symptoms of an ordinary cold. But in all 
 doubtful cases isolate and wait for light, remembering " that nephritis occur- 
 ring after an anomalous rash makes it practically certain the primary attack 
 was scarlet fever." Broncho-pneumonia under similar circumstances justifies 
 a diagnosis of measles. 
 
 Prognosis in scarlet fever must be largely influenced by the character of 
 the then prevailing epidemic and the general condition of the child. The viru- 
 lence of the scarlatinal poison and the susceptibility of the one attacked deter- 
 mine the degree of restlessness, jactitation, and delirium observed. Initial 
 eclamptic attacks rarely occur, except in unusually nervous, susceptible chil- 
 dren, and their occurrence is of very unfavorable portent. 
 
 As a rule, the early and extensive implication of the cervical lymphatics is 
 a forerunner of serious throat complications. Nasal diphtheria complicating 
 scarlatina is of the gravest import, and the gravity is proportionate to the early 
 age of the child, children under four years giving as high a mortality as 28 
 per cent. The younger the child the more guarded should be the prognosis, 
 especially when associated with diarrhoea, which is regarded by Ashby as a 
 very serious symptom. 
 
 Where the temperature continues high (104°-106°), and there is much 
 diarrhoea or extreme restlessness, or the angina is malignant, the prognosis is 
 always grave. Drowsiness is always an unfavorable symptom, and a high tem- 
 perature continued into the second week is sufficient. ground for anxiety. 
 
 Desquamation is seldom completed before the sixth week, and is not always 
 at an end in twice that time, Finlayson fixing the infective period of this 
 disease as seven to eight weeks. 
 
 The nephritis complicating or following scarlet fever is more dangerous than 
 the primary disease. Where persistent vomiting occurs, not only on the first, 
 but on subsequent days, the prognosis is correspondingly grave. 
 
 Post- scarlatinal nephritis is the most favorable form of parenchymatous in- 
 flammation of the kidneys, usually ending in recovery in two or three weeks by 
 means of copious diuresis, but it is worth remembering that the excessive excre- 
 tion of uric acid, which persists well into convalescence, may form gravel or 
 calculi. As a rule, epithelial casts and detritus persist after the disappear- 
 ance of the albuminuria, sometimes for an exceedingly long time, especially in 
 cachectic children. 
 
 Death rarely occurs before the fourth day, and usually not later than the 
 seventh, except from post-scarlatinal nephritis. Sudden death may result from 
 rapid and uncontrollable increase of dropsy, either into the peritoneum, pleura, 
 pericardium, or ventricles of the brain, or from oedema of the lungs or glottis. 
 Or, stopping short of immediately fatal results from oedema, the end may come 
 more slowly from inflammation of the lungs or pericardium, or still more slowly 
 from gangrene of the genitals or from bed-sores. Or, as may be inferred from 
 the above, the nephritis may assume a chronic form. 
 
 The relation between the intensity of the scarlatinal eruption and the dan- 
 ger of subsequent nephritis is by no means constant, although the writer has 
 come to dread its appearance in the lighter cases because these are the ones in 
 which the care of the parents is apt to be relaxed with the apparent rapid con- 
 valescence of the child. 
 
SCARLET FEVER. 145 
 
 Serious cerebral affections, such as paralysis, blindness, aphasia, loss of 
 memory, hemiplegia, may remain as sequelae of scarlatina. 
 
 Mortality varies widely with the epidemic. That in the Manchester Chil- 
 dren's Hospital varied from 6 to 25 per cent, according to the epidemic, the 
 average for ten years (1877-87) being 11.8 per cent. Of 10,000 cases 
 reported by Collie, the mortality was 12.5 per cent, for all ages, that between 
 three and four years reaching as high as 25 per cent. 
 
 These figures, it must be confessed, are too high for the average American 
 practitioner, but he may, like foreign physicians, be compelled to radically 
 change his ideas on the subject. Brettonneau, for instance, up to 1799 
 thought scarlatina the mildest of all the exanthemata ; and so also the Irish 
 physicians thought from 1804 to 1831. But Brettonneau was obliged to entirely 
 change his views after encountering the fatal epidemic at Tours in 1824 ; and 
 a similar outbreak in Dublin in 1881 completely revolutionized the views 
 of the Irish physicians in regard to the fatality of scarlet fever. 
 
 Treatment. — A hopeful fact, always to be borne in mind in any choice of 
 treatment adopted in scarlatina, is that it is a self-limited disease, and that no 
 remedy has yet been discovered that will either abort or greatly modify its 
 course. The medical literature of the past twenty-five years teems with alleged 
 specifics, but all of these by subsequent trials have been found no better nor 
 worse than those proposed before them. Nevertheless, the intelligent physi- 
 cian owes it to himself and his patients that he shall not desert them upon the 
 rocks of medical agnosticism nor wreck them upon the snags of polypharmacy. 
 If he cannot abort the disease, he may make its course less uncomfortable to 
 his patient, and by careful foresight ward off many a threatening complication. 
 
 Diet is not unimportant in scarlet fever, for our aim from the very begin- 
 ning should be to tax the kidneys, already in a catarrhal condition, as little as 
 possible with nitrogenous materials. Hence the ideal food for the scarlet-fever 
 patient is koumyss, skimmed milk, or milk and Yichy. But the ordinary 
 American child will not long tolerate such light diet, especially when rapidly 
 convalescing, so we are usually forced to add to our diet-list broths, soups, 
 light puddings, and baked apples, happy if thereby we reduce meats to a 
 minimum. While the writer cannot agree with Jaccoud that a milk diet is an 
 absolute safeguard against post-scarlatinal nephritis, it is true that a liquid 
 diet and warmth should be carefully secured for at least four weeks. 
 
 General Treatment. — If the initial nausea is vexatious, it may often be 
 allayed by: 
 
 1^. Aquae cinnamomi 
 
 Liquor calcis da f,lj. 
 
 Tinct. gelsemii f3ss. — M. 
 
 Sig. Teaspoonful every hour. 
 
 For the high arterial tension and fever, tincture of aconite, given according 
 to the plan of Ringer — i. e. a drop every quarter hour until arterial tension is 
 decreased, and then given sufficiently to hold the pulse at that point every two 
 or three hours — is very satisfactory. 
 
 Chloral hydrate is a favorite with the writer, almost entirely displacing the 
 tinct. ferri chloridi of his earlier practice, except in those cases where there is 
 malignant angina from the beginning. In such cases nothing has been found 
 superior to the tincture of the chloride of iron (one drop per dose for each 
 year of the child's age), with whiskey or brandy, given according to Dr. Chap- 
 man's plan. The surprising tolerance of such children for alcoholic stimulants 
 
 10 
 
146 AMERICAN JEXT-BOOK OF DISEASES OF CHILDREN. 
 
 shows that their power is expended otherwise than in their usual effects upon 
 the brain. Many such children will take f 3ss of brandy every hour without 
 showing any of the usual physiological effects. In ordinary cases, however, 
 small doses of chloral hydrate seem to be all that is necessary to relieve rest- 
 lessness, moderate the angina, and, to a limited degree, act as an antiseptic. 
 For the first forty-eight hours such a prescription as the following has often 
 proven most useful : 
 
 ^. Chloral hydrate 3ss-j. 
 
 Camphor water f §ss. 
 
 Syrup of orange-peel f ^iss. — M. 
 
 Sig. To alternate with aconite as required. 
 
 When the eruption is tardy in appearing, a hot salt or mustard bath will 
 expedite matters, or, if these are ineffectual, packing in a sheet wrung out of 
 hot water and sprinkled with mustard rarely fails. 
 
 The throat is too often neglected, and yet here is the focus from which 
 spread many of the dangerous complications of this disease. Local antiseptics 
 may be a modern device, but Underwood came very near to the writer's ideas 
 when he wrote on this subject many years ago : " The throat must be often 
 syringed with .... though the quality is perhaps of far less importance 
 than its being frequently made use of, which is absolutely necessary, especially 
 
 in young children Even syringing the throat with hot water is 
 
 found to administer immediate relief." The local treatment of the throat with 
 peroxide of hydrogen spray, as directed under the head of Prophylaxis, can 
 hardly begin too early, and the same may be said of the inunction of the body 
 with some antiseptic ointment. Quinine internally may be added later if there 
 is evidence of failing strength. 
 
 Cerebral symptoms, unless associated with scanty urine, may be rendered 
 tolerable by the addition of bromide of potassium (grs. v-x) to each dose of the 
 chloral hydrate mixture, with a mercurial purge and the application of cold 
 to the head. Phenacetin is sometimes a great comfort in such cases, but the 
 writer discourages the use of the other antipyretics in scarlet fever, except as a 
 last resort in abnormally high temperature. Even in these cases persistent 
 sponging with cool water, or even cold affusion, ought first to be tried. Per- 
 sistent drowsiness always awakes suspicion as to post-nasal complications, and 
 emphasizes the necessity of nasal irrigation, frequently repeated. 
 
 Scarlatinal arthritis in cachectic children may proceed to suppuration and 
 destruction of the joints, but, fortunately, most of these cases are more pain- 
 ful than dangerous, and yield promptly, like true rheumatism, to fair doses 
 of salicin and codeine and wrapping the affected joints liberally with cotton 
 batting. 
 
 Cervical adenitis is more frequently overtreated than neglected, for the 
 swollen and tender glands apparently require immediate attention. And yet 
 the trouble lies farther back, for the de'bris that blocks these inflamed glands 
 comes usually from the pharynx. Hence efficient pharyngeal and nasal cleans- 
 ing will do more for adenitis than poultices, lotions, or ointments. So-called 
 energetic treatment too often precipitates the very troubles we are seeking to 
 guard against. Instead of poultices and iodine, simple rest and warmth will 
 often work wonders even in brawny, swollen necks where suppuration appears 
 inevitable. At all events, camphorated oil, applied on absorbent cotton, should 
 be tried before proceeding to more vigorous measures. 
 
 Diarrhoea is apt to be quite persistent, and occasionally painful, when once 
 
SCARLET FEVER. 147 
 
 it makes its appearance. So far, I have rarely seen it assume a dangerous 
 aspect, for it usually can be held in check with paregoric alone or conjoined 
 with bismuth in an emulsion. 
 
 Scarlatinal Nephritis. — Individuals and epidemics of scarlet fever vary 
 so greatly in their liability to nephritis that it is difficult to rightly estimate its 
 prophylactic treatment. From 60 to 70 is given by various authors as the 
 average percentage in dangerous epidemics, and from this it falls to 6 or 7 per 
 cent, in ordinary cases. The writer believes that this latter proportion can 
 be still further reduced by the proper care of children in the mildest form of 
 the disease, for these are the very ones which give us the highest proportion 
 of fatal cases of nephritis. It follows, then, that all children ill with scarlet 
 fever should be kept in bed during the rash, no matter how mild it may be; 
 and, furthermore, such children should be confined to warm rooms, or, better 
 still, to bed, for four or six weeks from the appearance of the initial symptoms. 
 At least twice a week during this time the urine should be examined, and upon 
 the appearance of the slightest unfavorable symptom the child should be sent 
 back to bed again if he has already been allowed to be about the room. 
 
 But should these premonitory symptoms be disregarded, or if, in spite of 
 these precautions, scanty albuminous urine and dropsical effusions appear, then 
 the physician's most energetic efforts must be directed toward making the skin 
 or intestines temporarily assume, as far as possible, the functions of the kid- 
 neys, throwing on the latter, at the same time, as little work as possible in the 
 way of the excretion of nitrogenous refuse. (See Diet.) The copious use of 
 water, if tolerated by the stomach, will act as one of the very best of the 
 diuretics. Long ago Roberts placed pure spring water at the head of the list, 
 and the writer has not yet found any diuretic to displace it, though lemon- 
 juice, raspberry vinegar, or skimmed milk may be added without harm to 
 induce the child to drink more freely of the water. 
 
 Should the urine still remain scanty, then diaphoresis must be induced in 
 order to increase the action of the skin — first, by means of baths, and then, if 
 necessary, by drugs. A warm bath (98°-100° F.) for fifteen to twenty 
 minutes is often grateful to the child, and, if supplemented by a flannel pack, 
 is very efficient. The hot-air or steam bath, as described under the treatment 
 of Acute Nephritis, may likewise be employed with success. Any of these 
 methods will be assisted by the internal use of diaphoretics, chief of which 
 are the preparations of jaborandi. Sips of a hot infusion of the leaves 
 (3j to Oj) act both as a powerful diaphoretic and sialagogue. To avoid the 
 latter action Smith prefers the alkaloid pilocarpine, fa to fa grain, conjoined 
 with an alcoholic stimulant every four to six hours. Should this fail, the 
 same writer speaks highly of the following prescription : 
 
 1^. Potassii acetatis 
 
 Potassii bicarbonatis 
 
 Potassii citratis da £ij . 
 
 Infus. tritici repentis f^viij. — M. 
 
 Sig. Teaspoonful every three or four hours to a child of five years. 
 
 More palatable and fairly efficient is the following : 
 
 1^. Liq. ammonii acetatis 
 
 Syr. acidi citrici da f 3ij . — M. 
 
 Sig. Teaspoonful every hour in hot lemonade. 
 
148 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Or, where there is considerable dropsical effusion, this can be with advantage 
 alternated with diuretin (gr. j-iv), given in a large amount of water. 
 
 Dropsy usually requires, in addition, the free use of some hydragogue cathar- 
 tic, of which the compound jalap powder (gr. v-x) is certainly the most efficient 
 and unpleasant. Hence, when it is found impracticable to repeat the dose as 
 often as required, it may be supplemented by a cream-of-tartar lemonade, made 
 by dissolving a tablespoonful of the salt in hot water, diluting with an equal 
 amount of cold, sweetening to taste, and adding sufficient claret or port to make 
 agreeable. Most children will take this laxative readily. 
 
 Or the following prescription of J. Lewis Smith may be employed : 
 
 ~fy. 01. cinnamomi gtt. viij. 
 
 Magnesii sulphatis 3j. 
 
 Potassii bitartratis lij. — M. 
 
 Sig. One teaspoonful repeated from two to four hours, until catharsis 
 occurs. 
 
 But the use of laxatives should be continued no longer than is strictly 
 necessary, for their repetition brings anaemia, a result greatly to be deplored. 
 
 After relieving the initial congestion of the kidneys, stimulating diuretics 
 are helpful; and of these digitalis has justly a high reputation. The infusion 
 is a reliable preparation, and may be given in connection with acetate of potas- 
 sium, as in the following mixture : 
 
 ]^. Potassii acetatis Iss. 
 
 Infus. digitalis f^vj. — M. 
 
 Sig. One teaspoonful every four hours. 
 
 Local treatment will also greatly help in relieving the fever and backache. 
 Foreign writers speak highly of the use of leeches over the kidneys in these 
 cases, but the majority of American physicians are willing to rely upon the use 
 of poultices or plasters. A large warm flaxseed poultice, containing mustard 
 or digitalis, often acts like a charm. Smith prefers one made of 1 part each 
 of powdered mustard and ginger to 16 of ground flaxseed, and advises dry 
 cupping when the child is not frightened thereby. Sluggish kidneys may be 
 gently stimulated by capcine plasters or some mildly stimulating embrocation, 
 and a flannel bandage worn day and night. 
 
 It ought never to be forgotten that while the liability to heart failure is 
 not as great in scarlatinal nephritis as it is in the convalescence of diphtheria, 
 yet it is a possible danger, and one from which death may rapidly occur. An 
 irregular, flickering pulse requires absolute confinement to bed and the con- 
 tinued use of some chalybeate tonic. A pleasant one may be found in the 
 following : 
 
 1^. Tinct. ferri chloridi f^iij- 
 
 Acidi phosphorici dil f^vj. 
 
 Glycerini f^vij. 
 
 Vini xerici f liv. — M. 
 
 Sig. Teaspoonful four times a day. 
 
 Hematuria can best be controlled by gallic acid and ergotine, and threat- 
 ening convulsions kept in check by rectal injection of chloral and bromide 
 of potassium (gr. v and gr. x) in milk or water. Nitro-glycerine tablets (^ gr.) 
 
SCARLET FEVER. 149 
 
 are very valuable for temporary stimulation of the heart, and may be used hypo- 
 dermatically if the need be pressing. 
 
 Prophylaxis. — All attempts to procure personal immunity by means of 
 inoculation have up to the present time proved ineffectual. The same may be 
 said of prophylactic medicaments, for it is more than doubtful whether any 
 known drug has the power to prevent the occurrence, or to greatly modify the 
 course, of scarlet fever after its incubation. Even Hahnemann's vaunted 
 specific, belladonna, has failed so often and completely that it need only 
 be mentioned as one of the curious delusions of medical history. The same 
 may be said of sulphocarbolate of soda (Beebe's), quinine, salicylate of sodium, 
 and the other alleged preventives which from time to time appear and dis- 
 appear in medical literature. The fact is that epidemics of scarlatina vary 
 widely in their intensity and danger. Hence it is that in one epidemic the 
 liability to contagion is reduced to a minimum, and whatever may be used at 
 that time receives credit for prophylactic powers which fail miserably when 
 next put to the test. Our efforts must, therefore, be confined to isolation of 
 the patient and disinfection of whatever touches or comes from him, for it must 
 be remembered that not only the desquamatory scales, but also blood, serum, 
 breath, urine, and faeces probably carry infection during the entire course of 
 the disease. 
 
 Now, as every case of scarlatina, even the mildest, may communicate a 
 dangerous form of the disease, it is always wisest that every case should be 
 treated as if it might develop a most dangerous epidemic. Six weeks of quar- 
 antine are none too long for an average case of scarlatina, and this should be 
 indefinitely extended as long as desquamation may require. Seven years' 
 experience in one of the orphan asylums of Chicago has convinced the writer 
 that this is not only theoretically possible, but actually does prevent the spread 
 of the disease, for never during these years has there been a general epidemic 
 of scarlatina in the asylum, although sporadic cases have been not infrequent. 
 In such institutions isolation can be more effectually carried out than in private 
 families, but the effort should be made, and is usually attended with the hap- 
 piest results. Long ago Dr. Budd wrote in reference to scarlatina : " Time 
 after time have I treated this fever in houses crowded from attic to basement 
 with children, who have nevertheless escaped infection by the simple method 
 of isolation." Reliable statistics show that 50 per cent, of the children thus 
 protected escape infection, and still better results ought to be obtained by local 
 and personal disinfection added to isolation. 
 
 Disinfection of the sick-room should never be omitted. For this purpose 
 J. Lewis Smith highly recommends volatilization of the following mixture in 
 boiling water: 
 
 ly. Acidi carbolici 
 
 01. eucalypti da f 3j. 
 
 01. terebinthinae f^vj. — M. 
 
 Sig. A tablespoonful to be added from time to time to a pan of hot water, 
 to be kept boiling on a gas stove or grate fire. 
 
 The sick-room should be the largest, most sunshiny, best-ventilated room 
 in the house, and, if possible, should have an open fireplace. All curtains, 
 pictures, ornaments, and furniture not absolutely necessary for the comfort of 
 the patient should be removed before the child is placed there, and no one but 
 the nurse and physician allowed to enter. The nurse should wear a loose 
 wrapper and cap, to be dropped inside the door should she be compelled to 
 meet other persons for any purpose outside the door. 
 
150 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 An ordinary bed-sheet, tacked by one edge over the door and kept moist- 
 ened with a 2 per cent, solution of carbolic acid, has apparently been helpful 
 in preventing the spread of the disease in asylum practice, where, the writer 
 agrees with J. Lewis Smith, the "area of contagiousness is small, and hence 
 the disease is more easily quarantined than either measles or pertussis." 
 
 For disinfection of the patient J. Lewis Smith recommends as a local dis- 
 infectant to the faucial mucous membrane corrosive sublimate, 2 grs. to a pint 
 of water (1 drachm containing -^ of a grain). This may be used as a gargle, 
 or as a spray from a hard-rubber atomizer. The same solution may be em- 
 ployed for cleansing the nasal cavities. The writer's preference for faucial 
 application is a solution of eucalyptol in peroxide of hydrogen (gtt. xv to fsj), 
 used in the cup of an ordinary steam atomizer. The same solution may be 
 applied upon a swab to the fauces if there be extensive necrosis : or, diluted 
 with an equal amount of water, it may be used for washing out the nares with 
 a douche or fountain syringe. 
 
 Others speak highly of 50 per cent, boroglycerin for topical disinfection of 
 the throat, and all sorts of more energetic disinfectants have been recommended 
 (mineral acids, chlorine-water, galvano-cautery, etc.) with less obvious justifica- 
 tion. 
 
 The frequent anointing of the body with some form of non-irritant anti- 
 septic ointment in order that the action of the skin may be encouraged, rest- 
 lessness allayed, and the scattering of the scales reduced to a minimum, is 
 strongly advised. Such an ointment as carbolic acid, grs. 20, thymol grs. 10, 
 to vaseline and lanoline each half an ounce, may be favorably employed. This 
 should be applied at least twice daily, the skin having been previously cleansed 
 with warm water in which a little soda is dissolved. J. Lewis Smith speaks 
 highly of the following: 
 
 1^. Acid, carbolici 
 
 Olei eucalypti da 3J . 
 
 Olei olivse ^vij. — M. 
 
 Sig. For inunction every three hours. 
 
 Even the old-fashioned fresh lard or ham-rind will be found grateful to the 
 patient and helpful to the health officers. An excellent and more elegant 
 prescription is : 
 
 Ify. Thymol gr. x. 
 
 01. theobromse |j. 
 
 Alcohol q. s. — M. 
 
 Ft solutio. 
 Sig. For inunction twice or three times a day. 
 
 Disinfection of the room in which the patient has been is scarcely less 
 important than that of the patient, since the virus of scarlet fever is so 
 tenacious in its potency that it will persist for years in houses or rooms not 
 properly disinfected. If the walls are papered, they may be rubbed, as is 
 done by paper-cleaners, with slices of rye bread, which will remove microbic 
 spores and scales ; or, better, if possible, they should be repapered, calcimined, 
 or whitewashed. Previous to this, sulphur— 1 lb. to each 100 cubic feet of 
 room-space— should be burned in the infected apartment, which should be 
 kept closed for eighteen hours thereafter. 
 
 The efficiency of sulphur dioxide as a disinfectant is greatly increased by 
 
SCARLET FEVER. 151 
 
 combining with it the vapor of water in a hermetically closed room (Squibb). 
 Hence the room should be closed as tightly as possible by pasting strips of 
 paper over the door-jambs and keyholes before burning the sulphur candles. 
 To increase the efficiency of the sulphur dioxide by its union with aqueous 
 vapor, the candles may be placed on bricks in an ordinary wash-tub partially 
 filled with water, and allowed to burn in the closed room until they go 
 out for want of oxygen. After the room has been opened and aired as fully 
 as possible, it ought never to be reoccupied until the walls have been cleaned 
 as previously directed or thoroughly scrubbed. 
 
 All sheets, bedding, towels, and articles that can be washed should be im- 
 mediately thrown into boiling water after being used, and those articles that 
 cannot be washed or boiled should be fumigated with sulphur, baked, or, still 
 better, destroyed by burning, as should all toys and books used during the 
 convalescence of the patient. 
 
RUBELLA. 
 
 By WILLIAM T. PLANT, M. D., 
 
 Syeacuse. 
 
 Perhaps there is no other disease of brief duration and benign character 
 that has been so much written about and so variously named as rubella. It 
 was for so long held to be related to measles or scarlet fever, or both, that the 
 following names have naturally come from such views of its nature : French 
 and German measles or scarlet fever ; false, bastard, and hybrid measles ; and 
 epidemic roseola. These and others not worth remembering have come down 
 to us. The German name, Rotheln, is not, and will scarcely become, popular 
 in America, because of its foreign appearance and difficult pronunciation. 
 More attractive and satisfactory than all other names, and now quite generally 
 adopted by English-speaking people, is that of rubella — a diminutive of 
 rubeola, first suggested by Veale not many years ago. Indeed, the disease 
 seems to have been waiting for a name, and only lately to have found a fitting 
 one. 
 
 Previous to the middle of the last century rubella had had no very clear 
 description or decided differentiation from measles, and almost down to the 
 present time very many in the profession have regarded it as a sort of modi- 
 fied or mongrel measles. Now, however, through a happy agreement of 
 medical opinion, the following points may be regarded as settled : 1st. Rubella, 
 though much resembling measles and somewhat resembling scarlet fever, is a 
 distinct entity, independent of these as of other diseases. 2d. It confers no 
 protection against measles or scarlet fever, nor can either of these affections 
 influence or prevent an attack of rubella. 
 
 Rubella is an acute, contagious, eruptive febrile disorder, due to a specific, 
 but as yet unisolated, poison. It runs a rapid course and terminates almost 
 always in recovery. It occurs, with few exceptions, but once in a lifetime ; 
 and commonly travels in epidemics of rather limited extent, though sometimes 
 it spreads over large tracts of country in a short time; and not infrequently the 
 observant physician encounters sporadic cases whose origin he cannot make 
 out. At times it appears to part with its tendency to spread, though probably 
 at all times its contagious property is less pronounced than that of measles. 
 
 Incubation. — The period of incubation varies greatly. Griffith observed 
 a large institution-epidemic, originating from a child in whom the eruption 
 appeared upon the day of admission. The first case was observed after five 
 days, and 28 cases developed within eleven days after the earliest possible 
 exposure. Other observers give periods varying from ten days to three weeks, 
 the majority stating it to be from two to three weeks. The variability of this 
 period, as Griffith has pointed out, offers a striking contrast to the fixed period 
 of incubation of measles. Ordinarily, there are no symptoms observable dur- 
 ing this stage. Occasionally, Squire states, the throat is complained of, and 
 epistaxis and enlargement of the post-cervical glands may be observed. 
 
 152 
 
RUBELLA. 153 
 
 Symptoms. — The prodromal stage is short, not more than a few hours, 
 or a day at the most, though in many cases the eruption, like that of varicella, 
 may be the first evidence of disease, especially in older children. When 
 symptoms are observed they may comprise malaise, nervous irritability, slight 
 suffusion of the conjunctivae, perhaps with lachrymation and slight coryza, pains 
 in the limbs, drowsiness, hoarseness, slight cough, sore throat, enlargement of 
 post-cervical and post-auricular glands, with possibly an elevation of tempera- 
 ture of 1° to 3° F. Any or all of these symptoms may be wanting, and the 
 first evidences of disease, as already stated, may be discovered in the rash. 
 
 The eruption of rubella appears first behind the ears and upon the fore- 
 head and face, especially upon the oral circle, spreading rapidly over the rest 
 of the body, and reaching the legs last. When first discovered it may have 
 already extended to the chest or abdomen. In rare cases the distribution of 
 the rash may remain limited, as in a case observed by Griffith, in which, though 
 the symptoms were severe, the rash could be found only upon the face and 
 neck. 
 
 In appearance the rash is maculo-papular, pin-head to split-pea in size and 
 pale rose in color. The spots are usually discrete, and are separated by areas 
 of healthy skin; but in certain localities subjected to warmth and pressure 
 they may become confluent and simulate closely the rash of scarlatina. Upon 
 the chest and back the rash is usually darker red in color, and more pro- 
 fuse. From this, the typical appearance of the eruption, various departures 
 occur, so that in one case the eruption of measles may be closely simulated, 
 and in another the rash of scarlatina. This variability of the eruption is 
 one of the most characteristic features of the disease. A study of these mani- 
 festations seems to warrant the recognition of two distinct types of variation 
 from the normally developed rash : 1. Rubella Morbilliforme. — The eruption 
 is discrete, the papules are nearly the size of a split pea, and more or less 
 grouped, strongly resembling measles. 2. Rubella Scarlatiniforme. — Here 
 the whole body is rapidly covered with a diffuse rash of bright rosy-red hue, 
 which is raised somewhat from the surface of the skin, and often occurs in 
 patches with well-defined margins. A few papules may often be found near 
 the margins or within the reddened areas, and can be best seen perhaps on 
 the fingers or wrists, or on the forehead. 
 
 In some cases, indeed, coalescence of papules may take place after some 
 hours, and, as Tonge-Smith has pointed out, the rash may thus become blurred 
 into a confluent blush on the second day, so as to be indistinguishable from 
 scarlatina except from the history. Instances, however, will occur where the 
 greatest minuteness of examination will fail to give conclusive evidence of the 
 nature of the rash, particularly in the scarlatiniform variety. 
 
 In the development of the eruption variations will also be observed. Thomas 
 states that ordinarily the maximum of the development of the eruption on dif- 
 ferent parts occurs at different times, following the sequence of its first appear- 
 ance, and this opinion is shared by Hardaway, Emminghaus, Roth, and Griffith ; 
 other writers state that the eruption reaches its height on the second, rarely, 
 as Cheadle asserts, on the third, day. The average duration of the eruption is 
 fixed by Griffith at three to four days, though it often lasts a much shorter 
 time, or may continue longer. As the eruption fades, slight brownish or yel- 
 lowish pigmentations may be visible for a few days. Desquamation does not 
 occur in all cases : according to the testimony of a few competent observers 
 it has never been observed. It does, however, occur, but is always slight 
 and furfuraceous in character, and is usually completed in a few days. 
 
 With the appearance of the rash or slightly preceding it other symptoms 
 
154 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 appear. Catarrhal symptoms, referable to the conjunctivae and nasal passages, 
 are frequently present, but in slighter degree than is usual in measles, photo- 
 phobia and marked coryza being quite rare. A loose cough is not unusual, but 
 is distinctly less severe than that of measles. Sore throat is one of the most 
 constant of the symptoms. It appears usually as a redness of the mucous 
 membrane, especially marked about the uvula and upper portions of the 
 anterior pillars ; the tonsils are at times involved, and may be considerably 
 swollen, giving rise to pain in swallowing. Griffith mentions an occasional 
 eruption of small yellowish-red or brownish-red spots of pinhead size visible 
 over the soft palate and uvula and the inner surface of the cheeks. This 
 sore throat, however, is of little importance, and rapidly subsides, often to 
 recur in the last stage of the disease. This secondary angina, accord- 
 ing to Eustace Smith, is very characteristic of rubella. The tongue is 
 either clean or has a thin yellowish-white coating, quite different from the 
 characteristic "strawberry" tongue of scarlatina, the appearance of which 
 is never simulated, according to the testimony of the great majority of 
 writers. The temperature varies greatly, ranging up to 103° or 104° F., 
 though, as a rule, rarely reaching 101° F., and often is not materially 
 elevated. It is apt to be highest on the first or second day of the rash, and 
 may then subside suddenly or fall gradually with the disappearance of the 
 eruption. Pulse and respiration are rarely disturbed except in proportion to 
 the rise of temperature. 
 
 Probably the most characteristic symptom of the disease is enlargement of 
 the lymphatic glands, which to greater or less degree is present in almost every 
 case. Those mainly affected are the post-cervical and post-auricular glands, 
 but in many cases the axillary and inguinal glands are also involved. The 
 swelling is hard, tender, and reaches the size of a pea. It is an early symp- 
 tom, noticeable often on the first day, at times before the appearance of the 
 rash, and practically it is never delayed beyond the second day. Griffith, how- 
 ever, believes that this glandular swelling, while a very constant symptom of 
 rubella, is probably nearly equally as frequent in measles, and that it is by 
 no means of as great diagnostic importance as is usually supposed. 
 
 Nausea and vomiting are extremely rare, and, though reported in isolated 
 cases, should not be classed as symptomatic of this disease. The bowels also 
 show no special disturbance of function. Slight oedema of the face may be 
 observed when the rash is well marked. Itching of the skin is rarely present 
 and is never troublesome. 
 
 Reinfection, or relapse, is of very rare occurrence, but has been occasion- 
 ally observed within one to three weeks after the onset of the original attack. 
 
 Complications and Sequelae.— In the disease as we know it at the present 
 day complications or sequelae directly traceable to it are extremely rare. Those 
 most commonly mentioned involve the respiratory organs and air-passages, such 
 as bronchitis and pneumonia, naso-pharyngeal catarrh, stomatitis, and perma- 
 nent enlargement of the tonsils. Transient albuminuria is mentioned by Em- 
 minghaus, Kingsley, Reed, Cheadle, and others, while Mettenheimer, tonge- 
 Smith, and Squire doubt its occurrence, and Hardaway considers it entirely 
 anomalous, if not due to mistaken diagnosis. Otorrhcea, ciliary blepharitis, 
 and phlyctenular keratitis have been observed. 
 
 Prognosis. — Rubella is not a dangerous disease, and recovery is usually 
 complete in a fortnight. Death occasionally occurs in severe cases and in 
 some epidemics, and this from some serious complication. 
 
 Diagnosis. — From measles rubella may usually be distinguished by the 
 short duration of its prodromal symptoms and the absence of marked catarrhal 
 
RUBELLA. 155 
 
 symptoms and hoarse ringing cough ; by the slight degree and the variability 
 of fever ; by the presence of sore throat and of enlargement of the post-cer- 
 vical and post-auricular glands ; and, in less certain degree, by the appearance 
 of the eruption. From scarlatina it may be distinguished by the absence of 
 vomiting at the onset, by the suffusion and faint congestion of the conjunc- 
 tivae ; by the swelling of the lymph-glands, which occurs early, bears no rela- 
 tion to the severity of the faucial inflammation, and affects the post-cervical 
 and post-auricular glands rather than those of the throat ; by the appear- 
 ance of the tongue, and lack of acceleration of pulse out of proportion to the 
 elevation of temperature ; by the absence of albuminuria ; by the branny 
 character of its desquamation ; and, finally, by the appearance of the rash, 
 which is more rosy in color and somewhat raised from the surface, often occurs 
 in patches with well-defined margins, and is less burning to the touch. 
 
 Anomalous cases, however, arise which tax to the utmost the physician's 
 skill in diagnosis, and the occurrence of other more typical cases in the same 
 family may be the only means of distinguishing rubella from one or other of 
 the more serious affections which it simulates. 
 
 Treatment. — Probably no disease needs less medical treatment. Its own 
 direction being toward recovery, it may generally be safely left to follow it. 
 The patient should be sent to bed, as well for the safety of others as for his 
 own. As there is conjunctival irritation in most cases, the room should be 
 darkened. 
 
 The diet should be light and bland, as toast, bread and warm milk, and 
 various broths. Cool water should not be denied. If itching be trouble- 
 some, it may be allayed by frequent tepid bathing. Treat headaches by 
 applying cloths wrung from cold lotions or by hot foot-baths made more 
 effective by mustard. 
 
 The sore throat is well treated by the steam atomizer or by gargles, as fol- 
 lows : 
 
 i^. Potassii chloratis 3iss ; 
 
 Grlycerini feiij ; 
 
 Tinct. ferri chlorid f^ss ; 
 
 Aquae q. s. ad fgviij. — M. 
 
 Sig. Gargle once in three or four hours. 
 
 In a disease of such mild character it is doubtful whether any quarantine 
 precautions need be advised, except to prevent loss of time and inconveni- 
 ence in the school-room, where the disease is readily disseminated, often 
 by cases passing without recognition. From this point of view two weeks 
 after the beginning of the attack may be considered an ample period of 
 quarantine. 
 
CHICKEN-POX. 
 
 By WILLIAM T. PLANT, M. D. 
 
 Syeacuse. 
 
 Varicella, or chicken-pox, the lightest of the exanthemata and usually 
 a disease of trivial importance, was first described as a distinct affection a few 
 years before the close of the seventeenth century. There can be no doubt that 
 it had existed from a period far remote, but it was not until then differentiated 
 from small-pox and other eruptive disorders. Dr. William Heberden, an Eng- 
 lish physician who lived between 1710 and 1801, was the first to give a full 
 and accurate description of this disease, though several writers before his day 
 had described it less perfectly, and one of them, Dr. Richard Morton, gave it 
 its earliest and best name of chicken-pox. 
 
 It is an acute, infectious, and transient affection, runs a definite course, and, 
 with very few exceptions, occurs but once in the same person. Though it 
 bears some resemblance to the lighter forms of variola, it has no relation to 
 this disease, as has been abundantly proven by the observations of two cen- 
 turies. Therefore, the name varicella, conferred upon it by Vogel in 1764, is 
 founded upon error and is misleading. 
 
 It is essentially a pediatric disorder, as it only affects infants and young 
 children — at least the writer does not remember to have met with it more than 
 once or twice in adults. It may be regarded as quite a rare affection after four- 
 teen or fifteen years of age. It travels in epidemics, often widespread, regard- 
 less of season, race, country, or climate, and of everything but age. 
 
 Incubation. — The incubative period is rather long. Henoch fixes its 
 duration at 12 to 13 days; Gerhardt, 14 to 15; Eichhorst, 13 to 16; Striim- 
 pell, 13 to 17 ; and Semtschenko, 3 to 26. In cases of the inoculated disease 
 d'Heilly has observed as short an incubation as 3 days ; but with the affection 
 as ordinarily contracted this period of latency may be assigned between the 
 lowest and highest figures given by the authorities quoted, averaging 13 to 
 17 days. 
 
 Symptoms. — At the close of the incubation the active period of the disease 
 is often ushered in with a little chilliness, aching of head and limbs, diminution 
 of appetite or complete anorexia, and perhaps nausea. With these symptoms 
 there is usually moderate fever — from 99° to 102°. It often happens, how- 
 ever, that the eruption is the first symptom noticed, no complaint of illness 
 having been previously made by the child. Only in rare instances are the 
 phenomena of invasion alarming or even severe. Decided chills, fever of high 
 grade, and even delirium, are occasionally met with at the onset, and in one 
 case under the writer's care the disease was ushered in by two severe convul- 
 sions. Some authors allude to this very rare mode of beginning. But, 
 whether these first symptoms of invasion are usually mild or entirely unnoticed 
 or exceptionally severe, they are of short duration, and the eruptive stage is 
 soon established. As it first appears, irregularly scattered over the body, the 
 
 156 
 
CHICKEK-POX. 157 
 
 eruption consists of some small rose-red papules which very quickly develop 
 into vesicles. This change is effected so quickly that very often the papular 
 stage is over and the vesicular stage well under way before the eruption is 
 discovered. The vesicles are seldom either numerous or large. Varying in 
 number from a dozen or two to a hundred or more, they are scattered rather 
 irregularly over the trunk, limbs, and scalp, but are most abundant upon the 
 back. They seldom make very much show on the face. Frequently a few 
 are found on the forehead and temples when all other parts of the face are 
 quite free. Often, if searched for, some blebs may be found upon the mucous 
 membrane of the mouth and fauces, where they quickly rupture and leave 
 small ulcers. In the severer cases mild sore throat, laryngeal irritation, or 
 slight hoarseness is sometimes noticeable, and in the light of the interesting 
 observations of Boucheron and of Marfan and Halle', to be presently referred 
 to under the heading of Complications, it seems quite certain that hyperemia 
 of the upper air-passages and vocal cords may be present, and that vesicles 
 may occasionally form upon the vocal cords, and possibly still lower down in 
 the bronchial tree. 
 
 The vesicles of chicken-pox are quite variable in size : some are not larger 
 than pin-heads, while others reach the size of small peas. It was presumably 
 the resemblance in average size to the "chiok-pea," or "cicer," of Southern 
 Europe that suggested to Dr. Morton the name of chicken-pox. 
 
 The tegumentary covering of the vesicle is very thin, being composed only 
 of the outer layers of the skin. It contains an alkaline serum of crystal 
 transparency, whence another admirable name for the affection, " cry 'St alii" 
 and the German " Wasserpocken." It was long ago aptly said that the rash 
 of chicken-pox suggests an appearance as if scalding water had been flirted 
 over the surface, each drop having raised a small transparent blister. Some 
 of the vesicles are surrounded by a narrow, often linear, and very pink are- 
 ola ; others rise abruptly from a surface of natural color. 
 
 A peculiar and distinguishing feature of chicken-pox is that the eruption 
 comes out in successive crops. Before, or as soon as, the first vesicles have 
 arrived at their full size others are just beginning ; and this may be repeated 
 twice or thrice, or even four times. 
 
 In the disease as ordinarily observed the vesicles never become pustular 
 like those of small-pox, unless from scratching or other irritation, with conse- 
 quent secondary infection ; and, according to the usual teaching, they are 
 neither partitioned nor umbilicated, as are those of variola, and are rarely so 
 numerous as to become confluent. Walsh, however, quite recently has stated 
 that the eruption may be macular and papular, with an inflammatory areola 
 about the vesicles, which may be confluent, umbilicated, partitioned, and pus- 
 tular, and finally may leave depressed cicatrices not unlike "pockmarks." In 
 these times of general vaccination, with its protecting or, at least, mitigating 
 influences, cases manifesting such peculiarities of the eruption must be regarded 
 with grave suspicion, and the possibility of a masked variola must be taken 
 into serious consideration, especially if the patient be an adult. 
 
 Another peculiarity of this disease is that, if the eruption is at all copious, 
 many, perhaps most, of the vesicles abort and shrivel away before making much 
 progress toward a completed development. I have observed that late vesicles 
 are especially prone to abort. The other vesicles advance rapidly to maturity 
 and enter on a speedy decline. The fluid becomes opalescent and turbid, and 
 dries down into a thin yellowish crust that soon crumbles and falls off, leaving 
 a temporary redness of the skin. In case of injury or irritation of a vesicle 
 sufficient to cause a slight superficial destruction of the derm, and sometimes 
 
158 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 even without this in vesicles of unusual size, healing is followed by a slightly 
 excavated depression in the surface of the skin. Many persons bear in after- 
 life one or more of these pits upon the face as a reminder of this childish 
 
 malady. 
 
 During the eruptive stage the fever, which is almost uniformly intermittent 
 in type, varies in degree with the acuteness of the attack and the extent of the 
 eruption, mild casesfwith only a few vesicles, being almost apyretic ; severe 
 cases, with a profuse eruption, being attended by a temperature of 104° or 
 more. The usual range and duration of elevated temperature is illustrated in 
 the accompanying charts (Fig. 1). 
 
 The whole course of chicken-pox seldom exceeds eight or nine days, or 
 possibly ten or twelve at the most, and in the uncomplicated cases convalescence 
 
 
 
 
 
 
 
 
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 Temperature Charts of Varicella (Ashby and Wright). 
 
 is rapid. As seen in young infants, however, especially in those already 
 weakened by chronic digestive ailments, the disease, however mild in its mani- 
 festations, may be followed by a period of innutrition of more or less gravity. 
 In hospital epidemics varicella is certain to add to the mortality among this 
 class of patients. 
 
 Recurrence. — Second attacks of varicella are rare. In twelve epidemics 
 studied by Semtschenko in Kasan, embracing 872 cases, only 14 instances of 
 recurrence were found, the intervals varying from eight to eighteen months 
 after the primary attack. In 5 other cases there were two subsequent attacks 
 of the disease. 
 
 Complications and Sequelae. — While ordinarily chicken-pox runs an 
 
CHICKEN-POX. 159 
 
 uneventful course in a previously healthy child, and is followed by rapid and 
 complete recovery, recent observations have emphasized the fact that the 
 kidneys may early present inflammatory changes, which may occasionally lead 
 to a fatal termination. Attention was first drawn to this in 1884 by Henoch, 
 who reported 4 cases of post-varicellous nephritis, one of which terminated 
 fatally ; and since then more than 30 cases have been published, principally by 
 German observers. Cassel, one of the most recent of these, saw 6 cases out of 
 12 in a single epidemic in Berlin, in 1894, which showed albuminuria or actual 
 nephritis, the earliest on the fourth or fifth day of the disease. Three of these 
 were fatal — one, ten months old, from nephritis alone on the twelfth day, the 
 others in association with pneumonia. Two other cases dying from nephritis 
 have been recorded — one each by Hogyes and Hagenbach, the latter referring 
 to the condition as one of acute parenchymatous nephritis, while the former 
 stated that the convoluted tubules and loops of Henle were alone affected. 
 This testimony is sufficient to indicate the necessity for keeping close watch 
 upon the urine during, and for a time after, the disease. 
 
 Von Starck has seen in a boy of two years, on the tenth day following the 
 onset, a generalized oedema without albuminuria or other signs of nephritis. 
 It was attributed to a peculiar action of the virus of the disease upon the ves- 
 sels of the subcutaneous connective tissue, comparable to the condition signalized 
 by Quincke and others as occurring after scarlatina. 
 
 The occurrence of a scarlatiniform erythema during the decline of the 
 eruption has been occasionally observed. In one case lately reported by 
 Comby albuminuria of four days' duration and suppuration in a submaxillary 
 lymph-gland followed the erythema. The precise nature of this rare compli- 
 cation is still unsettled. 
 
 Suffocative laryngitis has been observed in 2 cases by Marfan and Halle, 
 as previously noted — one preceding, the other accompanying, the appearance 
 of the eruption. The first case, a child of three years, was seen first after an 
 illness of three days. The voice was hoarse and respiration difficult, with 
 supra- and infrasternal recession. The throat was reddened, but otherwise not 
 abnormal. On the fourth day the eruption appeared upon the surface, but 
 the laryngeal symptoms increased, and necessitated tracheotomy, The child 
 recovered. The second case, in a weakly infant of nine months, showed a sim- 
 ilar affection of the larynx coincident with a profuse confluent eruption. Death 
 occurred on the seventh day from acute diarrhoea and broncho-pneumonia. The 
 autopsy showed a small round, deep ulcer at the posterior part of the margin 
 of the right vocal cord. Boucheron also saw a case which proved fatal from 
 spasm of the glottis, due probably to hypersemia of the vocal cords. 
 
 Various other affections have been noted as occasional complications of 
 this disease, among which may be mentioned furunculosis, osteitis, synovitis, 
 otitis media, and submaxillary and cervical adenopathy, at times associated 
 with inguinal bubo, and rarely going on to suppuration. 
 
 Varicella may complicate or be complicated by other infectious diseases : 
 such combinations as varicella and pertussis, varicella and measles, varicella 
 and scarlatina, varicella, measles, and pertussis, and varicella, measles, and 
 diphtheria, are occasionally observed. Profuseness of the eruption alone may 
 constitute a serious complication, as is illustrated by a fatal case in an infant 
 of eight and a half months seen by Nisbet, who attributed its death to the 
 fact that the eruption covered every portion of the body, producing the effect 
 of an extensive burn. 
 
 Secondary infections are not very unusual. Of these erysipelas is the most 
 common, and is always a grave complication. In a circumscribed epidemic 
 
160 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of 15 cases Bolognini observed 12 in which secondary infection of the vesicles 
 by staphylococci and streptococci took place during the stage of desiccation, 
 causing the vesicles to enlarge to the size of bullae, which, breaking, gave issue 
 to a thick creamy pus. In one case, the only one resulting fatally from abscess 
 of the kidney, pure cultures of the streptococcus were obtained. All of these 
 children had transient albuminuria, without other signs of nephritis. 
 
 Varicella G-angraenosa. — Among the secondary infections should be con- 
 sidered the rare condition which is described under this name. It was first 
 brought to notice by Hutchinson in 1882, and was for a time thought to be 
 peculiar to varicella ; but subsequent observations have shown that an identi- 
 cal process may occur in connection with vaccinia, pemphigus, and other dis- 
 crete pustular lesions. Dermatologists now describe the general affection 
 under the name of dermatitis gangrenosa infantum. Tuberculosis, rickets, 
 and inherited syphilis seem to exercise a predisposing influence, but it has been 
 occasionally observed in apparently healthy children. 
 
 As seen in connection with varicella, it may begin while the vesicles are 
 still present ; it is then observed first upon the head or upper portions of the 
 body. It will be noticed that ulceration has begun beneath the crust, and 
 often a pustular margin with an inflammatory areola is found, resembling 
 closely a vaccinal pustule. The destructive process extends in depth and 
 periphery until it forms a black slough reaching an inch or more in diameter. 
 After a time separation of the slough occurs, leaving a sharply-cut oval or 
 roundish excavated ulcer. "When the vesicles have been closely aggregated 
 several gangrenous areas may coalesce to form larger ulcers of irregular 
 contour. 
 
 When the gangrenous process begins as late as two w T eeks or more after 
 the onset of the disease, after the varicellous lesions have healed, the ulcerations 
 are more apt to begin upon the lower portion of the body, especially upon the 
 buttocks and thighs. Pinhead-sized maculo-pustules first appear, which in- 
 crease in size, rupture, and form crusts, under which the gangrenous process 
 begins as in the case of pre-existing varicellous lesions. 
 
 In the severer cases, which begin early in the course of the exanthem, haem- 
 orrhage into the vesicle precedes the other changes; and, with this, haemor- 
 rhages from the nose, mouth, or stomach, as well as beneath unaffected por- 
 tions of the skin, may be observed. Such cases run a rapid course, and ter- 
 minate with symptoms of general pyaemia. 
 
 Of the pathology of gangrenous varicella nothing definite is known. There 
 can be little doubt, however, that it results from a secondary infection, in 
 the milder cases probably with the ordinary pyogenic organisms ; and in the 
 more malignant cases, such as those recently reported by Lock wood and Silver 
 (Archives of Pediatrics, Sept., 1897), the coincidence of an acute blood-infec- 
 tion may be reasonably presumed. 
 
 Even in its mildest manifestations gangrenous varicella is a serious affec- 
 tion, but in the virulent types associated with marked blood-dyscrasia the 
 prognosis is wellnigh hopeless. 
 
 Diagnosis. — It is usually only to settle this important question that the 
 physician is summoned. Apart from variola or its milder manifestation, vario- 
 loid, eruptive vaccinia and herpes zoster are the only diseases with which 
 varicella might reasonably be confounded. 
 
 From eruptive vaccinia, apart from the history of a recent vaccination, 
 varicella may be distinguished by its successive crops of rapidly developed 
 vesicles, which will have almost disappeared before the vaccinal lesions could 
 have reached the height of their development and shown a marked areola. 
 
CHICKEN-POX. 161 
 
 From herpes zoster, its more general distribution, which does not follow the 
 course of certain nerves, and the absence of pre-eruptive pain, should serve to 
 differentiate it. 
 
 From well-marked variola and varioloid, varicella should be readily distin- 
 guished by a consideration of the following points of difference : 
 
 Chicken-pox. Variola. 
 
 Only infants and young children affected. All ages affected. 
 
 Invasion short ; general symptoms usually Invasion three days ; general symptoms 
 very light. severe. 
 
 Febrile stage transient, commonly highest Initial fever falls with appearance of erup- 
 at beginning of the eruption. tion, to be followed by the secondary rise 
 
 with pustulation. 
 
 Eruption vesicular almost from the first. Eruption papular for 3 or 4 days. 
 
 Eruption superficial : never shotty. Eruption deep-seated : hard, snotty. 
 
 Seldom umbilicated. Generally umbilicated. 
 
 Vesicles not distinctly multilocular. Vesicles always multilocular. 
 
 Vesicles always discrete. Eruption often confluent. 
 
 Eruption little on face, hands, and feet. Eruption most on face, hands, and feet. 
 
 Xo pustular stage. Pustular stage never absent. 
 
 Uninfluenced by vaccination or previous Prevented by vaccination or previous small- 
 small-pox. pox. 
 
 Mild and abortive cases of varioloid occur, however, and present the great- 
 est difficulty in diagnosis. The invasion may be short, and so mild as to 
 attract no attention ; the lesions may be few and scattered ; fever may be 
 insignificant ; and the vesicles may abort before reaching the pustular stage. 
 In such a case error in favor of the milder disease is easily made, and may be 
 followed by most disastrous consequences. Only a most careful study of the 
 history and course of development of the attack can lead to a satisfactory 
 decision ; and if the patient should happen to be an adult, this fact should 
 weigh decidedly in favor of the more serious disease. 
 
 Prognosis. — As a rule, when occurring in a previously healthy child, 
 chicken-pox rarely gives rise to "anxiety as to its outcome. Among debili- 
 tated, strumous, and syphilitic infants prognosis should be more guarded, lest 
 the gangrenous complication supervene, the prognosis of which has been 
 already stated. 
 
 Treatment. — A disease whose course and duration are fixed, and whose 
 ending is almost always favorable, requires little aid from medicine. The 
 child should be confined to bed during the active stage of the disease, and if 
 fever be high a foot-bath should be given at the start, followed by a simple 
 diaphoretic febrifuge. Except in the case of very young children, whose 
 digestion is liable to passing disturbance from the disease, no special restric- 
 tion in diet need be made unless the fever remains high for several days. 
 As a rule, the eruption causes little irritation, and needs no treatment except 
 a soothing dusting powder upon the back and upon the parts kept warm by 
 the clothing. Upon the face large vesicles may be punctured early, and 
 covered with a thin film of collodion to protect them against injury or 
 secondary infection from scratching. For similar reasons the child's hands 
 should be disinfected and the nails kept clean and well trimmed. 
 
 In all cases the urine should be watched, and from time to time during 
 the course and convalescence should be examined for albumin or other evi- 
 dence of nephritis. If convalescence be protracted and the child exhibit 
 evidences of anaemia or disturbed nutrition, iron and cod-liver oil, with a 
 bitter tonic, should be prescribed, with perhaps a change of air, preferably 
 a short sojourn at the seashore. 
 li 
 
162 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Gangrenous varicella demands a much more rigid treatment. Constitu- 
 tionally, the strength must be kept up by nourishing diet and by liberal 
 stimulation, according to the indications, with some suitable preparation of 
 alcohol, with strychnine, and with quinine. Locally, the gangrenous lesions 
 must be treated with antiseptic and deodorizing washes, such as solutions 
 of permanganate of potassium, peroxide of hydrogen, or bichloride of mer- 
 cury, and kept covered with a protective ointment containing iodoform, 
 ichthyol, or some other drug of this class. 
 
 Quarantine. — With a disease ordinarily so benign little effort is usually 
 made to carry out quarantine. In many children's hospitals epidemics of 
 varicella run their course unchecked, usually for want of sufficient facilities 
 for isolation ; and ordinarily the disease seems to have little disturbing effect 
 upon the children except in the rare instances where a gangrenous compli- 
 cation occurs or among the athrepsic babies, as already pointed out. In 
 family practice a period of three weeks from the beginning of the disease 
 may be considered a sufficient time for isolation. As with other infectious 
 diseases, a thorough cleansing of the body and scalp and a change of clothing 
 should be ordered before the child is allowed to mix with his playmates 
 again. Without such precaution the danger of infecting others may last for 
 some time, as was instanced in a case coming under the author's observation 
 where the disease was communicated to an infant by a child who had recov- 
 ered from an attack fully four weeks before the only occasion of their meeting 
 and playing together. 
 
VARIOLA AND VARIOLOID. 
 
 By C. G. JENNINGS, M. D., 
 Detroit. 
 
 Variola, or small-pox, is an acute, specific, highly infectious disease, 
 characterized by a typical range of temperature and a specific inflammation of 
 the skin appearing usually on the third day of the disease as a papular eruption, 
 which quickly becomes vesicular and finally pustular. The pustules desiccate, 
 and leave permanent cicatrices wherever suppuration has invaded the deep tissue 
 of the skin. 
 
 Etiology. — The nature of the contagium of variola is unknown ; analogy, 
 however, points to a micro-organism as the infectious principle. There is no 
 evidence of the development of the disease de novo, each case being transmitted 
 from a parent case in another individual. Individuals of both sexes and of all 
 ages, unprotected by vaccination, are subject to the disease. Even the foetus 
 in utero does not enjoy immunity. 
 
 The disease is transmitted by direct contact, through the medium of infected 
 articles and through the air. While scarlatina, measles, and other exanthemata 
 will infect at the distance of only a few feet, small-pox has a striking distance 
 that is very much greater. In the Sheffield epidemic (1887) the influence of 
 the Sheffield hospital could be traced over an area having a radius of four 
 thousand feet. 
 
 One attack, as a rule, renders an individual immune. In countries where 
 the disease is prevalent a second attack is not uncommon. The writer saw a 
 negro woman, ill with discrete variola, who was sadly disfigured by two previous 
 attacks. The disease prevails most extensively among unvaccinated communi- 
 ties. The negro race is particularly susceptible. The disease is most infective 
 during the periods of suppuration and desiccation. Although apparently inde- 
 pendent of climate, small-pox is a disease of the winter and spring. 
 
 Pathological Anatomy. — The characteristic anatomical lesion of variola 
 is found in the skin and mucous membranes. Small areas of congestion appear 
 in the skin. The vessels of the corium dilate and become tortuous, and the 
 connective tissue in the centre of the congested areas is thickened by oedema. 
 Coagulation necrosis of the epithelial cells quickly follows, with thickening of 
 the epidermis. These changes form the papules. Serum is poured out between 
 the necrotic cells, and a vesicle forms. The changed cells form a meshwork in 
 which the fluid is enclosed. Trabeculae bind down the centre of the vesicle, 
 while its periphery continues to distend, producing umbilication. Pus-cells 
 form rapidly in the vesicle, and in a few hours it is transformed into a pustule. 
 Inflammatory injection and thickening of the connective tissue surrounding the 
 pustule now take place. If the necrotic process is confined to the superficial 
 layers of the skin, resolution takes place without pitting. If the deep tissue 
 is involved, a cicatrix results. Desiccation of the pustule follows, leaving a 
 crust of dried cell-de'bris and pus adhering to the skin. Then the epidermis re- 
 
 163 
 
164 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 forms under the crusts, the inflammatory injection and infiltration subside, the 
 crusts drop off, and resolution is complete. 
 
 The process in the mucous membrane is the same. Perfect pustules, how- 
 ever, are rarely seen, because the macerated roof yields early to the pressure, 
 and an aphthous-looking ulcer results, often covered by a pseudo-membrane. 
 In hemorrhagic small-pox the pustules contain blood, and extravasations may 
 occur in the skin and mucous membranes at any point, and in the substance 
 of all the organs. More or less intense congestion and septic inflammation 
 may be found in the brain, liver, lungs, kidneys, and spleen. 
 
 Incubation. — The duration of the period of incubation of variola is, on 
 the average, twelve days. Exceptionally it may be shortened to ten or length- 
 ened to fifteen days. When transmitted by inoculation the disease appears on 
 the eighth day or sooner. During the period of incubation the child, as a rule, 
 shows no symptoms. 
 
 Symptoms. — The clinical history of small-pox may be divided into four 
 stages : Invasion ; eruption ; secondary fever ; desiccation or decline. 
 
 The stage of invasion is ushered in abruptly. Older children complain 
 first of chilliness, and often there is a distinct rigor. The phenomena of severe 
 fever quickly follow. In addition to the usual symptoms of fever there are 
 headache of unusual severity, persistent vomiting, great prostration, and 
 severe backache. In younger children and infants the disease begins with 
 fever, great nervous irritability, and vomiting. Very often convulsions mark 
 the onset of the disease. They may be frequently repeated, with inter- 
 vals of stupor or delirium. The skin is dry or perspiring ; the tongue coated, 
 with dark-red edges. The bowels may be constipated, but often a sharp 
 diarrhoea is present during the whole of the invasion stage. Abdominal pain 
 and tenderness are frequent. Respiration is rapid. The pulse is full and 
 quick, ranging from 120 to 160. The temperature quickly reaches a high 
 point, ranging from 102° to 105° F., or higher. The high temperature is 
 maintained during the invasion stage with but slight remissions. The maxi- 
 mum temperature of this stage is usually reached just before the appearance 
 of the eruption. Partial paraplegia, numbness, and incontinence of urine 
 and faeces, are sometimes seen in children. 
 
 In children more frequently than in adults initial or accidental rashes 
 appear about the second day, and cause much difficulty in diagnosis. The 
 initial rash may be erythematous, simulating scarlatina or erysipelas; or 
 macular, simulating measles. It is very evanescent, and usually ushers in an 
 attack of varioloid. A number of observers have noted that the areas of skin 
 affected by the prodromal rash escape the variolous eruption. Petechias from 
 one-twelfth to one-fourth of an inch in diameter are sometimes seen in this 
 stage of the disease scattered over the lateral thoracic and lower abdominal 
 regions. This rash is often of grave prognostic significance. 
 
 The average duration of the stage of invasion is three days. In grave 
 cases it is often shortened to two, while in varioloid it is often prolonged to 
 four days. As a rule, the longer the incubation stage the milder will be the 
 subsequent course of the disease. Notable exceptions to this rule are the 
 delayed rashes of cases complicated by severe internal diseases, and, as Moore 
 observes, of cases showing an early hsemorrhagic tendency. 
 
 The Stage of Eruption.— On the third day of the disease, with the vari- 
 ations noted above, the true rash of small-pox begins. The eruption shows first 
 on the face, quickly extending to the scalp and neck. Exceptionally it covers 
 the wrists early. After the face and neck, it next invades the trunk, extremi- 
 ties, and finally the palmar and plantar surfaces, taking from twenty-four to 
 
VARIOLA AND VARIOLOID. 165 
 
 forty-eight hours to cover the cutaneous surface. Rarely, in very young 
 infants, the rash appears first about the lower part of the abdomen and on the 
 inside of the thighs. Other exceptions to the usual sequence are sometimes 
 met. The rash is most abundant on the face and on the back of the hands. It 
 shows early and abundantly on irritated areas of skin. 
 
 The eruption begins as small, slightly raised, pale-red macules, and passes 
 through four stages of development — viz. macules- papules, vesicles, and 
 pustules. The macules in a few hours become fine, conical papules, pin-head 
 in size and larger. The papular stage continues for two days. The well- 
 developed papules are hard and shotty to the sense of touch, " feeling like 
 grains of shot underneath the skin." Gradual augmentation in the size of the 
 papules takes place. On the third day a minute vesicle appears at the apex of 
 the older papules ; it rapidly grows, and transforms the papule into an umbili- 
 cated vesicle with cloudy contents. By the fifth day of the rash the fluid in 
 the vesicles becomes turbid, and by the sixth day it is distinctly purulent. 
 The eruption has now reached the pustule stage, or stage of maturation. The 
 mature pock is globular and about the size of a pea. The increase of the con- 
 tents has distended the chamber and removed the umbilication. The pustule 
 is, in fact, a small abscess. It is usually surrounded by a swollen, red, inflam- 
 matory zone, the halo of the pustule. 
 
 Synchronous with the development of the cutaneous eruption a true vario- 
 lous exanthem appears upon the mucous membranes. The visible mucous 
 membranes are nearly always affected, and, in severe cases, the rash extends 
 throughout the whole alimentary and respiratory tracts. The urethra, vagina, 
 and conjunctivae are often invaded. 
 
 With the appearance of the eruption a remarkable amelioration in all the 
 symptoms takes place. The temperature rapidly falls, often reaching the 
 normal point or a little above on the fifth or sixth day. This fall of the tem- 
 perature is pathognomonic of the disease. The pulse loses its rapidity and 
 the gastric and intestinal irritability subsides. In cases of severity the remis- 
 sion is less marked, and the severe symptoms of the incubation stage persist 
 with but little relief. In discrete small-pox convalescence often sets in after 
 three or four days of the mild febrile movement which follows the sharp decline 
 of the beginning of the eruptive period. 
 
 In children, with the beginning of the vesicular stage the eruption in the 
 mouth and throat becomes a source of distress and danger. The vesicles rup- 
 ture, and a streptococcus pseudo-membrane covers the resulting erosions and 
 often extends over a large area of mucous membrane. Nasal and pharyngeal 
 obstruction results, with distressing symptoms, and if the larynx be invaded, 
 croup with dangerous stenosis may supervene. 
 
 In typical variola the maturation of the rash is accompanied by the onset 
 of the secondary fever or fever of suppuration, which is of indefinite duration 
 and varies in intensity w T ith the severity of the attack. The child becomes 
 restless and there is mild or active delirium. The temperature ranges from 
 101° to 104° F., with morning remissions and evening exacerbations. The 
 pulse is quick and hard. Often the symptoms assume the typhoid type, with 
 low delirium or stupor, a rapid, feeble pulse, and subsultus tendinum. A tem- 
 perature that frequently rises above 104° during the stage of suppuration is 
 of grave significance. (See Fig. 1). 
 
 The stage of desiccation or decline begins on the twelfth or thirteenth day 
 of the disease. The pustules begin to dry up, the inflammation and swelling 
 of the skin subside, the temperature gradually falls, and there is a general 
 improvement in all the symptoms. Many of the pustules rupture and the 
 
166 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 exuded contents form discrete or coalesced crusts. Cicatrization goes on under- 
 neath the crusts, and they finally drop off, leaving dark, violaceous blotches that 
 
 Fig. 1. 
 
 Temperature Chart of Variola of Moderate Severity. 
 
 are gradually changed to white, irregular, depressed cicatrices. The whole 
 course of the disease occupies from three to five weeks. 
 
 Based upon the distribution and amount of the rash, variola is classified 
 into — 
 
 (1) Discrete variola, in which the rash is scanty and the individual lesions are 
 more or less separated from one another by healthy skin. The disease is rarely 
 dangerous to life, its symptoms are mild, and its course is often interrupted 
 before the development of the pustular stage. The secondary fever is absent 
 or of short duration. 
 
 (2) Confluent variola, which is marked by an eruption that covers almost 
 the entire cutaneous surface and invades the mucous membranes with great 
 severity. The pustules upon the hands and face "run together, so that the 
 epidermis is raised by a milky, sero-purulent secretion;" on other parts of the 
 body the eruption is more or less discrete. The invasion stage is severe, and 
 the rash appears as early as the second day. Severe vomiting and diarrhoea, 
 stomatitis, salivation, pseudo-diphtheria, great and painful swelling of the face, 
 hands, and feet, pygemic abscesses, high fever, violent delirium, and great pros- 
 tration are marked features of this type of the disease. The mortality is great, 
 and convalescence is very slow and often interrupted by serious sequelae. 
 
 In addition to these chief varieties we recognize — 
 
 (3) Hamiorrhagic variola, a malignant form of the disease, characterized 
 by profound alterations of the blood, leading to the formation of petechial 
 blotches and ecchymoses and more or less profuse hsemorrhages from the mucous 
 membranes. 
 
VARIOLA AND VARIOLOID. 167 
 
 (4) Varioloid is variola modified in its course, duration, or intensity by 
 vaccination, previous attacks of variola, or inherited insusceptibility. The 
 invasion stage of varioloid is more irregular in duration than that of unmodi- 
 fied variola, and the symptoms may be so mild as to escape observation, or so 
 intense as to simulate the onset of grave variola. Three types of variation in 
 the clinical history of varioloid may be distinguished : (a) After an invasion 
 stage of the severity of typical variola a copious eruption appears. With the 
 appearance of the rash, however, a rapid defervescence begins, and the eruption 
 is aborted in the papular or the vesicular stage. If it go on to the pustular 
 stage, the pustules quickly run their course without causing much discomfort 
 to the patient, and leave only faint cicatrices or none at all. Or, (b) the dis- 
 ease runs a course typical in all respects, but the pustules are few in number 
 and the accompanying symptoms very mild. Again, (c) the symptoms of inva- 
 sion are well marked. A trifling eruption of maculo-papules appears and 
 quickly fades. Instead of rapidly convalescing, however, the patient shows a 
 period of anaemia and mental and physical prostration out of all proportion to 
 the preceding symptoms. 
 
 Complications and Sequelae. — The complications of variola are few in 
 number. Streptococcus invasion of the subcutaneous connective tissue may 
 give rise to multiple abscesses, phlegmonous erysipelas, boils, and, rarely, in 
 scrofulous children, to gangrene; the deeper structures, the joints, and the vis- 
 cera may also be invaded. In children the most frequent complications are 
 inflammations of the mucous membranes. Pseudo-diphtheria of the pharynx, 
 nose, and larynx is frequent in severe variola ; rarely the membrane invades 
 the bronchi. Bronchitis and broncho-pneumonia, pleuritis with resulting em- 
 pyema, purulent otitis media, and pericarditis or endocarditis often occur. 
 Conjunctivitis is present in all bad cases; sometimes the inflammation is very 
 severe, and results in ulceration of the cornea and destruction of the eye. 
 Enterocolitis is often the cause of death in infants. 
 
 Diagnosis. — Typical variola in the eruptive stage presents no difficulty of 
 diagnosis. Mild and atypical cases, however, are often very perplexing. The 
 invasion stage may be mistaken for a continued fever or pneumonia. The 
 sharp pain in the back, the vomiting, and the marked nervous symptoms should 
 put the physician on his guard. The initial erythematous rash, coming on the 
 second day, and the vomiting, are very like scarlatina. The small, often 
 irregular, and very rapid pulse, the peculiar tongue, and the pharyngitis are 
 distinctive of scarlatina. The rash of scarlatina, again, has a different initial 
 distribution; it first appears on the face, neck, and front of the chest. 
 
 An initial macular rash, or the papular stage of variola, may simulate 
 measles. In measles the gradual onset of the invasion stage, the tendency to 
 sleep, the catarrh of the conjunctival and respiratory mucous membranes, the 
 absence of the backache, severe headache, and vomiting, are distinguishing fea- 
 tures. With the appearance of the rash in measles the fever and all the other 
 symptoms increase; in variola they decrease. The "grisolle sign" is a cer- 
 tain means of distinguishing the papules of variola from the macules of measles : 
 "If upon stretching an affected portion of the skin the papule becomes unpal- 
 pable to the touch, the eruption is caused by measles ; if, on the contrary, the 
 papule is felt when the skin is drawn out, the eruption is the result of small- 
 pox." 
 
 The differential diagnosis of variola and varicella sometimes presents great 
 difficulty. Varicella is characterized by a short period of invasion, the erup- 
 tion usually being the first indication of ill-health that the child manifests. 
 The varicellous vesicle is located beneath the most superficial layers of the epi- 
 
168 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dermis. The macular stage of varicella is short, and the macule is soft and 
 but slightly elevated above the surface. The vesicle does not become pustular, 
 but remains filled with clear or opalescent fluid for twenty-four or forty-eight 
 hours, and then dries into a light, easily-detached crust. The distribution of 
 the vesicles, abundantly over the back and sparsely on the face and hands, is 
 very characteristic of varicella. Occasionally only the greatest care will enable 
 the physician to differentiate between these two diseases. No one symptom or 
 manifestation can be relied upon, but all the points in the history and develop- 
 ment of a given case must be carefully considered. 
 
 Prognosis. — The frequency of complications involving the mucous mem- 
 branes in children, and their feeble powers of resistance make the prognosis of 
 variola in early life very grave. According to Moore, the disease is most 
 fatal in unvaccinated children under five years of age. The younger the child 
 the graver the prognosis. " The influence of vaccination for good is unques- 
 tionable, the mortality being 50 per cent, among the unvaccinated in general, 
 20 per cent, among the badly vaccinated, and only 2^- per cent, among the 
 efficiently vaccinated" (Moore). Hemorrhagic and confluent variola are very 
 fatal. The complications that unfavorably influence the result are — pneumonia, 
 empyema, multiple abscesses, septicaemia, pseudo-membranous laryngitis, and 
 entero-colitis. Favorable cases present a mild or no secondary fever, and are 
 not prolonged by complications. 
 
 Treatment. — There is no drug that will prevent the development of variola 
 in an infected individual. The efficacy of vaccination in arresting or modify- 
 ing the disease after exposure is a disputed question. Curschmann has no con- 
 fidence in the measure. Welch, however, from an experience in 159 cases, 
 believes it to be of great utility, and his results warrant the use of the measure 
 in every person exposed to variola: " In order that protection shall be complete 
 it is necessary that the insertion of the vaccine lymph should be made almost 
 immediately after the reception of the contagion ; but if made at a somewhat 
 later date a modifying effect may be obtained. No part of the incubation 
 period should be considered too late to make use of this remedy, since this 
 period is sometimes prolonged beyond its usual limit, in which case a late 
 vaccination may prove of value" (Welch). 
 
 A child ill with small-pox should be placed in a very well-ventilated room 
 of a temperature of 65° to 70° F. The strictest attention should be .paid 
 through the whole course of the disease to the smallest details of the hygiene 
 of the patient and the sick-room. If the attack be severe, the hair should be 
 closely cut. The diet should be light and nutritious. Effervescent waters, 
 milk and seltzer, sour wine, champagne or lemon-juice and apollinaris, Belfast 
 ginger-ale, and egg-water form agreeable and nutritious drinks. During the 
 period of invasion the febrile symptoms, vomiting, headache and backache, 
 and the nervous phenomena may demand treatment. A gentle cathartic should 
 be given at the onset of the disease. A febrifuge, like tincture of aconite, 
 spirits of nitrous ether, or a solution of acetate of ammonium may be given in 
 proper doses. Gastric irritability may be controlled by effervescing citrate 
 of potassium, chloroform-water, or subnitrate of bismuth. Chloroform-water 
 and morphine are very useful, combined as follows: 
 
 1^. Morphine sulphatis gr. i 
 
 Aq. chloroformi f^ij. M. 
 
 Sig. A teaspoonful may be given every half hour to a child of five years. 
 
 Insomnia or convulsions demand the administration of chloral or bromide 
 
VARIOLA AND VARIOLOID. 169 
 
 of potassium. Baths, temperature 95° F., are most useful to control the fever 
 and nervous symptoms, and they may be repeated every four, six, or eight 
 hours as may be necessary. One of the coal-tar antipyretics may be given. 
 They have a remarkable power to control the pain, nervous symptoms, and 
 fever at the onset of an acute disease. Given in proper doses and in selected 
 cases, their effect is only for good. Applications that irritate and redden the 
 skin are to be avoided. An ice-bag or a cold-water coil to the head lowers 
 temperature and relieves cerebral symptoms. 
 
 During the eruptive stage, after the development of the secondary fever, 
 the same conditions for internal treatment are met. The fever is to be con- 
 trolled, preferably by the bath, made lukewarm or cool as the season and the 
 condition of the patient dictate. Cool sponging, cool compresses, or the wet- 
 sheet may replace the tub. The coal-tar antipyretics are to be given with 
 caution. Delirium and convulsions are to be met by bromide of potassium, 
 chloral, or the bath ; insomnia, by these remedies or sulphonal. When there is 
 intestinal irritability, chloranodyne is an admirable sedative. Quinine and the 
 tincture of chloride of iron in full doses have the confidence of able practi- 
 tioners as being useful to combat septic symptoms. Variola with mild secon- 
 dary fever will not usually demand alcoholic stimulants. In grave cases moder- 
 ate stimulation should be begun early, and as the strength wanes under the influ- 
 ence of continued septic absorption the alcohol should be pushed to the full 
 limit. A child of five years will take from two to four ounces of whiskey or 
 its equivalent in the twenty-four hours, sometimes more. 
 
 The nose, naso-pharynx, and throat should receive strict attention to 
 relieve inflammation and avoid septic absorption. Irrigation of the pharynx 
 with solution of potassium chlorate, boric acid, or witch-hazel should be begun 
 early. The writer finds a solution of listerine and hydrogen peroxide one of 
 the most satisfactory local remedies for pseudo-membranous and septic con- 
 ditions of the mouth and throat, for example: 
 
 Solution of hydrogen peroxide(15 vol.), 
 
 Listerine each 1 part. 
 
 Water 6 parts. 
 
 This solution should be thrown into the pharynx with an all-soft rubber 
 syringe, until thoroughly cleansed, every one, two, or three hours. This is the 
 most satisfactory way to cleanse a child's throat. The same solution, with 
 double the quantity of water, may be used in the nose with the same syringe. 
 When such thorough cleansing is not demanded, the spray from an atomizer 
 will serve, but it should not be trusted in severe cases. 
 
 To limit the development of the pustules and to prevent septic absorption 
 and pitting a great number of methods of local treatment have been proposed. 
 Secondary streptococcus-infection of the pustules without doubt plays an im- 
 portant part in the cutaneous destruction, septic absorption, and deep pus- 
 formations ; careful cutaneous disinfection during the papular and vesicular 
 stages of the eruption will tend to limit this secondary infection. The skin 
 should be bathed twice a day with soap and water, and this followed by spong- 
 ing with a boric-acid solution 1 : 20, diluted listerine, or corrosive sublimate 
 1 : 2000. Omitting the soap, the baths, varied to suit the condition, may 
 be continued during the whole course of the disease. Carbolic acid is an 
 excellent antiseptic and cutaneous analgesic. It is one of the most efficient 
 remedies for the relief of the itching and burning that accompany the develop- 
 ment of the rash. Compresses of antiseptic gauze, wet with a hot or cold 
 
170 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 solution, 1 : 500, may be kept constantly applied to the skin. Carbolic acid 
 may also be used in solution with glycerin or in an ointment. An ointment of 
 4 parts of salicylate of sodium and 100 parts of cold cream is commended. Anti- 
 septics may also be used as a spray or in the form of a powder, as subnitrate of 
 bismuth, boric acid, or a compound of aristol 20 parts, talc 100 parts. Powders 
 are most useful in the late stages of the eruption. Early opening of the pus- 
 tules is a measure advocated by many writers. It seems rational thus to treat 
 the pustules as small abscesses — to open them early, at least upon the hands 
 and face, and treat them antiseptically. A wet compress of antiseptic gauze 
 applied after evacuation and thorough cleansing with a three-volume solution of 
 hydrogen peroxide would certainly prevent additional destruction of the corium 
 from pus-microbe invasion. 
 
 In the stage of decline iron, quinine, and strychnine, highly nutritious 
 food, and moderate stimulation are demanded. Convalescence is often slow 
 and interrupted by complications. Arsenic, cod-liver oil, malt, iron, liquors, and 
 supporting treatment generally are necessary. The various complications and 
 sequels should receive the most approved medical and surgical treatment. 
 
 Quarantine. — A child with small-pox should be immediately isolated, and 
 a rigid quarantine maintained until the skin is free from crusts and compli- 
 cating suppurations have healed — a period of from five to six weeks. Con- 
 finement in a contagious diseases hospital gives most certain protection to a 
 community, although perfect isolation can be maintained in a private house. 
 For this purpose the highest, best-aired, and most remote room should be 
 selected, opening indirectly, if possible, to the rest of the house. Sheets wet 
 with an antiseptic solution should be kept hung over the doorway. All direct 
 communication of the nurse and patient with other members of the family 
 should be interdicted. Clothing, dishes, excreta, etc. should be disinfected 
 before being taken from the room. All members of the infected household 
 should cease direct communication with the outside world, and all exposed 
 individuals should be quarantined for a period of fourteen days after exposure. 
 
VACCINIA; VACCINATION. 
 
 By THOMPSON S. WESTCOTT, M. D., 
 
 Philadelphia. 
 
 Vaccinia, or cow-pox, is a contagious eruptive disease of the cow, charac- 
 terized by a more or less profuse eruption, upon the udder and teats, of papules 
 which develop into vesicles, and these, by drying, into crusts, or, through rup- 
 ture, into open ulcers. By inoculation of lymph from its vesicle the disease is 
 communicable to man, and is capable of conferring upon him immunity from 
 small-pox more or less complete and lasting. 
 
 History. — In the closing years of the eighteenth century, among all the 
 civilized nations of Europe and their colonies, the practice of inoculating for 
 small-pox had become the accepted therapeutic procedure for modifying the 
 ravages of this then most familiar and loathsome of diseases. The operation 
 was not, however, always successful in producing mild cases of the disease, and 
 even in its most favorable manifestation the communicated affection was still 
 variola, capable of being transmitted to others by effluvium, and necessitating 
 careful isolation, nursing, and medical treatment. So common was small-pox 
 that, according to the philosophy of the times, every individual had either 
 passed through, or was destined some time to experience, an attack of the 
 disease. In 1776, Edward Jenner, an English country practitioner living at 
 Berkeley in Gloucestershire, was first attracted by a popular belief, common 
 among the dairy-hands of this county, that any one who had contracted cow-pox 
 from milking cows affected with this disease was insusceptible to small-pox, and 
 was not a successful subject for variolous inoculation. This tradition seems to 
 have been quite well known among the dairy-hands of Gloucestershire and the 
 neighboring counties, and to have been noted by other practitioners through- 
 out the farming country. Intentional inoculation of cow-pox had even been per- 
 formed before Jenner's attention was directed to the matter: Robert Fooks, a 
 butcher of Bridport, as related by Pearson, had submitted to the inoculation by 
 means of a charged needle, as early as 1771, and Benjamin Jesty, a farmer of 
 Yetminster in Dorset, in 1774 inoculated his wife and two sons with the cow- 
 pox as a preventive of small-pox. But it was not until the subject received 
 the careful study and experimentation of Jenner, culminating in his celebrated 
 Inquiry, published in 1798, that the practice of inoculating cow-pox was estab- 
 lished upon a clinical and what, at least for the times, must be called a scientific 
 basis. The story of Jenner's struggles to convince his contemporaries of the 
 value of his observations forms a most interesting and instructive chapter in 
 the history of medical progress. The discovery spread with wonderful rapidity 
 throughout the civilized world, and it stands to-day as one of the greatest 
 blessings that human thought and observation have conferred upon mankind. 
 
 Etiology. — "Spontaneous" cow-pox, the term ordinarily though not very 
 accurately applied to cases of vaccinia occurring naturally in the cow, is an 
 
 171 
 
172 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 occasional disease among dairy herds. It is spread by contact, being usually 
 carried from one animal to another by the hands of the milkers, who in this 
 way are themselves liable to accidental inoculation. For this reason the affec- 
 tion is almost exclusively confined to milch-cows, and the eruption limited to 
 the udder or teats, although young calves or adult bulls may be readily inoculated 
 upon the belly, and exhibit phenomena differing in no way from those observed 
 in the cow. 
 
 The exact nature of vaccinal disease is a question which has been the sub- 
 ject of repeated theorizing and experimentation since the time of Jenner, and 
 even at the present day no consensus of opinion has been reached. Jenner 
 held that cow-pox was occasioned by the accidental conveyance of the virus of 
 "grease," an eruptive disease of the heels of the horse, to which also he 
 attributed, on conjectural grounds merely, the origin of human small-pox. 
 According to his view, a vaccinated person was a small-poxed person who, 
 instead of suffering from the humanized and virulent form of the disease, had 
 contracted it in its primitive mild character. This theory, at least in regard to 
 its ingenious attempt at the etiological unification of cow-pox and small-pox, 
 can be dismissed as a curiosity of medical history. 
 
 A second theory considers vaccinia as a distinct disease of the cow origi- 
 nating in a specific contagium, and being in no way related to or capable of 
 being originated by any other contagium, however closely its phenomena may 
 be simulated. It is evident that its rejection or its acceptance is to be based 
 upon the proof or refutation of other theories, and thus it can be more readily 
 discussed side by side with the third and remaining theory. 
 
 This theory, which offers in many respects the most rational view of the 
 question, regards cow-pox as small-pox modified and attenuated by passing 
 through the system of the cow. There can be no doubt that variola can be 
 artificially communicated to the cow, and can give rise to a vesicular eruption 
 resembling in all physical respects the lesions of spontaneous cow-pox, and that 
 virus from these vesicles can be conveyed to man, and produce at the points of 
 inoculation local effects in all appearance identical with those produced by 
 cultivated vaccine- lymph. Experiments of this kind are now quite numerously 
 recorded, among which may be mentioned the successful variolations of the 
 cow performed by Gassner in 1801, and after him those of Thiele of Kasan, 
 Ceely of Aylesbury, Badcock of Brighton, Martin of Attleboro, Mass., Voit, 
 Reiter, and many others. In some cases the virus thus obtained, when used 
 for experimental inoculation upon human subjects, especially in the early 
 removes, showed undoubted evidence of being variolous by giving origin 
 through infection to fresh cases of small-pox some of which were fatal. 
 Martin's variola-lymph produced quite an epidemic of small-pox in Attleboro, 
 Massachusetts, in 1836, and Reiter's experiments in Munich in 1839 had a 
 similar sequel. It is certain, however, that if in the selection of a variolous 
 virus the same care be exercised as was habitual with experienced small-pox 
 inoculators like Sutton and Dimsdale, a variolation of the cow may be effected 
 which will give origin to a lymph that need not necessarily convey infection 
 to those not inoculated. This was shown in the experience with Badcock 's 
 variola-lymph ; and, as Crookshank remarks, identical results were obtained 
 by Adams in many cases where lymph from a mild or "pearl " case of small- 
 pox was taken as a primary virus for successive arm-to-arm inoculations, with- 
 out having been first passed through the cow. 
 
 This whole subject was carefully investigated in 1865 by the Lyons Com- 
 mission under the direction of Chauveau, who, even in 1891, still showed him- 
 self the most distinguished champion of the dual nature of the two diseases. 
 
VACCINIA. 173 
 
 The result of the investigation of this committee unequivocally pronounced upon 
 the autonomy of cow-pox and the impossibility of converting small-pox into cow- 
 pox. A more recent investigation of the question by Fleming, a well-known 
 English veterinarian, confirmed the conclusions of the Lyons Commission. The 
 question is not, however, by any means settled. Even as recently as 1892, 
 Hime of England and Haccius and Eternod of Switzerland, published care- 
 ful studies in support of the older view, and, excepting in France and 
 America, the theory of the identity of the two diseases seems to be gaining 
 ground. 
 
 To complete the subject it may be stated that several years ago Depaul 
 of Paris established the fact that horse-pox, a febrile eruptive disease of the 
 horse, was capable of being conveyed by inoculation to the cow, and giving 
 rise to a lesion indistinguishable from that of cow-pox. Constantin Paul, 
 indeed, for a time used such virus for vaccination, but the practice fell into 
 disuse after the discovery of a case of spontaneous vaccinia at Beaugency. 
 
 Pathological Anatomy. — The structure of the vaccine pock resembles 
 that of variola (Cornil and Ranvier) . It is formed by the softening and 
 liquefaction of the epidermic cells, which appears to be caused by the micro- 
 organisms which early occupy the centre of the pustule. There is a central 
 necrotic zone, a middle zone characterized by tumefaction of the cells, and 
 a peripheral zone of irritation showing multiplication of nuclei (Pincus). The 
 cavity of the pock is partitioned or multiloculated, and its base, thickened and 
 infiltrated with lymph, constitutes the " vaccinal pulp." The derm is always 
 infiltrated with leucocytes. The lymph is a clear, transparent liquid up to the 
 fifth day in the cow and till the seventh or eighth in man ; it maintains its 
 infective qualities at a low temperature, but loses them quickly in warmth. His- 
 tologically, it contains leucocytes, red globules (after the eighth day), granula- 
 tions and cellular debris, free nuclei, and micro-organisms. 
 
 Keber in 1868, and subsequently Chauveau and Burdon-Sanderson, 
 observed the existence in lymph of minute rounded organisms to which the terms 
 vaccinads or microspheres have been applied. Keber attributed to them the 
 specific properties of the lymph. More recently (1890) the experiments of 
 Straus, Chambon, and Menard have shown that lymph from which these bodies 
 had been removed by filtration loses its infective power, even when injected in 
 quantity beneath the skin, so that it may be concluded that these micro-organisms 
 are the agents of infection. No distinct microbe, however, has as yet been 
 satisfactorily isolated. In 1883, Quist cultivated upon alkaline serum a coccus, 
 which, when inoculated upon a child, rendered it refractory to subsequent vac- 
 cination. Voigt (1885) isolated three micro-organisms, of which one, a coccus, 
 was found capable of causing typical experimental cow-pox in the calf, from 
 which the same organism was again obtained. Garre* (1887) confirmed the 
 results of Voigt, cultivating a coccus which existed in a pure state under the 
 derm subjacent to the pustule, and which caused cow-pox in the calf, but not 
 in man until after passage through the calf. 
 
 Varieties of Lymph. — Practically, there are two sources from which vac- 
 cine-lymph may be obtained — either directly from the bovine through the 
 agency of vaccine farms especially established for its propagation, or indirectly 
 therefrom after passage through the system of one or more human beings, the 
 healthy infant being the medium usually chosen. Lymph from the so-called 
 cases of spontaneous cow-pox is very rarely to be had, and is said to be untrust- 
 worthy in its infective powers ; while variola-vaccine must still be considered 
 as of experimental value merely, and not to be ordinarily employed. At the 
 present day it may be said that in no essential respect is humanized virus to 
 
174 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 be preferred to animal lymph, if we except its slightly greater promptness of 
 action, which may, however, have some value in time of epidemics. The pos- 
 sibility of the transmission of syphilis through humanized lymph derived from 
 a syphilitic patient, while exceedingly rare, is still a constant danger, and pleads 
 strongly against the use of any humanized virus except from an unimpeach- 
 able source. In selecting lymph, either from the calf or from the human 
 vaccinifer, a characteristic vesicle from the fifth to the seventh day should be 
 chosen. 
 
 Symptoms. — When carefully selected and cultivated vaccine-lymph is 
 introduced by inoculation into the human system, the following phenomena will 
 be normally observed : At or close to the site of inoculation at the end of the 
 second or beginning of the third day a slight papular elevation is observed ; 
 by the fifth or sixth day this has become a distinct vesicle, of bluish-white 
 color, with rounded elevated edges and a cupped central depression — the so- 
 called umbilication. By the eighth day the vesicle is perfected, and is then 
 circular, pearly in color, and distended with a colorless lymph, the central 
 depression remaining well marked. On or about this day appears the areola, 
 a reddish blush of the skin surrounding the pock to a distance of several 
 inches, and accompanied by induration and swelling of the underlying connec- 
 tive tissue. After the tenth day the areola begins to fade, the vesicular con- 
 tents begin to dry in the centre, the process extending to the surrounding 
 lymph, which becomes opaque and gradually desiccates, until by the fifteenth 
 day a hard brownish thick scab is formed, which is gradually detached and 
 falls in the fourth week. A circular, depressed, pitted, or sometimes radiated 
 cicatrix remains. If there have been several points of inoculation close toge- 
 ther, a compound vesicle of irregular shape may result. Even with a single 
 surface of inoculation one or more additional vesicles may arise at some little 
 distance from this point. 
 
 Constitutional symptoms are almost always notable to some degree in a case 
 of primary vaccination. The temperature may rise one or two degrees on the 
 third or fourth day, and remain elevated for several days. In children rest- 
 lessness, irritability, and loss of appetite may frequently be noticed. The 
 axillary glands or the inguinal glands, depending upon the choice of the arm 
 or leg for operation, will usually show some swelling and tenderness for several 
 days. In many cases, mostly those of secondary vaccination, the constitutional 
 symptoms are more severe ; the fever higher, with transient delirium ; nausea 
 or perhaps vomiting ; and distressing headache. Itching of the skin round 
 about the pock is commonly experienced, perhaps throughout the whole course 
 of the case, and this may be so severe as to constitute a true pruritus. 
 
 Irregularities in the Course. — Various irregular manifestations of the pock 
 have been described by earlier writers, but in later years, since the more 
 general employment of animal lymph, these irregular forms have become much 
 rarer. One peculiar abortive form, the raspberry excrescence, should be men- 
 tioned. Here the pock is rather slow in appearing, and never reaches full 
 development, but becomes a flat, hard, reddish papule, resembling a naevus, 
 and finally, after weeks or months, disappears without cicatrix. It is probably 
 an abortive form, and does not protect against small-pox or subsequent 
 vaccination. 
 
 Another irregularity is the so-called eruptive vaccinia, in which there is a 
 generalized eruption of pocks, the disease manifesting itself as a true exanthem. 
 Very rarely cases have been observed in which the susceptibility of the skin 
 was so great that repeated accidental auto-inoculations took place from the 
 merest scratches of the nails. 
 
VACCINIA. 175 
 
 Complications. — Inflammatory phenomena, due to traumatism, irritation, 
 infection, or special conditions of the system predisposing to cutaneous disease, 
 are at times manifest. These may vary from a simple erythema to intense 
 phlegmonous inflammation or ulceration and gangrene, with septic absorption. 
 Injury to the pock before complete maturation may be followed by a gangrenous 
 condition of the underlying derm, sometimes giving rise to a peculiar moat-like 
 depression around a central elevated core. Mothers are very prone to attribute 
 any irregularities or unusual violence in the maturation of the pock to " bad 
 virus." Occasionally, especially when human crusts have been used, this 
 may be a just charge; but it can be authoritatively stated that complications 
 arising from impurities of the lymph will almost invariably show their presence 
 long before the pock has reached its full development, usually within a few 
 days after the operation. 
 
 Erysipelas is very prone to infect vaccination wounds. It may appear as 
 early as the second or third day, and in this case the prognosis is especially 
 grave. Vaccination should never be performed when erysipelas is prevalent, 
 except in face of the greater danger of variola. 
 
 Glandular Enlargement. — The natural involvement of the axillary and 
 cervical glands, usually insignificant, may in certain subjects become extreme, 
 and even go on to suppuration during maturation or toward the decline. In 
 children of strumous habit vaccination may act as the exciting cause of chronic 
 enlargement and cheesy degeneration of glands in these chains. 
 
 Abscess and boils may follow in various parts of the body, especially in 
 children of tubercular tendency. 
 
 Eczema and other skin affections are apt to be aggravated or relighted by 
 vaccination. Various roseolous rashes may be observed during the maturation 
 of the pock, and are only important as requiring differential diagnosis from 
 intercurrent and perhaps more serious affections, such as erysipelas, scarlatina, 
 and rubella. Impetigo contagiosa has been observed not infrequently, and 
 seems to bear some relation to vaccinia, which is as yet not clearly understood. 
 
 /Syphilis. — Chiefly to Viennois in France and Hutchinson in England are 
 we indebted for the demonstration that syphilis may be communicated by 
 humanized virus through contamination with the patient's blood, which, as 
 Ricord has shown, is always present in the lymph. Accidental conveyance of 
 the disease by imperfectly cleansed instruments used for vaccinating is also to 
 be mentioned. 
 
 The treatment of complications will not differ from that to be employed 
 in the conditions occurring independently of the vaccinal disease. 
 
 Method of Operation. — Inoculation can be accomplished in numerous 
 ways. Some practitioners advocate a series of superficial cross-bar incisions 
 made with a sharply-pointed lancet or the back of the point of an ordinary 
 bistoury ; others employ a sharply-pointed rake-like instrument made for the 
 purpose, while tattooing with a sharp needle point has been advocated. Alto- 
 gether the most satisfactory method of preparing the spot for vaccination, and 
 one which robs the little operation of its terror to children and mothers, con- 
 sists in gently scraping away the external horny layer of epidermis with the 
 edge of a bistoury or lancet held obliquely to the surface. For this purpose a 
 dull instrument is sometimes advocated, but a sharp edge is more effectual and 
 expeditious. An area as large as the little finger-nail can be readily abraded 
 in this manner without giving rise to a whimper on the part of the child. The 
 abraded surface should be slightly red and glazed by the outpouring of lymph, 
 but no blood should be drawn. The next step is the inoculation of the lymph. 
 In arm-to-arm vaccination the lymph is directly transferred from the pock to 
 
176 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the abraded surface. When the dried animal virus is used, it should be 
 liquefied by dipping into cold sterilized water just before the surface is 
 prepared, so that in the brief interval it may become completely softened. 
 
 Any portion of the cutaneous surface may be chosen for the insertion, 
 but customarily the outer aspect of the left arm over the insertion of the 
 deltoid is selected. For cosmetic reasons in girls the leg is often preferred, 
 and in this case a point over the head of the fibula or over the junction of the 
 two heads of the gastrocnemius is the usual choice. The primary vaccination 
 of the infant may be undertaken at any time. In the face of an epidemic the 
 new-born babe should be vaccinated within twenty-four or forty-eight hours 
 after birth, and, as the experience of Wolff has shown, in such cases humanized 
 lymph is to be preferred as producing less constitutional disturbance. Ordi- 
 narily, however, the operation may be deferred until about the third month 
 when the child is in good physical condition and before the disturbances of 
 dentition have commenced. 
 
 Protective Power of Vaccination. — The experience of the past one hun- 
 dred years offers the most just and conclusive evidence of the power of vaccina- 
 tion as a preventive of small-pox. From one of the commonest and most virulent 
 of diseases small-pox has become in civilized countries one of the rarest of the 
 exanthemata. A most significant fact in favor of vaccination is given by 
 Gay in a study of small-pox in London. He states that in the last forty years 
 of this century, owing to improved sanitation, epidemics of measles, scarlatina, 
 diphtheria, and whooping-cough have all undergone a decrease, but that this 
 is only a small fraction of that which has occurred in small-pox, their highest 
 figures not amounting to a tenth part of the decrease of small-pox — a result 
 which is dependent upon only one possible cause, vaccination. Drysdale states 
 that during the epidemic in Berlin in 1872 and 1873 the mortality rose to 243 
 and 263 per 100,000 ; then, vaccination in the first year of life and revaccina- 
 tion in the twelfth being made compulsory, during the first year of enforce- 
 ment (1875) the mortality fell to 3.6 per 100,000, to 3.1 in 1876, and to 0.3 
 in 1877. 
 
 The protective power is not absolute in all individuals, nor can the period 
 of protection be stated for any given case. Marson, whose experience with 
 small-pox in London was very extensive, stated that the disease was more fatal 
 among those whose scars were imperfect or few in number than in those show- 
 ing well-marked and multiple cicatrices. While some doubt of the value of 
 this theory may be expressed, it would seem wisest to vaccinate in all cases by 
 at least two insertions, sufficiently far apart to prevent coalescence during 
 development of the pocks. As a general rule, it may be stated that immunity 
 in the great majority of cases will be attained by re vaccination every four or 
 five years, and always when small-pox becomes epidemic. If absolute im- 
 munity from small-pox be not conferred, the course of the disease will be 
 greatly modified and ameliorated. In some very rare instances vaccination 
 and revaccination seem to offer no obstacle to the development of severe 
 variolous disease. According to Biedert, after a successful vaccination im- 
 munity is secured in about eight days. Vaccination after infection with 
 variola does not guard against the development of the disease, but if done 
 eight days before the eruption appears the evolution will take place benignly. 
 
PAROTITIS. 
 
 By ANDREW F. CURRIER, M. D., 
 
 New York. 
 
 By the term " parotitis " is to be understood an inflammation of the parotid 
 gland. By the inelegant term mumps we usually understand an acute infec- 
 tious disease, often epidemic in character, in which the parotid gland is always 
 inflamed, other glands being also involved occasionally. If it were possible to 
 dislodge the term " mumps " from the mind of the profession and the public, 
 it would be in the line of progress, for, like many other terms which cling to 
 medical nomenclature, it is inaccurate, inelegant, and would be inexpressive 
 were it not for its arbitrary association with acute epidemic parotitis. 
 
 This affection is usually regarded as one of the diseases of childhood. It is 
 unfortunately true that many mothers think it necessary that their children 
 must experience this and several other infectious diseases at some period of 
 their childhood, forgetful of the fact that disease is always to be avoided if 
 possible. It is true that one attack of epidemic parotitis usually furnishes 
 immunity from others of the same character, but until we are further advanced 
 than at present in the science of preventive inoculation it will not be wise to 
 encourage the acquirement of infectious disease from such a motive. Small- 
 pox, and possibly hydrophobia and tetanus, furnish exceptions to this rule, 
 and the day is probably dawning w T hen the list can be lengthened. 
 
 Epidemic parotitis is not limited to the period of childhood. Many epi- 
 demics are recorded in which it prevailed exclusively among men. This is 
 especially true of soldiers in garrisons and barracks. Two such epidemics are 
 recorded by Girard in which the testicular complication was severe, and others 
 by Gnasco, Dogny, Jourdan and Laurens. Males suffer with it more frequently 
 than females. 
 
 But parotitis is not necessarily an infectious disease, for there is a form 
 which is purely traumatic and limited to the parotid gland, and another which 
 may be called an irritative form, in which malignant disease in or near the 
 gland incidentally causes true inflammatory action with infiltration and indu- 
 ration. Of this form nothing further need be said in this connection, the con- 
 sideration of the subject being limited (1) to its traumatic, (2) to its infectious, 
 aspect. 
 
 Pathological Anatomy. — Writers upon paediatrics have remarked the 
 incompleteness of the knowledge of the anatomy of this subject. This is due 
 to the small number of fatal cases, excepting those in which the disease has 
 occurred as a complication, and in which, from gangrene or abscess, the 
 gland-structure is more or less completely destroyed. Virchow studied the 
 disease in 1858, and his work is fundamental with reference to anatomical 
 knowledge at that period. The development of bacteriological science has 
 modified all our knowledge concerning infectious disease and its effects. In 
 general it may be said, with Ziegler, that the anatomical appearances are those 
 which are due to inflammatory, serous, and cellular infiltration of the inter- 
 12 177 
 
178 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 alveolar fibrous tissue of the glands, issuing either in resolution, fibroid indu- 
 ration, suppuration, or gangrene. Bamberger describes the gland as enlarged, 
 red, swollen with exudate in the interstitial tissue, the acini fused together, and 
 the cellular tissue of the entire gland involved. In severe cases the entire 
 glandular substance is involved and converted into a fleshy dry tumor. The 
 exudate may be absorbed, the gland resuming its normal size and consistency, 
 or the exudate in the cellular tissue may become thickened and organized, 
 leading either to permanent increase in size or to atrophy. 
 
 Etiology. — The two varieties or forms of the disease to be considered are : 
 (1) the traumatic, (2) the infectious. 
 
 (1) The traumatic variety is the result of blows or bruises, with more or 
 less effusion of blood into the gland and surrounding tissues. The inflamma- 
 tion and swelling may be extensive, especially in syphilitic or strumous sub- 
 jects, the great sensitiveness of the glandular system of such individuals ren- 
 dering them peculiarly liable to disease of this character even when the injuries 
 received have only been of moderate severity. It may also be the result of 
 burns about the face and neck or of the application of irritating chemicals and 
 caustics. This form of the disease is entirely distinct from the infectious, and 
 illustrates the fact, which for some time was in dispute, that inflammatory con- 
 ditions are quite possible without the influence of micro-organisms. 
 
 (2) The infectious form of the disease may be simple or immediate, symp- 
 tomatic or metastatic. That parotitis may be a complication of so many other 
 conditions is an argument against the proposition that it is always caused by 
 a specific microbe. There is scarcely an infectious disease in which it may not 
 so appear. It may complicate pneumonia, diphtheria, and typhoid fever, each 
 of which has its specific cause; hence we are obliged to refer it to that very 
 convenient class of diseases known as mixed infections, in which the limita- 
 tions to one who is not a bacteriologist are as yet rather vague. It is quite 
 proper to refer to the work which has been done with the view of placing its 
 etiology upon a definite basis (i. e. from a bacteriological standpoint). 
 
 Pasteur found a bacterium in blood taken from patients with this disease, 
 but inoculations of animals with cultures obtained from it were negative. 
 Bordas described a bacillus found in the blood which he termed bacillus paro- 
 tidis. In certain phases of its development it assumed an S or Y shape ; when 
 divided the ends became enlarged. It died at a temperature of 140° F., and its 
 spores at 194° F. Its development was arrested in 1 : 500,000 solutions of 
 mercuric bichloride. Cultures were made from the saliva of parotitic patients, 
 and were rich in the microbe. The investigations of Capitan and Charrin in 
 this field have been more extensive than others, and have to a great degree 
 furnished a basis for other work. They first examined the blood, saliva, and 
 urine from six cases. In the blood were found small, mobile microbes in great 
 numbers, most of them being spherical, but some rod-shaped. Similar bodies 
 were found in the saliva, while in the urine they detected neither albumin, sugar, 
 nor microbes. In 1881, after a study of the blood in thirteen additional cases, 
 they were able to confirm their previous discoveries. They particularly described 
 a bacterium two to three thousandths of a millimetre long and also a small micro- 
 coccus, the microbes appearing singly, doubly, and in chains. Cultures of the 
 microbes were successfully made, but inoculations of dogs, rabbits, and guinea-pigs 
 were negative. These discoveries were verified by Ve'drenes, Bouchard, Netter, 
 and Boinet, the latter finding the microbes in the blood of fifteen patients, also 
 in pus from an abscess of the nucha. Ollivier found the microbes in saliva, 
 urine, and blood from three subjects, and suggested that failure in the inocula- 
 tion of animals was due to the insusceptibility to parotitis of all species of animals 
 
PAROTITIS. 179 
 
 upon which experiments had thus far been conducted. He believed that we 
 could now see in parotitis not the simple effect of cold, or a manifestation of 
 the rheumatic diathesis, or a propagation of a phlegmasia of the mouth, but 
 an infectious disease caused by a specific agent and propagated by the diffusion 
 of that agent. Jaccoud has expressed himself almost equally hopefully. 
 
 In the simple or immediate form, which is the usual one in most epidemics, 
 the contamination of the atmosphere with the infectious elements, especially in 
 schools or barracks, in which the air-supply is deficient, explains its dissemina- 
 tion. This statement harmonizes with the fact that it is most prevalent in damp 
 and cold weather when the windows and doors of houses are closed and the tend- 
 ency or the necessity is to remain in-doors. The elements of the disease are 
 also carried from house to house in the clothes of physicians and visiting friends. 
 This explains the prevalence of epidemics in sparsely-settled localities. Infec- 
 tion is probably acquired in respiration, and those who are mouth-breathers are 
 the more susceptible. Whether the long period of incubation which follows 
 the reception of the infective influence means retention of the elements in the 
 ducts of the salivary glands or in the glands themselves, or whether there is a 
 process of germination within the blood and localization in the glands, we do 
 not know. The latter is the more reasonable hypothesis from the analogy with 
 other infective germs which are known to develop in the blood. As in all other 
 infectious diseases, the intensity is governed partly by the activity of the infec- 
 tious elements and partly by the resistance of the individual. 
 
 In the secondary, metastatic, or symptomatic variety of infectious parotitis 
 the inflammation is a complication of a pre-existing disorder. The list of 
 diseases in which it may play such a role is a long one, including the infectious 
 diseases in general, besides nephritis, pneumonia, meningitis, and surgical injur- 
 ies of all kinds ; for in all of them sepsis, and hence infection, are possibilities. 
 As an evidence of extensive or general systemic infection it is a symptom of 
 grave significance. With the diathetic diseases, tuberculosis, syphilis, and rheu- 
 matism, its significance is less grave than with the acute infectious diseases. 
 In this variety we cannot refer to a specific microbe as its origin. Some of the 
 conditions with which it may be associated have such origins (diphtheria, 
 pneumonia), and whether the complicating parotitis is due to the irritating 
 effect of such specific germs which have been retained within the gland, or 
 whether it is caused by those germs (streptococcus, staphylococcus) which 
 produce severe inflammation wherever localized, we do not as yet know. 
 
 Incubation. — The period of incubation of parotitis is a long one, but it 
 varies with the resisting power of the individual and the virulence of the 
 infective material. The long period of incubation, with the complicating con- 
 ditions which may arise in the mean time, may delay the determination of the 
 diagnosis. J. Lewis Smith regards the disease as primarily a systemic infec- 
 tious one, with an incubation period of nine to twenty-one days ; A. Jacobi 
 fixes it at two to three weeks ; Dauchez, at fifteen days ; Roth, at eighteen 
 days ; and Nicholson reports a case in which an interval of six weeks elapsed 
 between the involvement of the two parotid glands. 
 
 Symptoms. — The long period of incubation may be attended by symp- 
 toms of impending trouble. This is especially true with young children. 
 There may be malaise with moderate rise of temperature for several days, and 
 with very young children there may be convulsions, especially if digestive dis- 
 order coexist. With glandular swelling come also induration, sensitiveness, 
 pain on motion of the neck or jaw, loss of appetite, restlessness, and insomnia. 
 With the progress of the inflammation infiltration of the gland and the sur- 
 rounding tissues increases, and fever is more pronounced. These symptoms 
 
180 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 may continue for a week, and gradually subside, or the duration may be less 
 prolonged. The induration will gradually disappear and normal conditions be 
 resumed, or the gland may be permanently enlarged or it may atrophy. In 
 a certain number of cases abscess or gangrene will ensue, the gland will be 
 destroyed, and the final result be fatal ; but in the great majority these are 
 cases in which the system is so saturated with septic products that the outcome 
 would be fatal even if parotitis did not exist. 
 
 The inflammatory action which involves the parotid glands may include also 
 the other salivary glands, and even the cervical lymphatic glands. These com- 
 plications are frequently overlooked, being overshadowed by the more exten- 
 sive and apparent affection of the parotids. The appearance of an individual 
 with parotitis is sufficiently characteristic : there is glandular swelling, with 
 hardness and pain ; the swelling may be considerable or inconsiderable, and of 
 course the disfigurement of the face and neck will be governed accordingly. 
 The pain is constant and severe, especially in young children ; deglutition is dif- 
 ficult and often impossible on account of its painfulness. If abscess develops, 
 the pain has the acute throbbing character of abscess-formation everywhere. 
 Pain in the contiguous structures of the ear is almost always a marked feature 
 of the disease, and the nearness of the carotid artery and cerebral meninges 
 introduces elements of danger which must always be remembered, for serious 
 results in this quarter are by no means unknown. Considering the possibilities 
 of serious consequences, the small percentage of fatal cases when the disease is 
 uncomplicated is quite remarkable. 
 
 Complications. — In the traumatic form, in which the inflammation is a 
 simple one, complications are unusual. The inflammation subsides, as such 
 conditions do elsewhere, the result being resolution in the mild cases and sup- 
 puration in the severe ones, especially if the tissues have been bruised and 
 broken. In the epidemic infectious form complications are extremely common, 
 the genital organs being most frequently implicated. Thus with males there 
 is often an involvement of the testicles, spermatic cord, and inguinal glands ; 
 with females, the mammae, ovaries, labia majora^ and inguinal glands. These 
 complications may not be evident until the symptoms in the parotid gland 
 have begun to subside. In a recent epidemic in which one hundred and seven- 
 teen cases were observed by Demme, two were fatal from gangrene of the paro- 
 tid glands ; in three there was abscess of the cervical glands ; in two there was 
 acute nephritis. Musgrove and Slagle each saw a fatal case complicated with 
 uraemia. P. Smith saw two cases which were followed by insanity, and Par- 
 rott one which was complicated with orchitis and meningitis. F. W. Brown 
 records an epidemic of twenty cases in a boys' school, ten of which were com- 
 plicated with orchitis. Jackson observed four cases complicated with influenza. 
 This latter complication is more frequent than is generally supposed. The 
 writer recently saw such a case in an infant fourteen months old. 
 
 Among the sequelae of the disease Joffroy mentions peripheral neuritis, with 
 paralysis of the extremities lasting four months. Rotch and Moure each saw 
 two cases of deafness ; and Dufour, inflammation of the lachrymal glands. 
 The evidence is therefore abundant that we have in parotitis an infectious 
 disease with multiple localization. 
 
 Treatment. — If the disease be, as it appears, an infectious one, we have, 
 as yet, no method of treatment for aborting it. When the symptoms are 
 apparent, the indication is to relieve them as they arise. The pain may be 
 soothed by small doses of Dover's powder or paregoric, or phenacetin combined 
 with salol. Hot applications to the inflamed parts are always grateful, and 
 the surface may be kept moist with anodyne liniments. The bowels must be 
 
PAROTITIS. 181 
 
 kept open, fever may be reduced with aconite, and the diet must be fluid and 
 concentrated. Hot liquids will usually be preferable to cold, and will be 
 more quickly assimilated. The skin should be kept active by daily warm 
 baths, by alcohol, and by gentle friction. The opiates suggested will usually 
 be sufficient to relieve restlessness and induce sleep. As soon as the acute 
 symptoms have subsided the nutrition should be improved as rapidly as possi- 
 ble, and a tonic of iron, quinine, strychnine, and arsenic will be indicated. 
 
 Quarantine. — An important practical question is that relating to the time 
 in which patients with infectious parotitis should be isolated. This especially 
 concerns children who are attending school. A recent paper by Rendu is 
 devoted to this aspect of the subject. His studies have led him to believe that 
 the time of greatest danger of contagion is at the close of the incubation period, 
 at least twenty-four hours before the disease can be diagnosticated. Sevestre 
 and Comby had reached this same conclusion. If this be a fact, Rendu's 
 opinion that it is irrational to keep children out of school three weeks after the 
 symptoms of the disease have subsided is a just one, and teaches that isolation 
 should be limited to a period included between the time when the first symp- 
 toms appear and the time when the active symptoms have subsided. 
 
WHOOPING-COUGH. 
 
 By J. P. CROZER GRIFFITH, M. D., 
 
 Philadelphia. 
 
 Synonyms. — Pertussis ; Tussis convulsiva ; Hooping cough ; Chin cough. 
 
 Whooping-cough is a zymotic, contagious disease of childhood, character- 
 ized by a catarrh of the respiratory mucous membrane and a peculiar paroxys- 
 mal cough. 
 
 No description of any disease resembling pertussis can be found in the 
 writings of the Greeks, Romans, or Arabians, and it seems probable that the 
 failure to mention such a peculiarly characteristic disorder is proof that it did 
 not then exist at all, or at least in parts of the world with which medical 
 writers were acquainted. In fact, no account of it is found until Baillou, in 
 1578, described an epidemic which occurred at Paris, and spoke of it as an 
 affection not previously known. Little or nothing more was heard of it for about 
 a hundred years, when Willis wrote of " tussis puerorum convulsiva " in such a 
 manner that its nature and its identity with the pertussis of the present day 
 can admit of no doubt. Epidemics did not become frequent until the eigh- 
 teenth century, but the disease then rapidly spread, and by the middle of that 
 century had become widely diffused. From that period onward it has been 
 steadily on the increase, until it constitutes at present one of the commonest 
 diseases of childhood. 
 
 Etiology. — There are certain factors which seem to exercise a decidedly 
 predisposing influence upon the development of pertussis. There is a very 
 distinct tendency shown for it to occur in epidemics, which appear at intervals 
 of about two years, yet with no great regularity in this respect. The disease 
 may, however, occur sporadically, although such cases are always the result of 
 some preceding case. In the larger cities it is practically endemic, although 
 at times greatly more prevalent than at others. 
 
 The previous occurrence of the disease in an individual precludes the de- 
 velopment of a second attack. Nevertheless, undoubted exceptions to this 
 rule have been occasionally reported, though they are certainly rare. 
 
 Whooping-cough is more prevalent in the civilized portions of the world, 
 but its absence from any region seems to depend rather on the fact that it has 
 not yet been carried thither than on any conditions of climate or of race 
 which are unfavorable to its existence. The influence of season has been 
 much disputed, and the evidence is conflicting. It is certainly no powerfully 
 predisposing factor. The station in life and the general hygienic conditions 
 existing appear to be without influence, except in so far as the ill-ventilated 
 houses of the poor may possibly favor the increase of the germs in number 
 or in virulence, even as the crowding and lack of isolation certainly favor their 
 diffusion. 
 
 The previous state of the health seems to possess some predisposing power. 
 
 182 
 
WHOOPING-COUGH. 183 
 
 Most observers agree that, weakly, sickly children more readily contract 
 whooping-cough than do those in good health. It is a well-recognized fact, 
 also, that there is an intimate association between epidemics of measles and of 
 whooping-cough, and it is very widely believed that the existence of the first 
 disease strongly predisposes to the later development of the second. Whether 
 or not the association is an accidental one is still unsettled. The actual pres- 
 ence of any other disease is certainly no bar to the occurrence of pertussis. 
 As with other infectious disorders, there exists a certain individual suscepti- 
 bility to it. Some children never contract it, though often exposed. 
 
 Age exercises a powerful influence on the development of whooping-cough. 
 By far the greater number of cases occur before the sixth year. After this 
 time the frequency of occurrence diminishes very rapidly, and after the tenth 
 year it is comparatively infrequent. West estimates that over one-half the 
 cases develop under the age of three years. It is sometimes seen in adults, 
 but this is rather uncommon ; the rarity being due partly to the fact that so 
 many have suffered from it while children, and partly to a lessening of the 
 susceptibility with advancing years. It is not common during the first six 
 months of life. It is, however, distinctly more liable to occur at this time 
 and up to the age of one year than are the other infectious disorders of child- 
 hood. There are even a few well-authenticated cases reported in which it 
 appeared to have been contracted during foetal life. 
 
 It has been widely stated that girls are more liable to develop whooping- 
 cough than are boys. Statistics, however, are somewhat at variance, but 
 certainly show that there is no very material difference in the number of each 
 sex attacked. 
 
 The sole exciting cause of pertussis is contagion, and so powerful is this 
 contagiousness that by far the greater number of children exposed to the 
 disease will contract it. It is contagious during any part of its course, but 
 particularly in the paroxysmal stage. It is least so in the terminal stage. The 
 nature of the infectious principle can best be discussed when considering the 
 pathology of the affection. 
 
 As a rule, actual contact with, or close approach to, the sick child is neces- 
 sary for its development in a second case, but even a momentary exposure of 
 this sort is often sufficient to ensure an attack. Several observers have claimed 
 that the disease does not spread readily in well-ventilated and roomy hospital 
 wards. My own experience has not been at all in accord with this. The 
 infectious germs appear to be located in the secretion of the respiratory tract, 
 and are spread by this and by the expired air. Cases have been reported 
 which show that whooping-cough is mediately contagious through a third party 
 or through handkerchiefs or clothing which have presumably been infected by 
 the sputum of a patient. It is probable, however, that the disease is rarely 
 contracted in this way. 
 
 The contagiousness of pertussis extends slightly to the lower animals, and 
 cases are on record in which these have contracted it from the human subject. 
 
 The path by which the germs enter the system is not certainly known. 
 Although nearly all the evidence is in favor of the respiratory tract, the few 
 published cases of pertussis in the new-born indicate the possibility of their 
 entrance in other ways, as by the foetal circulation. 
 
 Pathology. — There are no post-mortem appearances characteristic of per- 
 tussis. The most constant change found is redness and swelling of the mucous 
 membrane of the respiratory tract, with the presence of a considerable quantity 
 of viscid mucus. There is often observed a tendency to congestion of various 
 parts of the body, due to the disturbance of the circulation which naturally 
 
184 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 attends the paroxysms. There are also found the various lesions correspond- 
 ing to the complications which have existed during life. 
 
 The nature of pertussis has been a much-mooted question, and is not even 
 yet entirely settled. It has been frequently claimed that the disease is a 
 functional disturbance of either the pneumogastric, phrenic, recurrent laryngeal, 
 or sympathetic nerves or of the medulla. According to this view, it is 
 simply a neurosis. Other writers have viewed it as a simple bronchial catarrh 
 due to cold merely, with which is associated a certain nervous element. En- 
 largement of the tracheal and bronchial glands has also been urged as the 
 cause of the disease, through their irritating pressure upon the terminal fila- 
 ments of the pneumogastric nerve. 
 
 The eminently contagious nature of whooping-cough, its occurrence in epi- 
 demics, the existence of a period of incubation, and the immunity from second 
 attacks seem to prove beyond a doubt that it is to be classed among purely 
 infectious disorders. Although this is the view which has recently found very 
 general acceptance, it is by no means a new idea. Even Linnaeus attributed 
 pertussis to the presence in the nose of the larvae of insects. Poulet dis- 
 covered bacteria in the expired air of patients with pertussis. Letzerich found 
 a micrococcus in the sputum which he believed to be the specific germ, and was 
 able to produce the disease in animals by introducing the secretion into the 
 trachea. Deichler claimed that there was always present in the sputum an 
 organism of the nature of a protozoon which possessed amoeboid motion. But, 
 although other investigators have repeatedly described various organisms as 
 existing on the respiratory mucous membrane, the researches of Afanassiew in 
 1887 have attracted the most attention. This observer isolated a short bacillus, 
 which he named the bacillus tussis convulsivce, and of which he was able to 
 obtain pure cultures upon various media. Animals inoculated upon the respi- 
 ratory mucous membrane with these cultures exhibited some of the symptoms 
 of the disease and developed catarrhal conditions of the respiratory tract, with 
 a tendency to broncho-pneumonia. These observations have been confirmed by 
 others, and a toxine has also been reported as present in the urine of patients 
 with pertussis which is identical with that produced by Afanassiew' s bacillus. 
 
 Even though it be admitted as most probable that some micro-organism is 
 the cause of the malad} 7 , it is by no means clear how the symptoms are pro- 
 duced or where the principal seat of the infection is. Some writers have 
 claimed that the trigeminal nerve is in a sensitive state, and that it is the irri- 
 tation of its terminal filaments by the infectious catarrhal process on the nasal 
 mucous membrane which brings on the paroxysms by a reflex action. Others, 
 again, have stated that the bronchial mucous membrane is the portion of the 
 respiratory tract chiefly involved, and that the terminal filaments of the pneu- 
 mogastric are those irritated. The careful investigations of Meyer-Huni and 
 of v. Herff, however, indicate that the catarrhal inflammation is most pro- 
 nounced in the mucous membrane of the nose, larynx, and trachea down to 
 the bifurcation, but especially so on the posterior wall of the larynx in the 
 inter-arytenoid region, the so-called "cough region." In the production of 
 the cough it would seem probable that a small quantity of mucus, perhaps 
 arising from below, accumulates upon the surface of the " cough region," and 
 there irritates powerfully the hyper-sensitive filaments of the superior laryngeal 
 nerve. Through a reflex action a series of clonic spasms of the expiratory 
 muscles is then set up. At last the crowing inspiration occurs, this depending 
 upon a spasm of the glottis, which, in its turn, proceeds from an irritation of 
 the convulsive centres in the medulla. This process is repeated again and again 
 until the offending secretion is expelled. 
 
WHO OPING- CO UGH. 185 
 
 The presence of this secretion does not seem, however, to be an essential 
 to the production of the cough, since paroxysms may be brought on by excite- 
 ment and other causes. This appears to indicate that the irritation of the 
 superior laryngeal nerve may be central, due to systemic infection. A great 
 preponderance of the nervous element of the disease over the catarrhal is 
 further shown by the greater frequency with which the paroxysms occur at 
 night, since this condition very possibly depends upon a less degree of resistance 
 of the respiratory centre during the night, and a consequent greater ease with 
 which convulsive expiratory efforts are brought about. 
 
 We therefore clearly have to do in whooping-cough with an infectious, 
 catarrhal process which affects particularly, and produces an unusual sensitive- 
 ness in, the mucous membrane presided over by the superior laryngeal nerve. 
 But still more prominent is a great excitability of the nerve itself and of the 
 other nervous portion of the respiratory apparatus, this being probably due to 
 the circulation in the blood of some noxious substance, the product of the in- 
 fecting germs, which possesses a special power over the portion of the nervous 
 system which controls cough. The apparent value in many cases of local 
 treatment directed to the respiratory mucous membrane indicates that the 
 abode of the germs is in this region, whence the poisonous products of 
 their growth are absorbed. On the other hand, the existence of pertussis in the 
 new-born, the result of foetal infection, points to the presence of the microbes 
 themselves in the circulation and in other parts of the body besides the respi- 
 ratory tract. From this point of view their situation in the latter region would 
 be a localization entirely secondary to the general systemic infection and, so to 
 speak, excretory. Which of these theories is correct cannot as yet be deter- 
 mined, although the resemblance of the disease to other infectious disorders cer- 
 tainly supports the latter view. 
 
 Incubation. — A period of incubation precedes the development of the 
 symptoms. Its exact duration cannot be easily determined, since the onset of 
 the disease is so insidious, and statements vary in regard to it. It is clearly 
 somewhat variable in length, and probably lasts from two to seven days, with 
 an average of three to four days. 
 
 Symptoms. — It is customary to divide the course of the disease into three 
 stages : 1st, the catarrhal or premonitory stage ; 2d, the paroxysmal or con- 
 vulsive stage ; and 3d, the terminal stage or stage of decline. This classifica- 
 tion is convenient, but somewhat artificial, since the stages only very gradually 
 pass into each other, and their duration cannot, therefore, be accurately deter- 
 mined. 
 
 1. Catarrhal Stage. — There is little in this which is characteristic of the 
 disease. The child gradually begins to exhibit symptoms of a severe cold, 
 with malaise, perhaps slight hoarseness, stoppage of the nose, tickling in the 
 throat, sneezing, irritation of the eyes and a dry, annoying cough. Fever is 
 generally slight and apt to come on in the evening only. Although it has 
 been claimed that the elevation of temperature is an evidence of the infection, 
 it is more likely that the degree of fever is dependent solely upon the intensity 
 of the catarrh. 
 
 Under treatment there may be a temporary improvement in some of the 
 symptoms, but all of them soon return in force, and the cough particularly is 
 troublesome and gradually grows worse in spite of medicine given. As days 
 pass by it shows a greater tendency to occur in long, severe paroxysms, and is 
 also much more annoying by night. On examination of the chest only a very 
 few rales may be heard. Nothing, indeed, is found to account for the severity 
 of the cough. Sometimes, though less commonly, the first stage is characterized 
 
186 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 by a severe bronchitis, with corresponding auscultatory signs and the presence 
 of high fever. 
 
 The duration of the first stage averages about two weeks, but it is subject 
 to great variations. Sometimes only two or three days elapse before the child 
 begins to whoop. The younger the age, the shorter, often, is the duration of 
 the catarrhal stage. In some instances the disease never passes beyond the 
 first stage, the diagnosis in such cases depending largely upon the existence of 
 the affection in other members of the family. 
 
 2. Paroxysmal Stage. — The complete development of the paroxysmal 
 cough marks the beginning of the second stage. The exact time of onset is, 
 as already stated, often difficult of determination. Except for the rarer cases 
 in which the whoop never occurs, it is convenient and most customary to date 
 the paroxysmal stage from the first appearance of this symptom. 
 
 The paroxysm of pertussis — or the "kink," as it is frequently called — is 
 very characteristic. Just before it begins the child seems anxious and irri- 
 table, or perhaps very quiet. It experiences some sort of a warning sensation, 
 as a pain in the region of the sternum, or nausea, or a tickling in the nose, or 
 a similar sensation in the larynx with an irresistible desire to cough. It at 
 once drops its playthings, runs to its mother or nurse, or grasps some near obj ect 
 for support; or, if asleep, quickly rises, sits upright, and begins to cough. 
 Sometimes, however, the cough seems to come suddenly, without the premoni- 
 tory sensation. The cough consists of a number of short, explosive expiratory 
 efforts very rapidly following one another, and without any inspiration between 
 them. These continue so long and are so violent that the face becomes turgid 
 and cyanotic, the tongue is protruded and driven against the teeth, saliva 
 flows from the mouth, the eyeballs are prominent, the eyes water, and the 
 pulse becomes rapid and small. The paroxysm lasts a few seconds until at 
 last both cough and all respiration cease. Then comes a peculiar, loud, crow- 
 ing inspiration, the whoop, which is the result of the air passing through the 
 spasmodically closed glottis. Immediately there begins another series of 
 expiratory efforts, to be again followed by the whooping inspiration ; and this 
 process repeats itself several times. The later series of expulsive efforts is 
 accompanied by abundant expectoration of ropy mucus and very often by 
 vomiting. As the paroxysm ceases the cyanosis disappears, and the child is 
 often left pale and exhausted for a short time ; but if it is strong and other- 
 wise well it soon resumes its play. Sometimes a crowing inspiration imme- 
 diately precedes the first series of expirations. Occasionally, too, after the 
 attack seems to be over there is a period of rest for a moment, and the whole 
 process is then repeated. A series of paroxysms may thus continue for as 
 long as ten to thirty and even more minutes. The usual duration of an 
 attack, however, is from a few seconds up to one or two minutes. The swell- 
 ing of the face, the puffiness of the eyes, and some degree of blueness of the 
 tongue persist more or less between the paroxysms, and may constitute quite 
 notable features of the disease. In bad cases the paroxysms may be attended 
 by haemorrhage from the mouth or nose or beneath the conjunctiva or else- 
 where. Involuntary voidance of urine or faeces may be occasioned by the vio- 
 lence of the attack. 
 
 The frequency of paroxysms and their intensity vary greatly. In mild 
 cases there may not be more than six to twelve in the twenty-four hours, while 
 in the severer ones they may number from forty to eighty. They are always 
 more numerous at night. An attack of coughing is often brought on by 
 exercise, crying, singing, loud speaking, eating or drinking, excitement of 
 any kind, a sudden change of temperature in the air, or the breathing of air 
 
WHOOPING-COUGH. 187 
 
 overloaded with carbonic dioxide. Depression of the tongue with a spatula, 
 producing gagging, is very apt to bring on an attack. 
 
 The general condition of the patient does not suffer materially in mild 
 cases. Sometimes, however, there is much exhaustion from the frequent 
 coughing and the loss of sleep, or vomiting may so regularly follow the 
 paroxysms that the nutrition suffers greatly and emaciation becomes marked. 
 In the milder cases vomiting does not at all interfere with the appetite, and 
 the child is soon ready to eat again ; so that quite sufficient food is retained 
 for the bodily needs. 
 
 More or less fever may occasionally be present in the second stage, espe- 
 cially at night, but, as a rule, fever is absent, and if continuously present 
 makes the existence of some complication probable. The urine in whooping- 
 cough sometimes contains sugar and frequently albumin. It was at one time 
 claimed that it was always saccharine. Auscultation of the chest in the interval 
 between the paroxysms reveals nothing abnormal, or only the presence of a 
 few mucous rales. During the whooping inspiration nothing at all, or at most 
 only a very feeble inspiration, can be heard. During the expiratory efforts, 
 too, very little respiratory sound is audible, and scarcely more than the sensa- 
 tion of a series of impulses can be perceived. 
 
 The total duration of the paroxysmal stage is exceedingly variable. In 
 general terms it may be given as from three to six weeks, but it may last a 
 shorter or a much longer time than this. 
 
 3. Terminal Stage. — The second stage merges so gradually into the suc- 
 ceeding one that no exact boundary between them can be recognized. The 
 third stage may be said to begin when the severity of the disease is clearly 
 diminishing. The attacks now grow less frequent and less severe ; the whoop- 
 ing and vomiting persist for a time, but gradually disappear ; and the cough, 
 although still paroxysmal, grows distinctly looser and of a more catarrhal 
 nature, and finally assumes the character of that of simple bronchitis. Haem- 
 orrhages occur much less frequently, if at all ; the bronchial secretion is now 
 more muco-purulent, and the general health, if previously affected, improves. 
 Finally the cough disappears entirely and the disease is over. 
 
 The duration of this stage is very variable. It may last from about ten 
 days up to several months, depending upon hygienic and other conditions. 
 Thus the approach of the winter season is liable to prolong it indefinitely. 
 Not infrequently, after all cough has ceased and the child has appeared 
 well, the development of a nasal or bronchial catarrh may be attended by a 
 return of the paroxysms. Such a return cannot, however, be properly desig- 
 nated a part of the third stage. 
 
 Complications and Sequelae. — Of the very numerous complications of 
 pertussis those connected with the respiratory tract are most prominent. 
 Bronchitis may be so in excess of the degree of catarrh usually present that it 
 constitutes a complication. This is not an infrequent occurrence. Atelectasis 
 very often develops in young children. It may affect only a small part of the 
 lung or may be more extensive and threaten life, and is especially apt to be 
 witnessed in weakly and rachitic children. Widespread broncho-pneumonia is 
 one of the most common and most dangerous complications of whooping- 
 cough. It usually comes as a result of atelectasis, but sometimes independ- 
 ently of it, and tends to run a very tedious course. As it develops the 
 paroxysmal nature of the cough is very liable to diminish or disappear. Like 
 atelectasis it is particularly prone to be seen in weakly children or when 
 measles has immediately preceded pertussis, or in children who have been sub- 
 jected to improper hygiene, especially exposure to cold. Pleural effusion. 
 
188 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 empyema and croupous pneumonia are of less frequent occurrence ; pneumo- 
 thorax is rare ; emphysema is common, but is generally only temporary. 
 Sometimes, however, it is permanent throughout more or less of the lungs. 
 Emphysema of the subcutaneous connective tissue has been reported but is 
 very uncommon. (Edema of the glottis is sometimes seen. The coexistence 
 of pseudo-membranous laryngitis is to be regarded as accidental. 
 
 A complication so frequent that it almost deserves to be called a symptom 
 is the occurrence of a superficial yellowish-gray ulceration over or at the sides 
 of the fraenuru of the tongue. It is probably produced by the forcible impulse 
 of the tongue against the lower incisor teeth during the act of coughing. It 
 has occasionally been seen in other disorders than whooping-cough. 
 
 Vomiting is generally to be regarded as a symptom of the disease, but the 
 irritability of the stomach may become so great that it constitutes a genuine 
 and very troublesome complication. In such cases vomiting is very frequent 
 and takes place after every slight cough. Loss of appetite, indigestion, and 
 diarrhoea are common complications, the latter being of a somewhat chronic 
 nature, with the evacuation of considerable mucus. Prolapse of the rectum 
 may result from the violence of the cough, and hernia may be brought about 
 in the same way. 
 
 Hemorrhages from various parts of the body occur during the paroxysms. 
 Bleeding from the nose and mouth is so frequent that it is to be included 
 among the symptoms of the disease. Subconjunctival haemorrhage is not 
 uncommon. Bleeding from the ear is a rare complication and haemorrhage 
 from the lungs is also unusual. Haematemesis, in which the blood comes origin- 
 ally from the stomach and is not previously swallowed, is certainly exceptional. 
 Haemorrhage into the skin occasionally occurs. Haemorrhage into the meninges 
 or within the brain is not an unusual complication, and is doubtless the cause 
 of many instances of convulsions and other cerebral symptoms. 
 
 Convulsions are a dangerous complication and are not infrequent, particu- 
 larly in young subjects. A persistent spasm of the glottis may sometimes 
 cause death. Hemiplegia, aphasia, sudden blindness and other evidences of 
 cerebral disturbance may be occasional complications. 
 
 General oedema of the skin has sometimes complicated the disease. Acute 
 nephritis has been quite often reported. 
 
 Whooping-cough may be associated with diphtheria, varicella, scarlatina, 
 or, in fact, any of the infectious diseases, but particularly with measles. The 
 latter combination especially renders the prognosis more unfavorable. 
 
 Rachitis, anaemia and other constitutional maladies may complicate per- 
 tussis and influence its course unfavorably, or they may develop as sequels to 
 it. Tuberculosis is a sequel very liable to arise in those who are predisposed 
 to it or whose general nutrition has greatly suffered during the first disease. Its 
 usual seat is the bronchial and intestinal glands or in some of the patches of 
 broncho-pneumonia, but from these foci a more or less widely-spread infection 
 may start. Epilepsy, various paralyses, aphasia, blindness, deaf-mutism fol- 
 lowing rupture of the drum-membrane, disseminated sclerosis and other con- 
 ditions have been reported as occasional sequels. Some of them are to be 
 viewed as accidental merely. 
 
 Diagnosis. — In the early stages of the disease the diagnosis can seldom be 
 made with any certainty. The absence or scarcity of physical signs in the 
 lungs, combined with the very harassing cough, which is markedly worse at 
 night, renders the case suspicious. This is especially true if whooping-cough be 
 prevalent at the time, or if there be a history of exposure to contagion. If the 
 cough assume a decidedly paroxysmal character, the diagnosis becomes still 
 
WHOOPING-CO UGH. 189 
 
 more probable. The occurrence of the whoop is usually conclusive, and even 
 in those cases where this at no time develops, the nature of the cough, with 
 such attending symptoms as vomiting, injection of the conjunctivae and the 
 like, makes the diagnosis fairly easy. 
 
 Severe acute bronchitis of the smaller tubes may sometimes be attended by a 
 very spasmodic cough and may simulate pertussis closely ; but the presence of 
 numerous rales, with decided fever and dyspnoea, and the absence of more than 
 a slight whoop will aid in distinguishing it. The same difficulty in diagnosis, 
 and for similar reasons, may exist in cases where pertussis closely follows 
 measles, since the severe bronchitis already present may appear to account fully 
 for the severity, and even the paroxysmal nature, of the cough. The development 
 of broncho-pneumonia during the first stage of pertussis may render the later 
 diagnosis very difficult, since it is apt to modify greatly the character of the 
 cough or even to prevent entirely the occurrence of the whoop. Tuberculosis 
 of the bronchial glands may produce a paroxysmal cough much resembling that 
 of pertussis. It is to be distinguished by a history of previous wasting and 
 ill-health, the chronic course without distinct stages, the imperfect development 
 of the paroxysms, which are unattended by abundant mucous expectoration 
 or vomiting, and the presence of fever. Sometimes evidences of tuberculosis 
 of the lungs are also present. A prolonged third stage of pertussis may readily 
 simulate pulmonary tuberculosis, and, indeed, it may be possible that the latter 
 disease is developing as a sequel. Only the later course of the case can 
 decide. 
 
 Prognosis and Mortality. — Although the prognosis is favorable in most 
 cases, yet pertussis is a far more dangerous disease than is ordinarily supposed. 
 In England and Wales 120,000 persons died of it between the years 1858 and 
 1867, and 85,000 succumbed in Prussia between 1875 and 1880. Dolan ranks 
 it third among the fatal diseases of childhood in England, and says it causes 
 one-fourth of the annual mortality among children in London. Smith esti- 
 mates that during fifty years there were 4840 deaths from it in New York City, 
 or 1 in every 76 deaths from any cause. The relative mortality, as compared with 
 the number of cases of the disease, is also larger than is commonly believed. 
 Statistics vary regarding it, but it may be said to range from 3 to 15 per cent. 
 
 It is upon the great frequency of the complications that the high rate of 
 mortality depends, for, if uncomplicated, the disease is not often dangerous. The 
 younger the child the more unfavorable is the prognosis. The mortality is very 
 much greater under two to three years of age than after this period, while after 
 the fifth year it is trifling. The prognosis is rather more unfavorable in females 
 than in males, owing possibly to a less degree of strength of constitution pos- 
 sessed by the former. The patient's previous general condition and the amount 
 of care received while sick affect the prognosis very materially. The children 
 of the poor, badly nourished and neglected as they so frequently are, are con- 
 sequently apt to suffer most. Rachitis or any other constitutional debilitating 
 disorder influences the course of the disease unfavorably. The presence of 
 the winter season increases the danger through the greater liability of respira- 
 tory complications. On the other hand, the heat of summer brings on debili- 
 tating intestinal disorders. As already stated, convulsions and broncho- 
 pneumonia are frequent and dangerous complications and the cause of many 
 deaths. 
 
 Many cases pass safely through the attack, but die from the sequela?. Some 
 become marasmatic and die without the exact cause being discovered, although 
 many of these are undoubtedly tubercular. Other cases show definite symptoms 
 of tuberculosis of various parts of the body. 
 
190 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Treatment. — Prophylaxis. — In view of the highly contagious nature of 
 the disease prophylactic treatment should be carefully carried out. Children 
 who have not yet suffered from it should be rigidly kept from the slightest inter- 
 course with those who are even suspected of being in the first stage of the 
 malady. Inasmuch as there exists the greatest possible carelessness on the part 
 of parents of the sick regarding the danger to others, it is better that unin- 
 fected children be removed entirely from the neighborhood whenever feasible. 
 Particularly is this true in the case of delicate infants. 
 
 How long the danger of infection continues and how long quarantine must 
 be maintained are not absolutely certain. It is admitted that the infectiousness 
 diminishes during the third stage, and it may be assumed that by the end of 
 two months after the onset of the disease the danger has entirely ceased. A 
 still better criterion, however, is the entire cessation of the cough. 
 
 If, after the child has been apparently entirely well for a brief period, the 
 cough, with or without the whoop, returns, it is probably safe to consider that 
 the risk of infection is over in spite of this. It often happens that the whoop 
 will thus return at intervals during months, or even for a year, whenever slight 
 bronchitis is contracted. Quarantine during this entire period is manifestly 
 unnecessary and impossible. The same is true of those cases which continue 
 to whoop once or twice a day for an indefinite time. In such we may consider 
 that after two, or at most three, months the disease itself is over, and that 
 simply a neurosis remains: the "habit," so to speak, of whooping persists. 
 
 Although whooping-cough seems in nearly every instance to be communi- 
 cated by the breath only, yet, to avoid the possibility of transmission in other 
 ways, disinfection of the clothing, bed-linen, and the like should be carried out 
 systematically, and the rooms used should receive a final disinfection before 
 being inhabited by other children. 
 
 Treatment of the Attack. — The hygienic treatment of pertussis is of the 
 utmost importance. Inasmuch as air loaded with carbonic dioxide has been 
 proven to bring on paroxysms of cough, children should be kept in fresh air 
 as much as possible. At the same time the very great sensitiveness of the 
 respiratory mucous membrane must be borne in mind, and all possibility of 
 taking cold must be avoided. In winter, therefore, it is often best to confine 
 the patient to the house except on dry and still days. Where possible it is 
 well to utilize two airy rooms, one of which shall be thoroughly ventilated and 
 then warmed while the other is in use. The child can be changed from one 
 to the other several times a day. The clothing should be warm enough to 
 prevent chilling and consequent taking cold. The food should be nutritious, 
 easy of digestion and assimilation, and frequently administered in cases where 
 vomiting is a prominent symptom. In some cases of this kind it may be neces- 
 sary to employ nutrient enemata. 
 
 It sometimes happens that change of climate will act most favorably upon 
 the course of a case of pertussis. This is particularly true of the third stage 
 if unusually prolonged. 
 
 The host of remedies recommended for pertussis is proof in itself that none 
 of them constitute an infallible cure. Rather, however, than decry all medi- 
 cation, as is the habit with some, we should remember that negative results in 
 the hands of one physician cannot vitiate positive results with any certain 
 method of treatment in the hands of another competent observer. Nothing is 
 more certain than that, although no medication is curative in all instances, 
 many different methods of treatment are of undoubted value in different cases. 
 Where, therefore, we fail with one, another must be tried in the effort to dis- 
 cover the remedy useful for the particular case. It must also be borne in min<3 
 
 . 
 
WHOOPING-CO UGH. 191 
 
 that to test the value of a remedy we roust give it in sufficiently large dose, 
 and further that it must be administered at the height of the disease, and not 
 when the third stage has already commenced, at which time almost anything 
 may seem to do good. 
 
 In the mild cases, where paroxysms are but few and of little severity, it is 
 best to omit all medication intended to control the disease, and simply to keep 
 a careful supervision over the patient. In severer cases, however, treatment is 
 demanded. The condition existing in each individual case, — and, to a less 
 extent, the stage of the disease — will exert an influence upon the choice of 
 drugs to be employed. During the first stage, when the cough is hard and 
 tight, with little expectoration and without full development of the paroxysmal 
 character, the medicines to be selected are those useful in an ordinary bronchial 
 catarrh. The same plan of treatment may be needed in the second stage, while 
 in other cases the copious expectoration permits the freer use of sedatives. 
 But inasmuch as the cough from the outset does not depend upon a simple 
 bronchial catarrh, it is oftener better to begin the employment of remedies 
 directed against the peculiar nervous character of the disease as early in the 
 case as the diagnosis can be made. This need not interfere with any symptom- 
 atic treatment indicated. When the third stage is well under way attention 
 must be paid principally to the accompanying bronchitis. Stimulating lini- 
 ments to the chest may be useful, and tonic remedies are often demanded. 
 
 An attempt to consider all the drugs which have been employed for the 
 treatment of pertussis would be so much a waste of time and space that only 
 the most important of them can be mentioned here. Belladonna is one of 
 those best and longest known and most widely used. Sometimes doses of 
 moderate size suffice, but in other cases it is necessary to give it in increasing 
 amounts until constitutional effects are seen. It often does great good, and 
 often, too, entirely fails to relieve. The initial dose for a child of two years may 
 be two minims of the tincture or one-twelfth of a grain of the extract three or 
 four times a day. Alum is sometimes of distinct benefit, particularly when the 
 abundance of the secretion appears to be the cause of frequent paroxysms. It 
 may be given in doses of two grains every three or four hours at two years of 
 age. It may sometimes be combined advantageously with belladonna. Quinine 
 has been widely used with varying results. On the whole, it may be con- 
 sidered a useful remedy. When given internally the doses should be rather 
 large — as one grain every two to four hours at two years of age — to produce an 
 effect upon the disease ; but there is risk of disturbing the digestion with it. 
 It may be administered with advantage in suppositories, or, if by the mouth, 
 disguised in syrup of yerba santa or syrup of licorice. Chloral is often use- 
 ful to produce sleep at night. Two to four grains may be given at bed-time 
 to a child two years old. There is some evidence that, administered at inter- 
 vals during the day, it exerts also a direct influence upon the course of the 
 disease. It can be exhibited either by the mouth or by enema. Its power of 
 depressing must not be forgotten. Opium is frequently of the greatest service 
 in obtaining temporary relief. Comparatively restful nights can often be pro- 
 cured by means of its administration at bed-time. It should, however, be re- 
 served for the severest cases. Bromide of potassium or of some other base has 
 been much recommended, and is often of distinct value. It lessens the nervous 
 irritability, and in this way diminishes the frequency and intensity of the 
 paroxysms. Its administration should be started immediately if evidence of 
 nervous disturbance indicate impending convulsions. The dose at two years 
 of age may be two to five grains, repeated according to the demands of the 
 case. It may often be advantageously combined with belladonna. Cannabis 
 
192 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Indica has been much used, and is probably one of the most reliable means 
 of treatment. Asafoetida is still a favorite with many. Carbolic acid, in doses 
 of one minim at two years of age, has been found of service in many instances, 
 but its toxic properties must not be forgotten. Peroxide of hydrogen has 
 been highly praised, as have terpene hydrate and infusion of wild thyme. 
 Ouabaine has been highly recommended. The dose is one-thousandth of 
 a grain every three hours at five years of age. It is a powerful respiratory 
 paralyzer. 
 
 Among the most important of other drugs which have been recommended 
 for internal administration, and which have doubtless proved of service in 
 some cases, are pilocarpine, lobelia, resorcin, grindelia, castania, drosera, cam- 
 phor, quebracho, hyoscine, turpentine, benzole, carbonate of iron, and conium. 
 
 Antipyrine, first recommended by Sonnenberger, has been used with 
 excellent results by so many that its value in the disease is now beyond ques- 
 tion. Although, like other remedies, it often fails to relieve, many of the 
 reported failures with it are doubtless due to the fact that it was not given in 
 sufficiently large dose. Children bear it surprisingly well, and bad results 
 following its administration are rare. The initial dose should be small, and 
 the amount gradually increased until a child two years old receives one to two 
 grains, or even more, every three hours. In a desperate case of pertussis in a 
 four-months-old child under my care, in which three-quarters of a grain of 
 antipyrine, given every three hours, failed entirely to relieve, an increase of 
 the dose to one grain every three hours rapidly brought the patient from a 
 condition of the greatest danger to one of comparative health. The child had 
 suffered from very frequent and violent attacks of cough, followed by spasm 
 of the glottis of so long duration that intense cyanosis with entire apnoea and 
 loss of consciousness repeatedly resulted. Within forty-eight hours after the 
 treatment had been instituted the little patient had passed an entire night and 
 and until afternoon on the next day with but a single paroxysm. 
 
 Phenacetin will sometimes be of service in cases where antipyrine has 
 failed, and the reverse, of course, also holds good. Acetanilid has sometimes 
 proved of use, but is less often employed and of less value than are its two 
 cogeners. 
 
 Bromoform, one of the newest remedies for pertussis, was first recom- 
 mended by Stepp in 1889, and has been largely used. It may be given in 
 doses of from two to four drops three or four times a day at two years of age. 
 It can be dropped upon moistened sugar or given in a mixture with alcohol, 
 syrup, and water. My experience with it, although satisfactory to some extent, 
 has not been as much so hitherto as published results had led me to hope. Some 
 cases improved, but oftener small doses failed to be of service, while larger ones 
 rendered the patient so sleepy and stupid that the remedy had to be abandoned. 
 Nevertheless, the large number of reported cases in which the results have been 
 extremely good indicate that the remedy is certainly of great value. 
 
 Local treatment of the respiratory mucous membrane has been largely em- 
 ployed. One of the most popular methods is the insufflation of quinine in the 
 form of a fine powder. This may be applied directly to the larynx by the 
 physician twice a day, or nasal insufflations may be made by the attendants 
 several times daily. Excellent results have been obtained in each way. 
 About one grain of quinine should be used at a time. Resorcin has been 
 highly recommended by Moncorvo. A 1 per cent, solution may be applied to 
 the pharynx and the opening of the larynx, or a powder may be insufflated 
 into the nose, using one-half to one grain at a time for this purpose several 
 times each day. The local application of a solution of cocaine has been advo- 
 
WHOOPING-CO UGH. 193 
 
 cated, but is not without danger, as reported cases have shown. It has, 
 however, often been of service in mitigating the severity of the disease. The 
 solution should be of the strength of from 1 to 4 per cent. 
 
 With the steam or hand-ball atomizer the fauces and nares may be sprayed 
 with the substances mentioned or with a weak solution of morphia. Bromide of 
 potassium in solution is sometimes of much service, and tannin can be employed 
 in the same way. Peroxide of hydrogen, in the dilution of one part in five, 
 may be sprayed in the nares and upon the fauces, and very excellent results have 
 been claimed for it. 
 
 Benzoin, boric acid, salicylic acid, iodoform, tannin, and other drugs, in 
 powdered form, have found their supporters as useful agents for nasal insuf- 
 flation. Benzoin is one of the best of them. Good effects can also be secured 
 with boric acid. 
 
 Various volatile substances may be used with the atomizer in the form of 
 vapor from boiling water. Carbolic acid is one of the best of these, and it is 
 often of great advantage to allow the sick-room to be permeated by it. The 
 action upon the cough is probably due in part to the anaesthetic effect of the 
 carbolic acid, and largely to the influence of the moist atmosphere of the room, 
 which loosens the mucus and facilitates its expectoration. Thymol, eucalyptol, 
 and turpentine may be vaporized in a similar way. Chloroform and ether have 
 been recommended for their general anaesthetic effect. 
 
 Remarkable results have been reported from the fumigation of the sick- 
 room by burning sulphur. The child is to be washed in the morning, dressed 
 in clean clothes, and placed in another room. The night-room is in the mean 
 time thoroughly fumigated with the sulphurous vapor, closed during five hours, 
 and then aired. The patient sleeps in this room at night. A single employment 
 of this procedure has been effective in some cases. 
 
 The inhalation of the air in the purifying-rooms of gas-works is a method 
 of treatment formerly much in vogue. The employment of the pneumatic 
 cabinet has likewise been recommended. The use of the constant electric cur- 
 rent has been advocated by several clinicians. The routine administration of 
 emetics, once a popular procedure, is no longer in favor. 
 
 Complications demand, of course, treatment applicable to them individually. 
 
 13 
 
TYPHOID FEVER. 
 
 By F. GORDON MOBRILL, M. D., 
 
 Boston. 
 
 Synonyms. — Enteric fever ; Slow fever ; Fall fever ; Gastric fever ; 
 Infantile remittent fever. 
 
 Definition. — An acute, infectious, continued fever, due to a specific cause, 
 and characterized by prostration, wasting, enlargement of the spleen, inflam- 
 mation of Peyer's patches and the solitary follicles of the intestine, and an 
 eruption of rose-colored spots, which disappear on pressure being applied, 
 and return rather slowly when it is removed. In children the solitary fol- 
 licles rarely ulcerate, the eruption may be absent, and it is sometimes impos- 
 sible to demonstrate enlargement of the spleen. The word " typhoid," first 
 suggested by Louis on account of the supposed resemblance of the disease to 
 typhus, has met with general acceptance in America and England, while in 
 France the term " dothienenterie " is frequently used by those who object to 
 "typhoid" as misleading. "Enteric fever" is perhaps preferable, as sug- 
 gesting the specific lesions of the disease, and is frequently employed as a 
 substitute for the original name by precisians or by medical writers for the 
 purpose of avoiding constant repetition. 
 
 History. — Previous to 1840 it was believed that children were exempt 
 from typhoid, although good descriptions of cases (some with autopsies) had 
 been published by Abercrombie, West, and others. During that year, how- 
 ever, Rilliet and Taupin published results of separate and independent 
 investigations of enteric fever in children, and the fact of their susceptibility 
 to the disease has since then become generally recognized. Later on it was 
 proved that while typhoid is rare in infancy, it may occur in children at any 
 age. Even so close an observer as Bouchut denied in 1867 that the disease 
 ever occurred during the first year of life ; but as a matter of fact the specific 
 micro-organism of typhoid has been found in the liver and spleen of an infant 
 who breathed only twelve hours, and whose birth took place during the 
 fourth week of the disease in the mother ; and in similar instances the 
 specific intestinal lesions have been discovered. So it may be stated that, in 
 childhood at least, no age is exempt. 
 
 Etiology. — As to the age at which children are most susceptible to the 
 infection, statistics vary, but the risk probably increases from birth up to the 
 tenth year, and then remains about the same until puberty is attained. The 
 influence of sex is not apparent, although more boys than girls find their 
 way into hospitals. The distribution of the disease is quite impartial, no 
 climate being exempt. In America it is everywhere the prevailing fever. 
 The influence of season is very marked, a large majority of cases occurring 
 during the late summer and early autumn months. A dry hot summer 
 increases the prevalence of typhoid — a fact which Pettenkofer attributes to 
 the more thorough drainage of the soil into wells and springs, which are low, 
 
 194 
 
TYPHOID FEVER. 195 
 
 and the water of -which is, of course, concentrated ; while Baumgarten sug- 
 gests that at such times the poison is more easily disseminated in the air. 
 Neither of these explanations is quite satisfactory, while each contains an 
 element of truth. 
 
 Family predisposition to contract the disease is not infrequently observed. 
 A marked instance of this susceptibility is cited by the late Charles Warring- 
 ton Earle (in his article on typhoid fever published in the first edition of this 
 book), where seven persons of one family contracted enteric fever by visiting 
 an infected room or nursing other cases so caused. As a rule, the previous 
 condition of health plays but an insignificant part in the etiology of typhoid, 
 which is directly caused by absorption from the alimentary canal of the 
 specific micro-organism (named after its discoverer, Eberth), which is a short, 
 thick bacillus with rounded ends and containing glistening spots which 
 remain unstained when subjected to the ordinary process. It occurs singly 
 or in chains, and its appearance varies in accordance with the medium in 
 which it is grown. The variety of ways by which different authorities say it 
 can be distinguished from the bacillus coli communis is suggestive of the fact 
 that there is a great liability to error ; and in this connection it is proper to 
 state that it is claimed that the Eberth bacillus has been found in the fecal 
 evacuations of persons free from any suspicion of typhoid, and who had never 
 had the disease. That the bacillus is often swallowed with impunity is un- 
 doubtedly true — the soil must suit the seed, as in other infections. Whether 
 the Eberth bacillus can remain inactive in the alimentary canal for any con- 
 siderable length of time, and then suddenly cause disease (as does the Klebs- 
 Loffler bacillus in the throat and nose), remains to be proved. Be this as it 
 may, the poison finds entrance to the body through the nose or mouth, and 
 usually in articles of food or drink. 
 
 Water that has been contaminated by the discharges of those having 
 the disease is by far the commonest source of infection. Examples of 
 this contamination through cess-pools, drains, and the washing of excreta 
 for a considerable distance into streams and reservoirs are too well known 
 to bear repetition here. In Paris the river Seine has a firmly established 
 reputation as a conveyer of the enteric bacillus. When the usual sources 
 of supply for certain quarters of the city fail, Seine water is substituted, 
 and an epidemic of typhoid follows with unfailing regularity in the course 
 of two or three weeks from the time when it is turned on. The bacillus 
 grows rapidly in fresh milk, which is a. frequent source of infection, and is 
 sometimes responsible for outbreaks confined, in the main, to children. 
 Washing the cans in infected water is the usual explanation of the contami- 
 nation. Any article of food or drink may be infected by the person having 
 the disease, or, indirectly, through carelessness on the part of the attendants. 
 Oysters may absorb the micro-organism from drainage, the bacillus retain- 
 ing its characteristics perfectly well after a fortnight's sojourn in sea-water. 
 Freezing does not destroy its vitality, and ice may thus act as a carrier of 
 the disease. 
 
 In view of the infinite variety of ways (food, drink, bedding, toys, books, 
 utensils of all sorts, and probably the air we breathe) in which the bacillus, 
 moist or dry, may be distributed, it is a matter of surprise that the disease is 
 not even more prevalent, as it doubtless would be if every one swallowing the 
 poison were susceptible. 
 
 After entering the alimentary canal, the micro-organism penetrates the 
 mucous membrane and gives rise to profound constitutional disturbance, 
 together with characteristic changes in the intestines and other organs. The 
 
19G AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 length of time which may elapse after exposure before the symptoms mani- 
 fest themselves varies within wide limits. It is fixed by the Clinical Society 
 as "eight to fourteen, sometimes twenty-four, days." Liberal as this rule 
 is, there are well-marked exceptions to it. In a recent epidemic near Boston 
 two children were taken obviously sick, with what proved to be typhoid fever, 
 forty-eight hours after drinking for the first and only time infected milk, to 
 which the source of trouble was clearly traced. In other instances five days 
 covered the period of incubation in children, and a somewhat longer period 
 in adults of the same families. 
 
 Morbid Anatomy. — The post-mortem appearances which enteric fever 
 causes in adults will be mentioned only for the purpose of contrasting them 
 with lesions of the same organs as observed in children. 
 
 Rose spots usually disappear after death, while accidental eruptions 
 (sudamina, etc.) persist. 
 
 The duodenum may be slightly congested, while the changes in the 
 jejunum and ileum are usually due to hyperplasia, and not (as in adults) to 
 ulceration. Peyer's patches and the solitary follicles are surrounded by 
 zones of congestion, but induration is rarely perceptible to the touch ; in 
 other words, the congestion is not sufficiently intense to interfere seriously 
 with the blood-supply, and for this reason ulceration, except to a slight 
 degree, is seldom present. Whatever the intestinal lesions may be, they are 
 seen in greatest number in the immediate vicinity of the ileo-caecal valve. 
 
 According to the combined statistics of Pfeiffer and Montmollin, lesions 
 of the intestinal mucous membrane, varying from the (usual) superficial con- 
 gestion to deep ulceration with perforation, were present in 72 per cent, of 
 their cases. 1 
 
 Ulcerations, when seen, rarely exceed ten or twelve in number, and 
 their superficial character contrasts strongly with similar lesions in adults, 
 which so frequently involve the submucosa, and may be so confluent in the 
 neighborhood of" the ileo-caecal valve as to form an eschar of great size. 
 Instances of deep ulceration are rare in children, but when present are due 
 to the same process as in adults, which reaches its height in eight or ten 
 days, and then undergoes a retrograde change or produces necrosis. Retro- 
 gression is fortunately the rule in children, and ulceration seldom reaches 
 the muscular coat of the intestine, which in adults usually constitutes the 
 floor. Perforation is very rare, but. does occur. As a rule, the solitary 
 follicles do not ulcerate : they are swollen and often present the appearance 
 described by French writers — a beard of two days' growth. In rare in- 
 stances they ulcerate, and I find in the records of the Boston Children's 
 Hospital one case in which this lesion w r as present in the solitary follicles of 
 the caecum, extending several inches below the valve. 
 
 The mesenteric glands are swollen, particularly in the vicinity of the 
 ileo-caecal valve, and the intensity of this condition does not necessarily cor- 
 respond to the extent of the intestinal lesions. Peritonitis, with or (rarely) 
 without perforation, is observed very exceptionally. The spleen is certainly 
 of normal size in some cases, but, as a very general rule, is swollen and 
 hyperbaric. If death occurs at a late stage of the disease, it may be soft, 
 and has been known to fracture (ante-mortem) on palpation. Hemorrhagic 
 infarcts are common. The liver may be hyperaemic and enlarged in severe 
 cases, or it may be soft and the bile colorless ; but, as a rule, hepatic lesions 
 are slight and insignificant as compared with those of adults. 
 
 1 It must be borne in mind that this estimate applies to fatal cases, in which intestinal 
 lesions are naturally much more frequent and serious than in those who survive. — F. G. M. 
 
TYPHOID FEVER. 197 
 
 The brain is singularly free from important pathological changes, and 
 even in cases -where nervous symptoms have been decidedly marked, nothing 
 beyond a congestion of the pia mater and (to a slighter degree) of the brain- 
 substance, together with extremely moderate distention of the arachnoid, is 
 observed. The heart is pale, and often softened by granular or fatty degen- 
 eration of its muscular fibres. Passive congestion of the lungs is common, 
 and patches of broncho-pneumonia of the deglutition type are not rare. The 
 kidneys may show signs of granular degeneration, but rarely of true ne- 
 phritis. The voluntary muscles, particularly the pectorals, recti abdominis, 
 and adductors of the thighs, may be in the same condition as those of the 
 heart just described. This of course may be the case after any prolonged sick- 
 ness, and is not peculiar to typhoid fever. 
 
 Ulcerations of the laryngeal cartilages, periostitis, osseous necrosis, and 
 suppurative parotitis are extremely rare, but have all been observed. In the 
 case which I have referred to as appearing in the Children's Hospital records 
 Eberth's bacillus was found in the lungs and in great abundance in the 
 spleen, liver, and kidneys. 
 
 Symptoms. — After a variable time from the date of exposure the child 
 begins to lose its interest in play, shows signs of lassitude, and is inclined to 
 lie down. Headache, anorexia, chills or chilly sensations, nausea, epistaxis, 
 pain in the back or legs, diarrhoea (or constipation) may be present. This 
 condition of things may continue for a week, or even longer, before the child 
 takes to bed and is obviously sick. More rarely the onset is sudden and 
 accompanied with vomiting. In either case, in the absence of any suspicion 
 of typhoid infection, the patient's condition often passes as the result of 
 indigestion or having " taken cold." But the usual remedies fail to give 
 relief — the symptoms persist, and are so marked as to make it evident that 
 no temporary indisposition can account for them satisfactorily. The arbitrary 
 date of the commencement of the "run " of the fever is now fixed. 
 
 The degree of constitutional disturbance which typhoid gives rise to in 
 children is usually much less than that which it causes in adults ; but it is 
 sufficiently well marked, as a rule (in America, at least, where the abortive 
 and extremely mild types are comparatively rare), by the end of a week to 
 enable one to make a diagnosis. The child lies with flushed cheeks and an 
 expression of marked apathy, which remains present until the fever subsides, 
 and occasionally for clays after the temperature has become normal. The 
 abdomen, flat at first, becomes swollen and tender on pressure, particularly 
 in the right iliac fossa. Sometimes abdominal pain is voluntarily complained 
 of. The spleen is apt to be swollen, and its lower edge can be felt (usually 
 below or under the false ribs, but occasionally more toward the front) in a 
 majority of cases. Rose spots may be visible on the abdomen, the lower 
 portion of the thorax, the inner surfaces of the thighs, or between the 
 shoulder-blades. A moderate diarrhoea may be present, but constipation is 
 more frequently the rule during the first week after the child comes under 
 observation. The urine is scanty and high-colored. Bronchitis or, rather, 
 cough, is not uncommon. The skin is usually dry and hot, but perspiration 
 is exceptionally observed during the early stage. 
 
 The lips are dry and scaly. Sordes may collect on the teeth and gums 
 if care is not observed. There is no characteristic appearance of the 
 tongue, which is almost always moist, red on the tip and along the edges. 
 and coated with a yellow deposit which is variable in thickness and distri- 
 bution, sometimes covering the entire upper surface, or being confined to the 
 anterior half or to the lateral portions only. Anorexia is complete, but the 
 
198 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 child takes kindly to cool liquids. Sleep is apt to be disturbed, and mild delir- 
 ium is not uncommon during the night. The pulse beats from 120 to 140 per 
 minute, and the temperature reaches 104° to 105° F. (oftener the former) at 
 night, with morning remissions of 1.5° to 3° F. As the disease progresses 
 emaciation becomes marked. Diarrhoea and abdominal pain, which may 
 precede or follow the loose discharges, are common, but constipation may 
 continue until the case terminates. Attacks of nausea lasting two or three 
 days may occur. Prostration and apathy are more profound, and there may 
 be retention of urine. 
 
 Toward the end of the second week of the child's confinement to bed in 
 mild cases, or a few days later in those of average severity, the tempera- 
 ture begins to descend by lysis (often preceded by very marked morning 
 remissions), and soon reaches the normal point. Convalescence now begins : 
 the appetite becomes ravenous, and, if no relapse occurs, complete recovery 
 in all but the matter of physical strength soon follows. The anaemic pallor 
 and weakness caused by enteric fever are very marked. The child's first 
 attempts to walk with its attenuated legs bear testimony to the severe con- 
 stitutional disturbance it has passed through. The hair falls out to a greater 
 or less extent, and this, together with a perceptible increase in height 
 (typhoid stimulates the growth of the long bones), causes the patient to pre- 
 sent a curious aspect. 
 
 The usual features of an average case having now been roughly outlined, 
 special symptoms and complications will be considered : 
 
 Relapse. — A recrudescence of fever from no apparent cause is not un- 
 common. It is apt to occur a very few days after the beginning of convales- 
 cence, and usually lasts a day or two only. True relapse, due to reinfection 
 after a perceptible period of apparent convalescence, is usually of sudden 
 onset, and occurs with varying frequency in different epidemics. At the 
 Boston Children's Hospital 17 per cent, of 100 recorded cases have had a 
 relapse on the (average) thirty-third day after the first symptoms of the orig- 
 inal attack were noted. The mean duration of these relapses w r as seventeen 
 days. Of those affected, 12 were girls and 5 were boys — a fact which cor- 
 roborates, in a modest way, Montmollin's statement that the frequency of 
 relapse is influenced by sex. As a rule, the relapse is neither so long nor so 
 grave as the original fever, but occasionally it may be severe enough to cause 
 death. A second relapse may occur. This happened in 4 of the 17 cases I 
 have referred to, and all of them recovered. Instances of a third relapse 
 have been recorded — the greatest number which I have seen mentioned in 
 connection with the typhoid fever of childhood. Intercurrent relapses are 
 not very uncommon, and an unusually prolonged pyrexia may often be 
 accounted for in this way. The symptoms of relapse differ in degree only 
 from those which the patient has already had. 
 
 Respiratory System. — Epistaxis is rather common, and of no importance 
 save from a diagnostic standpoint. It was noted in 5 per cent, of 70 cases 
 by Forchheimer, and in 20 per cent, of the 100 cases which I have mentioned. 
 Cough is frequent, and is usually caused by slight bronchial catarrh or 
 some ordinary affection of the upper respiratory tract : I find it noted in 36 
 per cent. Well-marked signs of bronchitis are somewhat rare. Broncho- 
 pneumonia (often of the deglutition variety) occurred in 7 per cent., and in 
 1 fatal case the Eberth bacillus was found in the inflamed lobules. Conges- 
 tion of the bases is usual in prolonged cases, and would be even more common 
 if children did not voluntarily change position far oftener than do adults. 
 Frank pneumonia is extremely rare, although typhoid patients are by no 
 
TYPHOID FEVER. 199 
 
 means proof against other infections. Ulceration of the vocal cords and 
 necrosis of the laryngeal cartilages, with resulting stenosis, have been observed. 
 The ordinary forms of sore throat are common enough, and diphtheria can be 
 readily contracted during the course of enteric fever. 
 
 Digestive System. — The lips are dry and apt to crack if the child is 
 allowed to pick at them. Herpetic eruptions are not common. The gums 
 may be soft and swollen. The brown tongue so often observed in adults is 
 seldom seen. The organ may be dry and red, but soreness is seldom present. 
 The bowels are usually constipated at first, and diarrhoea is apt to come, if at 
 all, during the second week. There may be seven or eight discharges in 
 twenty-four hours, which mayor may not be of the familiar "pea-soup" 
 variety. This condition usually subsides rather slowly under appropriate 
 treatment, but is apt to recur. Involuntary discharges are rare excepting in 
 very young children. Abdominal pain on pressure increases during the 
 second week. Intestinal hemorrhage (as would be naturally expected from 
 the rarity of deep ulceration) is seldom observed. It was noted in 4 per cent, 
 of the 100 cases mentioned. In 2 of these it consisted of small quantities of 
 blood passed with each evacuation for several days, and both recovered. In 
 1 instance it was slight, but the case was one of intense typhoid infection, with 
 many lesions of the internal organs, and the bleeding caused death from ex- 
 haustion. An autopsy failed to reveal the vessel from which the blood had 
 escaped, in spite of a very careful and prolonged search. In the fourth case 
 two profuse haemorrhages, which occurred within twenty-four hours, were 
 speedily followed by perforation, peritonitis, and death. Perforation (said 
 to be more common than haemorrhage) is rare. Professor d'Espine (of Geneva) 
 has seen but one case. It is apt to occur, if at all, at a late stage of the dis- 
 ease, and has been observed in one instance five weeks after the beginning 
 of convalescence. Peritonitis without perforation has been observed by J. C. 
 Wilson, J. Simon (of Paris), and other leading authorities, but is extremely 
 rare. Usually it is the direct result of perforation, and if the rupture takes 
 place at a point which is in contact with a solid viscus or a coil of intestine, 
 the peritonitis may be limited and recovery follow^. Otherwise the contents 
 of the alimentary canal escape, and speedily cause acute general inflammation 
 of the peritoneum (accompanied by pallor, clammy sweats, abdominal disten- 
 tion, small and frequent pulse), which proves quickly fatal. Enlargement 
 and suppuration of the parotid gland have been observed by various author- 
 ities. 
 
 The Skin. — Rose spots, if present, usually make their appearance within 
 a week after the disease is fairly established. As a rule, they are not so 
 well marked in children as in adults, and are less common and numerous in 
 America than in Europe, where an abundant eruption is regarded as a good 
 omen. Ashby and Wright state that they are absent in only 25 per cent, 
 of all (English) cases. I find them noted in 53 per cent, on the (average) 
 twelfth day after the first appearance of any symptoms of the disease. In rare 
 instances they are seen during a relapse, when careful daily investigation has 
 failed to discover them during the original attack. Furunculosis may occur 
 at a late stage or during convalescence. Sudamina and eruptions resembling 
 rose spots, but failing to disappear under pressure, are common — more par- 
 ticularly the latter. The nails become fissured transversely from temporary 
 cessation of growth. Wilson mentions a faint diffuse erythema of the legs 
 during the first week. Acute otitis media w T ith perforation (unless relieved 
 by incision) occurs in a certain percentage of cases, and this may or may not 
 influence the range of the temperature. In 40 cases which entered my wards 
 
200 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 during the fall of 1896, it was observed 5 times. Bed-sores are easily avoided, 
 except in the severest cases. 
 
 The Spleen. — It is probable that the spleen is enlarged to some extent 
 in all cases at some period of the disease, although this cannot always be 
 demonstrated by percussion or palpation. The fact that this organ has been 
 found to be of normal size in a few cases which have been autopsied is no 
 proof that it had not been enlarged during the acute stage of the fever. To 
 palpate the spleen the child is made to lie upon its right side, with the knees 
 flexed and drawn up, and the fingers are gently but firmly pushed upward 
 under the false ribs ; then, if the patient can be induced to take a deep breath, 
 the lower edge can often be felt. Percussion of the organ, unless the results 
 are corroborated by palpation, is not satisfactory. In 40 recent cases at the 
 Children's Hospital the spleen was palpable in 23. The enlargement 
 usually disappears very soon after the temperature becomes normal. If 
 it remains, relapse may be expected. Splenic enlargement is of course 
 not peculiar to enteric fever, but may be present in any infectious disease. 
 Bartholow cites a case of rupture of the organ from slight violence, and the 
 fact that at autopsies it has been sometimes found to be a mere bag of pulp 
 shows the possibility of such an accident being caused by too vigorous efforts 
 to detect t a symptom which is rarely essential to enable one to distinguish 
 typhoid fever from other diseases. Hepatic enlargement is very seldom of 
 sufficient extent to be noteworthy. 
 
 The Urine. — Ehrlich's diazo reaction, a description of which is hardly 
 needed here, has been found present in 136 of 196 cases of enteric fever 
 (Osier). Its diagnostic value is much impaired by the fact that it is not 
 infrequently seen in other acute febrile affections. In 50 selected cases 
 Dr. J. Bergen Ogden of Boston found that the reaction was present between 
 the (average) fourteenth and twentieth days of the disease, and remained so 
 for from six to eight days. 
 
 Nervous System. — Complete indifference to surroundings is the rule, and 
 delirium, if present, is usually of a mild and harmless type. Occasionally a 
 child will try to get out of bed, and is somewhat difficult to manage, and 
 mechanical restraint is required in rare instances. Mild delirium, associated 
 perhaps with night-terrors, is not at all unusual, and is easily controlled by 
 appropriate means. Trembling of the hands and twitching of the facial 
 muscles are rare. I have seen this in the form of a one-sided affection, and 
 the movements resembled those of chorea. Retention of urine is less com- 
 mon than in adults. Hyperesthesia of the lower extremities and pain in the 
 feet and ankles are sometimes observed, but any marked degree of peripheral 
 neuritis is extremely rare ; and the same may be said of cerebral meningitis. 
 Ominous brain-symptoms (active delirium, intense cephalalgia, strabismus, 
 vomiting, and retraction of the head) have been known to disappear in a few 
 days. Mental disturbances (delusions, melancholia, etc.), which appear in 
 exceptional cases during the course of enteric fever, sometimes continue long 
 after convalescence has been established, but they tend to disappear as the 
 child's strength becomes restored, and seldom last more than a few weeks. 
 Transitory aphasia and hemiplegia have been noted at a late period of the 
 disease. It may be said, in a general way, that all nervous symptoms occur- 
 ring during typhoid in children are likely to disappear in time. 
 
 The Heart and Pulse. — Slight myocarditis with a feeble apex-beat and 
 softened first sound, accompanied by a feeble and perhaps dicrotic pulse, 
 are common. In severe cases the pulse intermits or becomes irregular, and 
 in those in which the condition of the heart is the direct cause of death the 
 
TYPHOID FEVER. 
 
 201 
 
 sounds niay assume a foetal rhythm, which precedes a fatal termination for a 
 dav or two only. The average rate of the pulse is from 120 to 150, and its 
 curve quite closely follows that of the temperature on the chart. A slow 
 pulse with a high temperature is occasionally observed for a day or two, but 
 the reverse is extremely rare. In 3 of the cases which I have mentioned a 
 pulse of 180 was recorded, and 2 of them proved fatal. Endocarditis and 
 pericarditis are seldom seen. 
 
 Temperature. — It is said that the temperature during the initial stage 
 lacks the characteristics which are of such essential aid to the diagnosis of 
 
 Fig. 1. 
 
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 Showing temperature of initial stage. (Boy aged 5 years.) 
 
 enteric fever in adults, but an instance in which an accurate record of the 
 temperature was kept for several days before the diagnosis was made does 
 not confirm this statement. As may be seen by reference to Fig. 1, the tem- 
 perature rose steadily and reached 102° F. in forty-eight hours, when morn- 
 ing remissions promptly occurred, while the evening temperature continued 
 to mount higher. The remissions average about 1.5° F. after the disease is 
 
 Fig. 2. 
 
 ™«a« 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 
 
 DISEASE ,^ 
 
 
 
 
 
 
 
 Z ^ A Alt 
 
 o° afcjl . , 
 
 10 o rjTf^Lh J 
 
 
 Z tr^f^^A^ 
 
 98° — 
 
 U lJ — 1 1 — 1 1 
 
 Showing marked morning remissions during the last days of a short case, also slight recrudescence of 
 
 fever. (Boy aged 6 years.) 
 
 fairly established, and may be counted on with a considerable degree of cer- 
 tainty. During the few days preceding convalescence they often cover from 
 2° to 3° F., this corresponding (to a degree which the comparative insig- 
 nificance of the intestinal lesions would lead one to expect) to the second 
 stadium as seen in adults. During this short stage of marked remissions the 
 morning temperature may be normal for two or three days before convales- 
 
202 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 cence is attained, as shown in Figs. 2 and 3. Lysis is the general rule, 
 but occasionally the termination is somewhat abrupt, as it is apt to be in the 
 abortive cases of adults. The average highest temperature observed in 100 
 cases at the Children's Hospital was 104.5° F., and this was noted on the 
 (average) twelfth day from the first appearance of symptoms. The extremes 
 
 Fig. 3. 
 
 DAYS OF 
 MONTH 
 
 26 
 
 27 
 
 28 
 
 29 
 
 30 
 
 31 
 
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 5 
 
 6 
 
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 DAYS OF 
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 Showing morning remissions a few days before convalescence. (Boy aged 12 years.) 
 
 were 101° and 107.8° F., the latter case recovering. In 5 of 7 fatal cases a, 
 temperature of 105° F. or more was reached. 
 
 As regards the duration of the fever, a normal morning temperature was 
 observed on the (average) twenty-fourth day, and a normal evening tempera- 
 ture on the (average) twenty-ninth day after the first appearance of symp- 
 toms. This of course applies to pyrexia as a symptom per se, and not to the 
 child's general condition, convalescence being not infrequently well under- 
 way before an absolutely normal temperature could be recorded. A fall of 
 temperature accompanies any considerable haemorrhage. Fig. 4 shows the 
 descent attending two evacuations of coffee-colored blood (at least eight ounces 
 
 Fig. 4. 
 
 
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 Showing sudden fall of temperature after each haemorrhage. (Boy aged 10 years.) 
 
 each time) occurring on successive days. In one instance a sudden depres- 
 sion (6.8° F.) from no apparent cause was noted, and slow recovery followed. 
 Examination of a number of four-hour charts of cases in which neither anti- 
 pyretics nor cold baths were used shows that during the acute stage the 
 lowest temperature is recorded at 8 a. m., and the highest from twelve to 
 
TYPHOID FEVER. 
 
 203 
 
 fourteen hours later. A slight remission occurs after midday and midnight 
 Fig. 5 shows the tempera- 
 ture, pulse, and respiration 
 of a case of double relapse, 
 together with the number of 
 evacuations daily, the patient 
 eventually recovering. 
 
 Diagnosis. — It is usually 
 a sufficiently easy matter to 
 recognize enteric fever in a 
 child when the disease has 
 become fairly established, 
 but during the first four or 
 five days, in the absence of 
 other cases in the neighbor- 
 hood, it is frequently impos- 
 sible. The symptoms may 
 correspond to those caused 
 by digestive troubles, or by 
 some fancied exposure to 
 u taking cold," or by ephem- 
 eral fever due to an unknown 
 cause. In hospitals the pa- 
 tient is seldom seen until 
 there is good evidence of 
 serious illness. The diseases 
 with which typhoid is most 
 likely to be confounded are 
 — tuberculous or epidemic 
 meningitis, acute miliary 
 tuberculosis without brain- 
 symptoms, frank pneumonia, 
 and malaria. Tuberculous 
 meningitis is liable to oc- 
 cur in hospital patients 
 under constant observation 
 for disease of the hip or 
 spine, and the records of 
 cases of this kind show that 
 night-cries, a well-marked 
 tache cerebrale, and in- 
 equality of the pupils (aside 
 from the peculiarities of 
 pulse and temperature) are 
 the earliest signs which are 
 of essential aid in making 
 a differential diagnosis. Ep- 
 istaxisand bronchial catarrh 
 are of diagnostic value in 
 favor of typhoid, while 
 vomiting and headache are 
 more persistent in tuber- 
 culous meningitis. The temperature of an established case of enteric 
 
 Fig. 5. 
 
 
 3 
 
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 Showing respiration, pulse, and temperature of a ease with double 
 relapse. (Boy aged 8 years.) 
 
 fever 
 
204 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 differs from that of a beginning tuberculous meningitis, which is very irreg- 
 ular and seldom reaches 104° F. until unmistakable signs of brain-trouble are 
 present. A very quick pulse with a low temperature is common enough in 
 tuberculous meningitis, but rare in typhoid, in which disease the pulse follows 
 quite closely the temperature-curve on the charts. Irregularity of the respi- 
 ratory rhythm is sometimes observed in tuberculous meningitis. In any event, 
 a tapping of the spinal arachnoid or an examination of the blood (to be spoken 
 of later on) soon clears up cases which may remain doubtful in the absence 
 of other well-marked diagnostic signs. 
 
 The onset of well-marked cerebro-spinal fever is sudden, and accompanied 
 by intense cephalalgia, dilated or contracted pupils, which fail to respond to 
 light, and retraction of the head and neck — symptoms rarely present in the 
 typhoid of children, and almost never in the early stage of the disease. As 
 a matter of fact, one is much more apt to mistake a " cerebral " frank pneu- 
 monia for cerebro-spinal meningitis than the latter for an enteric fever. 
 
 In acute general tuberculous infection the abdomen is usually flat, the 
 temperature irregular, while the family history of the patient and the pres- 
 ence of enlarged superficial glands may aid in diagnosis. Bronchial catarrh 
 is common to both miliary tuberculosis and typhoid, and, so far as the spleen 
 is concerned, a considerable enlargement may be present in either. Rose 
 spots, epistaxis, and splenic enlargement may all be absent in enteric fever, 
 and the resemblance to general tuberculosis may be so close that only an 
 examination of the blood can conclusively settle the question. 
 
 Malaria in children is very apt to be accompanied by quotidian (double 
 tertian) paroxysms, which may cause it to be confounded with typhoid. But 
 the absence of rose spots and abdominal tenderness, together with the effect 
 of one fair-sized dose of quinine (administered immediately after a paroxysm), 
 quickly decides a question which is otherwise easily answered by an exami- 
 nation of the blood. 
 
 Frank pneumonia may closely resemble enteric fever when the physical 
 signs of consolidation fail (as they sometimes do) to develop for several days. 
 The temperature of the two diseases is very similar (barring the usual irregu- 
 larity of the morning remissions in pneumonia) ; abdominal pain is common 
 in either ; and in the absence of rose spots, abdominal tenderness, and en- 
 largement of the spleen, Widal's blood-test may be required to enable one to 
 reach a conclusion. 
 
 " Cerebral" pneumonia, as I have before remarked, is more likely to be 
 confounded with epidemic meningitis than with typhoid; but apex-pneu- 
 monia may come and go with few if any signs pointing to pulmonary trouble. 
 The evidence obtained by listening to the chest may be very indefinite — a 
 mere suggestion of bronchial respiration and dulness, which vanish rapidly 
 and require frequent examinations to detect. 
 
 Grippe is distinguished by a degree of prostration disproportionate to the 
 other symptoms, the absence of the characteristic temperature of enteric 
 fever, and the fact of its being epidemic. Very young children suffering 
 with grippe are apt to be extremely irritable — a mental condition which con- 
 trasts strongly with the apathy usual in typhoid. In the early stage of 
 either disease there may be fever, delirium, bronchial catarrh, muscular 
 pains, and diarrhoea, while later on the absence of rose spots, enlargement of 
 the spleen, and abdominal tenderness may render the differential diagnosis 
 extremely difficult. 
 
 In all doubtful cases evidence which seems to be almost always reliable 
 can be obtained by means of the test discovered and perfected by Pfeiffer, 
 
TYPHOID FEVER. 205 
 
 Gruber. Durham, and Widal. This consists in adding one part of blood-serum 
 from a suspected case to ten parts of a bouillon culture of typhoid bacilli. If 
 the culture is fresh and the serum that of a person having enteric fever, a cha- 
 racteristic reaction takes place, Avhich may be briefly described as a gradual 
 loss of motility on the part of the bacilli after their aggregation into groups. 
 This same reaction can be obtained from the milk of nursing women who may 
 happen to have typhoid, and occasionally from the urine ; but the latter is not 
 reliable, as the same phenomena may be produced by the urine of healthy per- 
 sons. The reaction can also be obtained with dry blood, a drop of which upon 
 a folded piece of sterilized non-absorbent paper is examined " by moistening 
 with a drop of sterilized water, mixing the solution with a drop of the bouillon 
 culture, and examining the mixture as a hanging-drop preparation under a dry 
 lens of medium power." l It is claimed that this method is less likely to give 
 rise to confusion than the one in which serum is employed, unless the exami- 
 nation be made without delay. 
 
 The great convenience of the dried-blood test, as compared with that in 
 which fresh serum must be used, makes it a subject for congratulation that 
 its reliability has been established by Drs. Johnston and McTaggart. As a 
 'rule, they have found the reaction well marked and prompt after the fifth 
 day of the disease. Samples of blood kept dry in the ordinary air and tem- 
 perature of the laboratory for sixty days still gave a good reaction. 
 
 Prognosis. — The combined statistics of Baginsky, Steflen, Montmollin, 
 Henoch, and Wolfberg give an average mortality of 7 per cent. Comby 
 states that it is between 6 and 7 per cent. It is my impression that it is 
 about the same in America as in Europe. At the Boston Children's Hos- 
 pital it has been nearly 7 per cent. The above figures, taken in the main 
 from results obtained in hospital practice, cannot accurately represent the 
 mortality of all cases, many of which are so light as to pass unrecognized, 
 and a certain proportion of which occur among children of the well-to-do, 
 who are treated in their homes and whose previous nourishment and sanitary 
 environment have been good. Perhaps 4 per cent, is a fairer estimate of 
 the proportion of fatal cases. Special symptoms which point to a fatal 
 termination are — pneumonia involving any considerable extent of lung, 
 tuberculosis, previous poor health, intense pyrexia, marked weakness and 
 irregularity of the heart, parotitis, considerable haemorrhage, peritonitis from 
 perforation, and symptoms of cerebral complications lasting more than a week. 
 The intensity of infection must be considered, as well as the fact that a mild 
 attack may kill a tuberculous or syphilitic child. Copious and obstinate diar- 
 rhoea and prolonged vomiting are unfavorable signs. 
 
 Treatment. — Adequate ventilation, liberal air-space, strict attention to 
 the comfort and cleanliness of the patient, and the steady maintenance of a 
 temperature of 65° to 70° F. are to be ensured. Children with typhoid 
 fever have no appetite, as a rule, for solid food > but they are (fortunately) 
 thirsty, and take cold milk with relish. Three- or four-ounce portions of 
 milk (less to very young children) should be given every three hours. In 
 this way a child five years old will take from eighteen to thirty ounces in 
 twenty-four hours, and older ones in proportion up to two quarts, which is 
 apparently the limit of their capacity. Should nausea or vomiting interfere, 
 the milk should be diluted with Celestins Vichy, or lime-water, and given in 
 very small but frequently repeated portions. As a rule, the stomach yields to 
 this simple treatment within forty-eight hours, but if these measures do not 
 
 1 Drs. "VVyatt Johnston and D. D. McTaggart of Montreal, in the American Medico-Suroical 
 Bulletin, Jan. 10, 1897. 
 
206 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 suffice, it is best to withdraw the milk and substitute teaspoonful doses of egg 
 albumin-water with a few drops of brandy. In cases of considerable severity, 
 where there are signs of prostration, brandy should always be used. A teaspoon- 
 ful ter in die is often enough to regulate a weak pulse and contributes greatly 
 to the child's comfort, but there should be no delay in increasing the amount 
 if the patient fails to respond to this very moderate stimulation. In looking 
 over the records of the Children's Hospital, I find but one case in which so 
 much as three ounces was given for any length of time — this in the middle 
 of a second relapse, from which the patient (a puny child five years old) com- 
 pletely recovered. There are but few children that will not derive benefit 
 from moderate stimulation at some period of an attack of enteric fever. Cold 
 water is often craved, and may be given quite freely if the amount of milk 
 taken besides is sufficient to nourish the patient. During the acute stage the 
 diet should be restricted to milk only, any change being liable to produce 
 gastric or intestinal disturbance. When the temperature shows that lysis has 
 begun, or when sharp morning remissions, together with the child's brighter 
 aspect, signal the speedy advent of convalescence, some form of predigested 
 starch and somatose may be safely given. The possibility of relapse must 
 be borne in mind, and, whether the improvement is followed by uninterrupted 
 recovery or merely precedes by a few days the occurrence of reinfection, an 
 increase of nourishment is plainly indicated. After convalescence (which is 
 tedious in the mildest cases) is fairly under way, the ravenous appetite may 
 be satisfied with no untoward results, unless a slight recrudescence of fever 
 (not a relapse) gives warning that the digestive poivers are being overtaxed. 
 
 The Brand method, so far as I have been able to ascertain, has never been 
 systematically employed in any large number of cases in children ; but the 
 marked reduction in the mortality of the disease attending this treatment in 
 adults certainly warrants its thorough trial in cases where a sufficient number 
 of competent attendants can be had to ensure its being properly carried out 
 —a condition by no means easy to fulfil. 
 
 In the first stage, if constipation is present, calomel can safely be given, 
 both as a purge and an intestinal disinfectant. Less than a grain (given in 
 triturates of gr. ^ every hour) is usually enough to produce one or two free 
 evacuations. If diarrhoea is present w T hen the patient has been ill but a short 
 time, calomel may still be used in the same way before employing drugs to 
 check the trouble. Of all intestinal antiseptics for continuous use (and the diar- 
 rhoea of enteric fever yields but slowly to treatment, as a rule), salicylate of 
 bismuth gives as satisfactory results, perhaps, as any. Given in five- or ten- 
 grain doses, ter in die (and an additional dose during the night if the trouble 
 persists and disturbs the child's sleep), it usually modifies the number and 
 character of the evacuations in a few days, and, should the same condition 
 recur (as it often will), there is no apparent advantage gained by changing 
 the treatment, so far as I have observed. Cool bathing will reduce a high 
 temperature, but the relief thus obtained is slight (a descent of 1-2° F.), 
 and so temporary as to hardly compensate for the trouble involved. Lacto- 
 phenin and pepsol (gr. 3-8) in divided doses are very effective antipyretics, 
 and perfectly safe unless there is some obvious contraindication to their use. 
 The former is not quite so effective as the latter, which will cause an average 
 reduction of 4° F. three hours after its administration. Quiet sleep may 
 often be obtained in this way where the temperature is high, and no harm 
 result, as far as I have been able to observe, from employing either drug in 
 suitable cases. If insomnia is a marked feature of a case in which the con- 
 dition of the patient does not warrant the exhibition of antipyretics, trional 
 
 
TYPHOID FEVER. 207 
 
 in five-grain doses is indicated. Very moderate doses (Tfl.ij-v) of digitalis are 
 most effective in regulating a weak or irregular pulse when brandy fails to 
 accomplish the purpose. 
 
 In ordinary cases the drugs that I have mentioned will fulfil all the 
 usual indications for interference with the natural course of a disease which, 
 fortunately, tends to recovery. Haemorrhage, perforation, organic brain- 
 trouble, and the overwhelming intensity of the infection, as seen in typhoid 
 fever of adults, are rare in children, and hence the treatment is comparatively 
 simple. Haemorrhage is the most frequent complication that demands imme- 
 diate and active treatment, and in case of any considerable bleeding the foot 
 of the bed should be raised, ice-bags applied to the abdomen, and astringent 
 remedies (gallic acid or a combination of lead and opium) given, together with 
 ergotin by hypodermatic injection. Perforation, if in a position to cause 
 general peritonitis, is speedily fatal without surgical aid, which should be 
 instantly obtained, and the results of which are thus far very encouraging, 
 as shown by the statistics of Drs. W. W. Keen and Thompson S. Westcott 
 of Philadelphia — 83 operations with 19.36 per cent, of recoveries. Five of 
 the cases operated upon were children, two of whom were saved. 1 
 
 Bed-sores are easily avoided by strict attention to keeping the child dry 
 and clean. Sordes are prevented by a little care on the part of the attend- 
 ants. Acute active delirium is rare, but forcible restraint is occasionally 
 required to prevent a child from getting out of bed. Mental disturbances, 
 which persist after convalescence is reached, almost invariably disappear 
 without special advice or treatment. Ominous symptoms of cerebral trouble 
 occurring during the acute stage often vanish so quickly as to preclude the 
 possibility of their being due to organic lesions. I have the notes of a case 
 in which a convergent strabismus, delirium, somnolence, and a tdehe cMbrale 
 disappeared twenty-four hours after they were noted. The application of 
 ice-bags to the head and an increase of stimulation are usually indicated 
 when nervous symptoms predominate. 
 
 Prophylaxis. — All soiled diapers and sheets are to be at once removed 
 and allowed to soak for six hours in a 1 : 40 solution of carbolic acid, and 
 then boiled and washed in vessels devoted especially to this purpose. The 
 nates must be carefully wiped with cloths dampened with a 1 : 40 solution. 
 These should be burned or treated in the same manner as the diapers after 
 being once used. Discharges which are received in bed-pans are to be cov- 
 ered with a 1 : 20 solution of carbolic acid or with thin whitewash, and, 
 after any solid fragments have been thoroughly broken up, should be allowed 
 to stand twenty minutes before being emptied into the hopper, which must be 
 kept scrupulously clean. Rubber covers should be provided for the bed, and 
 washed off with the 1 : 40 carbolic solution. Cups, glasses, spoons, and feed- 
 ing utensils of every description should be washed in a carbolic solution after 
 use, and subsequently boiled. The attendants ought to refrain from eating 
 or drinking when in the patient's immediate vicinity, and should wash their 
 hands and use a nail-brush frequently. All clothing and linen which comes 
 in contact with the child's person should be disinfected, and washed apart 
 from the belongings of other members of the household. A bichloride solu- 
 tion of 1 : 1000 may be substituted for the carbolic acid in the receptacles for 
 linen and other articles previous to their being boiled and washed. The con- 
 stant odor of carbolic acid in a private house is unpleasant, and is at times 
 (for obvious reasons) impolitic. 
 
 1 These statistics are included in a monograph on the " Surgical Complications and Sequels 
 of Typhoid Fever," by W. W. Keen, M. D. 
 
EPIDEMIC CEREBROSPINAL MENINGITIS. 
 
 BY ROLAND G. CURTIN, M. D., 
 
 Philadelphia. 
 
 Synonyms. — Epidemic meningitis; Fever with cerebro-spinal meningitis; 
 Meningeal fever ; Petechial fever ; Malignant purpuric fever ; Spotted fever ; 
 Cold plague. 
 
 Definition. — Epidemic cerebro-spinal meningitis is a specific infectious fever 
 (probably of microbic origin) in which the poison seems to have a special pre- 
 dilection for the meninges of the brain and spinal cord. It attacks the young 
 with greater frequency than any of the fevers outside of those belonging espe- 
 cially to childhood, and with more severity than any of the continued fevers. 
 The onset is abrupt (without prodromes). The prominent symptoms are chill, 
 more or less marked ; vomiting ; headache ; delirium, generally present in the 
 first and second day, later stupor and coma; pains, muscular and neuralgic, in 
 trunk and limbs ; stiffness or contraction of the muscles of the neck, rarely lower 
 down the back — all of which symptoms indicate inflammation of the meninges 
 of brain and spinal cord. Recovery may be quite rapid, when the disease 
 is of short duration and the nervous system is not seriously affected. In 
 most cases, however, recovery is exceedingly slow. Death is common among 
 children, especially in severe epidemics. The immediate causes of death are 
 convulsions, kidney complications, exhaustion, bed-sores, and abscesses or 
 gangrene. 
 
 If epidemic cerebro-spinal fever occurred prior to the commencement of 
 the present century, it was not recognized as a distinct disease. It was first 
 discovered in Geneva. In America the first reported cases occurred in Med- 
 field, Mass., in 1806, and since that time it has occurred in frequent epi- 
 demics in different parts of North America, and in fact it is reported as an 
 irregular epidemic visitor in all parts of the world. A sporadic form of cerebro- 
 spinal fever is recorded yearly in the mortality statistics of all the larger cities 
 of the United States : in studying the death-reports it must be acknowledged 
 and remembered that some physicians call simple acute meningitis and other 
 meningeal forms of disease, especially the continued fevers and tubercular 
 meningitis, by the name of cerebro-spinal fever. 
 
 Etiology. — The specific cause has not been positively determined. There 
 are physicians who have announced the discovery of a microbe similar in appear- 
 ance to the pneumococcus, but it has not been satisfactorily proved that this is 
 the specific causative germ. However, it is generally conceded that the dis- 
 ease is of microbic origin. 
 
 In a New York medical society meeting recently a physician stated that he 
 had made autopsies upon 3 cases of so-called sporadic cerebro-spinal fever, and 
 found specific germs of other diseases, all different. One had the typhoid fever 
 germ without intestinal evidence of the disease. I am of the opinion that 
 
 208 
 
EPIDEMIC CEREBROSPINAL MENINGITIS. 209 
 
 when we perfect our bacteriological knowledge all these sporadic cases will be 
 found to be due to infection of the brain and spinal cord by germs that usually 
 affect other tissues. 
 
 Epidemic cerebro-spinal meningitis is an infectious disease, and it is ques- 
 tionable whether it is contagious or not. Widely-separated districts are simul- 
 taneously visited by epidemics, and over extended districts isolated individuals 
 are attacked at the same time ; so that the idea of its being transmitted by 
 direct contact in these cases is untenable. Owing to the fact that this disease 
 has followed epidemics of influenza, and on account of the many points of sim- 
 ilarity in the two affections, Drs. Job Wilson and J. J. Levick have been led 
 to suppose that there is some connection between the two diseases. It is more 
 common in the winter and spring than in the summer months ; hence the name 
 "cold plague" has been given to it. Slight injuries, especially to the head, 
 fatigue, exposure to cold, and mental depression are exciting causes. 
 
 Pathology. — In the early or congestive stage nothing is found in the brain 
 and spinal cord except a congested condition of the meninges; the blood-ves- 
 sels are enlarged and gorged with blood of a dark color ; later, after exudation 
 has taken place, the serous plastic exudate is found, especially upon the pia 
 mater. In some malignant cases the exudation is found to be sero-purulent. 
 The lungs are observed to be in a state of hypostatic congestion : where lung 
 complications have preceded death w T e find evidences of croupous or catarrhal 
 pneumonia, and not infrequently inflammation of the pleura and pericardium. 
 Parenchymatous inflammation of the liver has been noted by some writers. 
 Congestion and sometimes an inflammatory condition of the kidney are found. 
 The heart is flabby, and the blood in malignant cases is frequently observed 
 in a fluid condition. The dusky spots or mottling that are occasionally encoun- 
 tered in malignant cases may be found in all the internal organs as well as on 
 the skin. 
 
 Symptoms. — The first symptom generally noticed is a chill, which may 
 be a slight creep or a profound rigor ; this usually comes on without any warn- 
 ing, and generally in the later part of the day ; it sometimes follows fatigue or 
 perhaps exposure to cold, and occasionally follows injuries to the head. Some 
 cases are stricken down suddenly, as if by a blow, without any previous warn- 
 ing. Headache is one of the most constant symptoms ; it is not always an 
 indication of the gravity of the disease. The pain is almost always frontal, 
 generally located between the eyes, and quite often spoken of as bitemporal ; 
 it is not infrequently located in the occipital region. It is sometimes excru- 
 ciating, causing the patient to cry out and toss about; at other times it is a 
 dull, heavy ache. It is sometimes intermittent, at others constant ; it may be 
 fixed or lancinating. The pain in the head seems to be the cause of one of the 
 prominent facial symptoms — viz. knitting of the eyebrows. An attack may be 
 ushered in by a convulsion, or by a sudden giddiness, causing the patient to 
 have a staggering gait; this giddiness may only be present while the patient is 
 sitting or standing, or may continue after assuming a recumbent position. This 
 symptom is sometimes complained of throughout the disease. 
 
 Delirium is rarely absent ; it is more apt to be noticed early in the case, 
 extending through the stage of congestion and sometimes through the whole of 
 the inflammatory stage ; it is exceedingly variable ; it may be wild excitement, 
 terrorizing, playful, or sombre. The child may continually mutter or now and 
 then cry out. Delirium is especially common in children, and may indicate 
 the gravity of the disease. Coma almost invariably precedes death, and is 
 always to be considered a grave feature ; coma vigil is a serious ataxic symp- 
 tom, in which the patient lies on his back, chin raised, eyelids widely separated, 
 
 14 
 
210 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 apparently regarding fixedly some object above the head of his bed, and is 
 accompanied by constant jactitation. 
 
 The headache, as before stated, often gives the appearance of great suffer- 
 ing, the brows being knit, especially when the patient is aroused ; the cheeks 
 are often flushed early in the disease, but not always so ; later the face is fre- 
 quently pale. In some rare cases the flush is not to be seen at any stage of 
 the disease. In some patients the features are swollen and of a dull, dusky, 
 purplish hue. Strabismus is more frequent in children than in adults. 
 
 Spinal pains are quite common, the pain being in the back of the neck, some- 
 times extending down to the lower end of the spine. Pressure and movement 
 have the effect of increasing the suffering ; the limbs and trunk are sometimes 
 very painful ; the pain may be of neuralgic character, radiating from centre to 
 periphery, and may attack one set of nerves, and remain constant or change 
 to other nerve-trunks or groups. Local muscular pains and soreness are not 
 infrequently present. 
 
 Tonic spasms give rise to tetanoid symptoms, such as opisthotonos, pleuro- 
 sthotonos, emprosthotonos : the former is the most common, the head being 
 drawn back and the spine curved backward, so that the patient's body is some- 
 times supported by the occiput and heels. Forced movement increases the 
 spasm as well as the spinal pains. In many cases these muscular spasms are a 
 simple stiffness of muscles or groups of muscles. 
 
 Clonic spasms are frequently met with. Subsultus is one of the common 
 symptoms, sometimes amounting to a violent agitation ; more commonly it is 
 simply a twitching, and may be the forerunner of convulsions ; this symptom 
 is sometimes present before the inflammatory changes in the nervous system are 
 sufficiently developed to produce it ; hence the reasonable supposition that it is 
 a result of the irritation produced by the blood-poison. 
 
 Paralysis occurs as a result of a loss of nerve-power, which may be caused 
 either by central trouble or by inflammation of the trunk of the nerve supply- 
 ing the part. These paralyses are sometimes temporary, at other times long 
 continued or permanent. Sudden loss of hearing or sight usually comes on at 
 the time the effusion takes place. Strabismus is especially common in children, 
 and is often a precursor or an associate of convulsions. The conjunctivae are 
 quite frequently congested ; at other times this symptom is absent, especially in 
 the milder cases. In almost every case where there is kidney complication the 
 conjunctival congestion is associated with a purulent secretion, which then be- 
 comes quite diagnostic. The pupil varies greatly ; early in the disease it may 
 be found to be dilated or contracted, but it is generally dilated. In cases with 
 coma and convulsions it is almost invariably dilated. Photophobia is especially 
 common in children. 
 
 The effect of the blood-poison upon the kidneys is to produce a catarrhal 
 inflammation in these organs similar to the catarrhal troubles found in other 
 organs. 
 
 The respiratory apparatus is involved in the disease, and some of the fatal 
 complications are seated in the lungs. Respiration is exceedingly variable. 
 Early in the disease it is likely to be hurried, and at times, later on, it may be 
 exceedingly slow ; it is sometimes interrupted or jerking, and the Cheyne- 
 Stokes variety is not infrequently seen in the later stages of fatal cases. This 
 latter is not so grave a symptom in the case of children as in adults. In some 
 instances death occurs suddenly from paralysis of the muscles of respiration. 
 Pleurisy, pneumonia, and bronchitis are complications which may occur at any 
 time during the course of the disease. 
 
 In exceedingly malignant epidemics there is a dusky mottling of the skin 
 
EPIDEMIC CEREBROSPINAL MENINGITIS. 211 
 
 and the internal organs, the color being purplish ; whence the name of " spotted 
 fever" often applied to the disease. These spots (which are oval in shape) are 
 usually from one-third to one-half an inch in their longest diameter. I have 
 seen them on almost every tissue or organ, external and internal, of the body ; 
 after death they may be of a slate-color with a chocolate tinge, or quite black. 
 
 1 had an opportunity in 1864 of seeing 14 cases of epidemic cerebro-spinal fever, 
 4 of which died; 2 out of the 4 cases had these spots. In the Philadelphia 
 Hospital epidemic I saw over 200 cases : the mortality was 43 ; of the fatal cases, 
 
 2 had these mottlings ; one of them was the first case that occurred, and died 
 after fifteen hours' illness. About sixteen years ago I was called in consultation 
 to see two young girls near Point Breeze, Philadelphia; they both had these 
 mottlings ; one died in twenty-four, the other in thirty-six, hours. At the time 
 only one other suspected case had occurred in the neighborhood ; this also was 
 a malignant one. The two girls had visited the abode in which this patient died. 
 
 Aside from the mottlings, there is nothing else that seems characteristic of 
 this disease in connection with the skin. Cutis anserina, simple erythema, 
 rubeoloid eruption of a bright cherry-red color in sthenic cases (darker in the 
 adynamic), dermatitis, miliary eruptions, herpes, petechia, and ecchymoses, 
 have all been noticed. Hyperesthesia is one of the most characteristic symp- 
 toms ; the skin is sore to the slightest touch, and at times the pressure of 
 the bed-clothes is sufficient to produce great discomfort. Anaesthesia of the 
 skin has also been observed ; it may be a simple numbness, at other times a 
 positive insensibility. In some cases the skin is found to be very hot ; in others 
 it may be quite cool; and occasionally the patient is drenched in perspiration 
 even when the symptoms are not of a grave nature. 
 
 The temperature of cerebro-spinal fever is exceedingly varied, so that in a 
 group of cases in the same epidemic it is quite dissimilar. The local inflam- 
 mation causes changes which prevent anything like uniformity. In the explo- 
 sive form, the so-called fulminant variety, it may be below normal ; in all others 
 there is more or less elevation. In some instances, early in the disease, the 
 temperature is not very high, and in others it rises to a high elevation after 
 the chill. When the local inflammations occur it is generally higher. In chil- 
 dren at this stage it is usually from 100° to 101°. The diurnal variation is 
 less than in typhus or typhoid fever. A sudden fall or rise of temperature 
 almost invariably ushers in serious symptoms : in fatal cases it has been found 
 at the time of death to be as high as from 107° to 110°. 
 
 The pulse in cerebro-spinal fever in children is usually quite rapid ; in 
 adults at the second and third stages of the disease it may be abnormally slow. 
 The difference is owing to the modified nerve-influence which the disease is 
 prone to exert. 
 
 Complications. — Among the complications observed in this disease may 
 be mentioned pleurisy, pericarditis, endocarditis, parenchymatous degeneration 
 of the liver and kidneys, and intestinal catarrh. " (Edema, hypostatic conges- 
 tion of the lungs, bronchitis, atelectasis, and broncho-pneumonia are not 
 uncommon lesions in cerebro-spinal meningitis" (Welch). 
 
 Sequelae. — Parotitis ; gangrene ; furuncle ; abscesses ; muscular and mental 
 weakness ; epilepsy ; impaired nerve-power, sometimes amounting to paralysis ; 
 general or special persistent emaciation ; and, in children, effusion following the 
 inflammation of the membranes of the brain sometimes results in chronic hydro- 
 cephalus. Dr. Chas. K. Mills, in a paper read before the Philadelphia Neuro- 
 logical Society in March, 1888, called attention to the occurrence of multiple 
 neuritis as a complication of this disease, and also suggested that multiple neu- 
 ritis might be the only result of the same infection that causes the meningitis. 
 
212 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Diagnosis. — In the earlier stages, especially in children, it may be mis 
 taken for scarlet fever. This is true where there is a general erythema or der- 
 matitis. The existence of the epidemic influence of either disease or the pres- 
 ence or absence of severe throat symptoms will greatly assist in the diagnosis. 
 The redness of the skin coming on in epidemic cerebro-spinal fever generally 
 appears later than that of scarlet fever, in which it usually happens in the first 
 twenty-four hours. The eruption is quite transitory, and is not, as a rule, 
 followed by desquamation or itching. 
 
 The abrupt onset and the greater activity of the symptoms, the absence of 
 tubercular manifestations elsewhere, the rarity of eruptions and extreme mus- 
 cular contractions, the slow regular course, and the higher temperature would 
 distinguish epidemic cerebro-spinal fever from tubercular meningitis. The 
 absence of exciting causes, the extremely faint muscular spasms, and the sen- 
 sitiveness of the skin, all help in distinguishing it from simple or secondary 
 meningitis. 
 
 The muscular spasms and general and muscular pains usually distinguish 
 this disease from ordinary cases of pneumonia, typhus, and typhoid fever; but 
 in the meningeal forms of these diseases it is extremely difficult to make a 
 diagnosis, though the sudden onset with meningeal symptoms will greatly assist. 
 The earlier symptoms should be studied to find out whether there were evi- 
 dences of pneumonia or any other previous disease. Abdominal symptoms 
 occurring early might suggest typhoid fever. The eruption of typhus is the 
 distinguishing mark in that affection. Rigidity of the muscles, present in 
 cerebro-spinal fever, is absent in the preceding diseases. I have known mis- 
 taken diagnoses to be made in cases of small-pox in the earlier stages. 
 
 Prognosis. — This is always grave in children, more so than in adults. When 
 we take into consideration the extreme susceptibility of the nervous system of 
 a child, we can readily see how dangerous this disease is during the earlier 
 years of life. Prognosis in adults is a difficult task, for in simple cases sudden 
 grave complications sometimes present themselves later in the disease, and, on 
 the other hand, a case with the severest early symptoms may be followed by 
 speedy convalescence. It is a disease in which it is impossible to estimate the 
 complications which may arise. 
 
 Unfavorable signs are profound coma ; low typhoid symptoms ; uraemia ; 
 great blood dyscrasia, shown by marked ecchymosis ; continued convulsions 
 and prolonged high fever. Protracted cases are likely to be followed by fatal 
 exhaustion. 
 
 Treatment. — The types and lesions of the disease are so various that the 
 details of the treatment are exceedingly difficult to formulate to meet all cases. 
 
 The prophylactic treatment consists in careful attention to sanitation, as the 
 disease is invited by uncleanliness of person or surroundings ; the same is true of 
 over-crowding. Exposure to heat or cold, and fatigue, either bodily or mental, 
 are favorable to the onset of the disease. Children in a locality where the 
 affection is prevalent should be furnished with fresh, nourishing, and easily- 
 digested food ; they should be isolated from the sick, and should have plenty of 
 sleep and pure air. Clothing from about the sick should be destroyed or care- 
 fully disinfected. The weak, old, and nervous should be removed from infected 
 localities. 
 
 Almost every remedy in the medical category has been tried to abort this 
 disease : bloodletting has had its votaries, and others have highly extolled the 
 virtue of mercurials in the earlier stages ; emetics, again, have been recom- 
 mended, but all have largely been abandoned. The plan pursued by most 
 recent authorities is to treat the disease symptomatically. 
 
 
EPIDEMIC CEREBROSPINAL 3IENINGITIS. 213 
 
 In the first stage we have a congested condition of the meninges of the 
 brain and spinal cord : the indication is to aid in the reduction of the quan- 
 tity of the blood in the meningeal blood-vessels ; first, for the purpose of reliev- 
 ing the symptoms, and, secondly, to reduce the inflammation and modify the 
 inflammatory products. One of the difficulties of administering medicine by 
 the mouth is the common symptom of vomiting, which is sometimes very per- 
 sistent. Venesection should not be practised in children. Some of the German 
 writers use early local bloodletting by wet cups and leeches. Dry cups to draw 
 blood from the internal congested vessels without removing it from the body are 
 of great value. The external application of cold to the head by ice, ice-water 
 cloths, cold-water cloths, is useful, and some have used hot baths to the body, 
 hoping to draw blood from the centre to the periphery. Hot mustard foot- 
 baths can be used with advantage to relieve the pain in the head and back. 
 If the stomach should bear it, potassium bromide and ergot may be adminis- 
 tered ; if not, the former may be given by enema, the latter hypodermatically, 
 for the purpose of favorably influencing the capillary congestion. For the 
 pain in the muscles the antipyretics have been used ; phenacetin is probably the 
 safest and best of all. It should be used in small, frequently-repeated doses, 
 and its use should be discontinued if the patient becomes weak or exhausted. 
 A mustard plaster, one part mustard to three of flour, placed over the spine, 
 often relieves the pain in that location, and counter-irritation to the nape of the 
 neck diminishes the pain in the head and relieves the delirium. Care should 
 be taken not to raise a blister, which would seriously complicate the case. 
 Liniments over the same region — turpentine or chloroform — may be used for 
 similar purpose. Belladonna seems to afford relief to the neuralgic pains and 
 muscular spasms. Dr. J. M. DaCosta highly lauds the use of hyoscine hydro- 
 bromate for the muscular spasms in this disease. For insomnia early in a case 
 chloral may be cautiously used in conjunction with potassium bromide. Chloral 
 sometimes causes cerebral excitement, and when this occurs it should be dis- 
 continued. Opium has always been used with the happiest results. It has been 
 recorded that in some cases large doses of opium are tolerated. The salicylates 
 and gelsemium will allay the pains in the trunk and limbs, but will not relieve 
 the pain in the head. A dark, quiet room should be selected for the patient in 
 any stage ; this is of great importance where there is cerebral excitement. 
 
 In the second stage the exudate is thrown out ; it may be serous, plastic, or 
 even sero-purulent ; the blood-vessels are dilated and engorged. Absorptive 
 remedies are now to be used. Potassium iodide to produce absorption of the 
 exudate, and oil of turpentine internally have been used late in this stage for 
 the same purpose, with seeming good results. Arsenic and iron are of great 
 use during convalescence to improve the blood. Stimulants, especially for chil- 
 dren, should be used with great caution, as an excess will irritate the brain and 
 excite the circulation in either the first or second stage. Hypophosphites, espe- 
 cially with strychnine, are beneficial during convalescence. Cod-liver oil when 
 digested often produces the happiest results. In the later stages of convales- 
 cence massage is of great importance to stimulate the circulation in the mus- 
 cles and nerves. Electricity is indicated for paralysis or weakness of the nerve- 
 trunks. For the same purpose alternate hot and cold affusions to the weakened 
 parts, and exercise, carefully regulated as to time and amount, greatly assist in 
 strengthening the muscles and nerves. 
 
EPIDEMIC INFLUENZA. 
 
 By CHAS. WARRINGTON EARLE, M. D., 
 
 Chicago. 
 
 Influenza is a general infectious disease producing catarrhal difficulties of 
 either the respiratory or gastro-intestinal tract, or painful symptoms referable 
 to the nervous system. In addition to the symptoms thus indicated, it is 
 attended with prostration out of proportion to the apparent involvement of 
 the organs named, and is liable to be followed by sequelae which affect pro- 
 foundly the further usefulness and comfort of the unfortunate victim. This 
 disease has been recognized and described in our country for two hundred and 
 fifty years, the first epidemic occurring about 1647. Other epidemics have 
 taken place from time to time, and have been referred to by writers under dif- 
 ferent names ; but the disease, as it affects us particularly, and its history, as 
 we understand it at the present moment, have come to us in the three consecu- 
 tive epidemics of 1890, 1891, and 1892. At the time of writing (January, 1893) 
 only a few sporadic cases have taken place during this year, and they have not 
 been severe. We cannot yet speak of an epidemic of 1893. During the period 
 referred to, great attention has been given to the study of the disease by our 
 profession, and, in certain instances, by governmental authorities. 
 
 Etiology. — It has not been believed until recently that the causes of this 
 disease are really known. Certain hypothetical causes have been advanced, 
 such as air, contagion, local conditions, general influences, etc. But during 
 the last three or four years very close investigations in regard to its etiology 
 have been made. The reports of the British medical government clearly show 
 that the spread of the disease depends upon human intercourse, and that it 
 spreads no faster than human beings, parcels, or letters can travel. 
 
 Bacteriological investigations have been 'carried on with great accuracy 
 during this time. Filatow wrote fully concerning the history and symptoms 
 of the disease under consideration, and Seifert investigated the bacteriological 
 history three or four years ago ; but particular investigations have been carried 
 on during the past year in the Berlin Institute by Drs. Pfeiffer, Kitasato, and 
 Canon ; and Sternberg remarks that there is good reason to believe that the 
 bacillus discovered by these investigations is the specific cause of the disease. 
 The following resume from Dr. Sissley of London gives much regarding the 
 etiology of the scourge under discussion : 
 
 (1) The first case of influenza in a town is generally a patient who has 
 come from an isolated place. 
 
 (2) Isolated cases precede the epidemic. 
 
 (3) Influenza extends along the lines of human intercourse. 
 
 (4) Isolated persons, such as prisoners and inmates of asylums and con- 
 vents, often escape the disease. 
 
 (5) The number of those affected in an epidemic increases till a maximum 
 is reached, and then declines, as in the case of other contagious diseases. 
 
 214 
 
EPIDEMIC INFLUENZA. 215 
 
 There is no doubt that nursing children three or four months of age feel 
 the influence of la grippe. Dr. Townsend of Boston has placed on record a 
 case where the mother had an attack of influenza about the time of her con- 
 finement, and the child in a few hours after birth began to sneeze and had all 
 the symptoms of this infection ; and an English observer records the case of 
 an infant who died on the third day of its life from this disease. It is somewhat 
 difficult to diagnosticate influenza in very young infants, but it is fair to sup- 
 pose that, when the infection is present in the house and parents and nurses 
 are under its influence, if infants present unusual symptoms of fever, exhaus- 
 tion, and the involvement of one of the three systems which are usually select- 
 ed by this infection, the disease is due to the poison of influenza. 
 
 The exact point at w T hich the infection may gain entrance to the system has 
 probably not been ascertained. That it may enter through either the aliment- 
 ary canal or the lungs there is no doubt, and in all probability these are 
 usually the points of entrance. One observer believes that the conjunctiva 
 is in many instances the structure through which the poison attacks the system. 
 
 Influenza and Diphtheria. — The marked similarity between the remote 
 effects of the poisons of diphtheria and influenza is very great, and it is quite 
 possible that the pathological findings in influenza may be quite as numerous 
 and significant as we already know they are in diphtheria. We possibly do 
 not know the exact cause of influenza, but we are certainly warranted in 
 assuming that there is a most profound toxic effect in influenza as well as in 
 diphtheria. The depression is profound, the recovery slow and tedious, and 
 the involvement of the nervous system in both diseases is extremely signif- 
 icant. The action of these two poisons upon the heart is somewhat similar. 
 Every practitioner of experience has noticed the slowness of the pulse and its 
 irregularity, and in some instances death has occurred in such an unexpected 
 manner that we could attribute it to nothing less than degeneration of the 
 heart-muscle. 
 
 Pathology. — There are but few special post-mortem findings known to this 
 disease which are of value to us as relating to children. Nearly every study 
 has been based upon examinations made in adults, and the records of autopsies 
 made solely and particularly to find the results of influenza on the tissues of 
 the young are extremely meagre. Ashby and Wright state that " at the post- 
 mortem no grave lesion is found, but there is usually venous congestion and 
 marked injection of the venous capillaries ; " and Vargas of Barcelona, whose 
 opportunities for seeing many cases profoundly sick with influenza have 
 certainly been very great, after remarking that rapid deaths are usually due 
 to severe attacks affecting the nervous system, says that while w r e cannot state 
 that there is an apoplectic form, in some cases the post-mortem revealed the 
 venous plexus congested, and also cerebral haemorrhages. The same author 
 also asserts that in cases where the gastro-intestinal symptoms predominated 
 there was tumefaction of Peyer's glands and of the solitary follicles. 
 
 In 115 references to influenza found in the British Medical Journal of 
 1891 and 1892, not one speaks particularly of the pathology as it is found in 
 children. And in the works of Filatow and Uffelmann, both written in 1892, 
 absolutely nothing is said regarding this part of our subject. The special 
 effects of the poison of influenza upon the tissues of the young have yet to be 
 described. * 
 
 Incubation. — This may be only a few days, possibly only a few hours, 
 or, on the contrary, the influence of the poison may be felt for weeks before 
 the active development of the disease. Others who have studied the disease 
 believe that two or three days is the usual time of incubation. 
 
216 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Clinical History. — The disease affects more particularly one of three groups 
 of organs : First, the respiratory and circulatory apparatus ; second, the gastro- 
 intestinal canal; third, the nervous system. 
 
 Sometimes the infection localizes itself in the respiratory tract, spending its 
 energy there, and the patient will pass through a severe catarrhal bronchitis or a 
 pneumonia with such general prostration as to endanger his life ; or the disease 
 manifests itself as a catarrhal inflammation of the stomach and bowels, with a 
 tendency to collapse on account of the extreme weakness which is induced ; or, 
 closely following the severe headache, which indicates that the nervous system 
 is the" first to be attacked, have come threatened convulsions and meningitis. 
 We have these organs affected singly, or in some cases a Complication involv- 
 ing almost all of them, such as a bronchitis with gastro-intestinal disturbance, 
 or a gastro-intestinal disturbance with great nervous prostration. 
 
 The invasion is rapid, and the disease is frequently ushered in with a chill 
 followed by delirium and rapidity of pulse. The face in many cases is red from 
 the commencement of the disease, and there is earache, vomiting, and an 
 increase in temperature. The fever is not high in the majority of cases, but 
 occasionally an unusually high temperature is noticed. In a majority of cases, 
 at some time during the disease, the temperature is subnormal, varying from 
 one-half to two degrees below the standard of health. This condition of tem- 
 perature is undoubtedly a result of the action of the poison upon the general 
 nutrition, the imperfect action of the lungs which is present in many cases, 
 and the general depression of the vital forces. There is also loss of weight. 
 This has been particularly brought out by Hansen of Copenhagen, who con- 
 cludes that, while in some cases there is simply a standstill, in many there is 
 an absolute diminution in normal Aveight. It is fair to conclude that this 
 evidence of waste — in other words, work — represents the conflict between the 
 poison of influenza and its subjects. In some cases this diminution of weight 
 is noticed when there are no other signs of the disease present. And finally 
 there is a very pronounced general weakness never before experienced by the 
 patient, and in no one organ or system of organs is it more noticeable than in 
 the circulatory apparatus. The pulse is usually accelerated, sometimes very 
 rapid, and the heart, in many instances, never regains its strength and vigor. 
 
 Special Features. — Respiratory Symptoms. — A catarrh of the respiratory 
 organs takes place with great frequency, and in its various phases extends to 
 every part of this system. Sometimes the upper breathing apparatus is attacked 
 first, and the disease rapidly spreads and involves the rest. The eyes are usu- 
 ally red and suffused, and in many cases not only is the middle ear involved, 
 but disease of this organ remains as a sequel for a long time. A general catar- 
 rhal bronchitis is frequently present, and in some instances pneumonia with all 
 its characteristic symptoms. There is in many cases, early in the disease, an 
 apparent localization of the infection in one or both of the lungs, threatening a 
 pneumonia, but this usually clears up in a very short time, and the disease be- 
 comes diffused throughout both lungs. Very often there may be only a severe 
 and perplexing cough, without any physical signs. Respiration is sometimes slow, 
 and in a few cases breathing for a few seconds has absolutely stopped. These 
 peculiar paroxysms have been repeated several times during the day, and in a 
 few instances life has been preserved during these attacks only by artificial 
 respiration. Thoracic pains are sometimes intense, and call for the external 
 application of anodynes. 
 
 Circulatory Symptoms. — There is usually from the first a rapidity and 
 weakness of the heart, and syncopal attacks occur in many cases. Depression 
 in the action of this organ and failure in its supply of nerve-force seem entirely 
 
EPIDEMIC INFLUENZA. 217 
 
 out of proportion to all other symptoms. While in many cases the temperature 
 and pulse seem fair, there is an unusual muscular weakness and a tendency to 
 syncope. I have not noticed organic heart disease, but cyanosis has been 
 present in a few cases, and in many instances palpitation and short breathing 
 are not only noticed during the active history of the disease, but also inter- 
 minably follow its unfortunate victim. 
 
 G astro-intestinal Symptoms. — The tongue is frequently flabby and coated, 
 and shows indentations of the teeth, indicating malnutrition. The appetite 
 is often entirely absent, and persistent vomiting takes place in many cases. 
 Herpes labialis is sometimes noticed, as also sordes. Diarrhoea to such an 
 extent as to become exhausting is frequent; constipation is sometimes present. 
 In some cases the diarrhoea and vomiting are so frequent and persistent, and 
 the child becomes so rapidly collapsed, that if the case occurred in the summer 
 a diagnosis of cholera infantum would undoubtedly be suggested. As the 
 result of this great withdrawal of fluids from the body, the eyes and fontanelles 
 are greatly depressed, and the child becomes restless and rapidly goes into 
 collapse. 
 
 Nervous Symptoms. — Extreme irritability and fretfulness are found in 
 the majority of childish patients. Headache and joint and muscular pains are 
 frequent and sometimes intolerable. In many cases there are noticed an indif- 
 ference and a hebetude which closely simulate a typhoid condition. Convul- 
 sions take place in a small percentage of children, and congestion of the 
 brain with drowsiness may be noticed. In one case which came under my 
 observation the child did not close its eyes for four nights. It was not uncon- 
 scious, but indifferent, and wanted to be left alone. In a few cases meningitis 
 will seem imminent, and the diagnosis will sometimes necessarily be held in 
 abeyance. In some children afflicted with influenza there is developed an 
 obstinacy which is truly remarkable ; they sometimes resist the slightest touch, 
 and refuse all examination on the part of the physician. This peculiarity is 
 regarded by some observers as of diagnostic importance in differentiating from 
 typhoid fever. 
 
 Temperature. — In addition to what I have already said, I have noticed 
 that the fever may be very high and yet recovery take place. On the other 
 hand, a temperature of 101° to 102.5° F. may persist for a period of two or 
 three months. In these cases I have suspected and have repeatedly examined 
 for evidence of tuberculosis, and have not found it, the patient finally making 
 a good recovery after this long period of sickness. In general, we may make 
 the statement that the temperature is more irregular in influenza than in any 
 other disease. 
 
 Complications and Sequelse. — These are numerous and varied, and attack 
 nearly every function and organ of the body. Glandular enlargements are 
 frequent. Inflammation of the parotid gland may take place. Abscess of the 
 antrum and inflammation of the connective tissue of the neck have been noticed. 
 Tuberculosis and tubercular meningitis may follow in a few cases. Conjunc- 
 tivitis may remain, and catarrhal inflammation of the middle ear, resulting 
 often in perforation and profuse discharge, will be noticed. At times this 
 involvement of the middle ear, while always a serious complication, may even 
 threaten the life of the patient. Diseases of the skin are sometimes noticed, 
 such as erythema, herpes, and urticaria. 
 
 Among the more general diseases that have been observed are rheumatism, 
 chorea, nephritis, and periostitis. Children having a tendency to rickets have 
 been known to develop the disease after having had an attack of influenza. 
 Among the complications which I have noticed, and which I have not seen 
 
218 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 recorded, is purpura. Of this I have seen four cases, all in young people, and 
 attended with extreme weakness and with evidence of more or less blood- 
 change. 
 
 As is not unusual in adults, acute mania has been observed to follow 
 the disease occasionally in children, but generally ends in complete recovery. 
 Dr. Julius Althus, in an extensive article on mental affections after influenza, 
 gives cases illustrating neurasthenia, hypochondriasis, melancholia, delirium 
 from inanition, homicidal tendencies, and general paralysis. He believes that 
 the psychoses observed after epidemic influenza are far greater than those after 
 any other infectious disease. 
 
 Diagnosis. — From the rapidity with which it seizes the patient, influenza 
 might be mistaken for sunstroke, an acute poisoning, or malignant malaria. It 
 can be confounded with all diseases of the respiratory apparatus, with typhoid 
 fever, and with meningitis. 
 
 From a simple catarrh, influenza will be distinguished by the fact that it is 
 epidemic, and that there is greater prostration, which continues for a longer 
 period of time, than in the first-named disease. The temperature is also higher, 
 and there is a tendency to catarrhal difficulties — at first local, but rapidly 
 spreading to other portions of the body. A mild catarrh, with severe neuralgia 
 and with unusual pain in the limbs, should be diagnosticated as influenza 
 if this disease be prevalent. The same may be said in regard to an irri- 
 table stomach, with diarrhoea and an unusual prostration. This in a time of 
 epidemic should certainly be classed as influenza. From pneumonia and bron- 
 chitis, simple or capillary, we differentiate influenza by the absence of the usual 
 physical signs, although at the commencement of the grippe in many cases 
 there will be symptoms of pneumonia, and it seems as if localization had indeed 
 taken place ; but frequently in a few hours this becomes diffused, and a general 
 bronchitis with the excruciating pain and prostration belonging to influenza is 
 detected. 
 
 From typhoid fever influenza is differentiated by the fact that no rose-spots 
 appear and no enlarged spleen is found, and the catarrhal condition, more par- 
 ticularly in the respiratory tract, predominates over all other symptoms. If 
 diarrhoea exists in influenza, it will be noticed that a cough and a catarrhal 
 state of the air-passages has preceded its development. The fever in influenza 
 is irregular ; in typhoid it is so regular and constant that it almost makes its 
 own diagnosis. It is not usual to notice the apathetic facial expression that 
 we have in typhoid. The face, however, is usually flushed in influenza — more 
 frequently pale in the continued fever. There are no rose-spots in influenza, 
 no tenderness and gurgling in the right inguinal region. 
 
 From meningitis influenza can usually be diagnosticated by careful obser- 
 vation of the eye and by the want of the rigidity of the muscles which we 
 find in meningitis. The disease of the brain usually develops rapidly, and if 
 death does not take place it disappears quickly. I must, however, say that 
 the differentiation of meningitis from certain forms of la grippe is attended 
 with great trouble, and a diagnosis must in some cases be withheld. When the 
 fever persists after all other symptoms of influenza have subsided, and there is 
 a cough with gradual emaciation, the closest care must be taken that a tuber- 
 cular disease does not come in. Particular attention should be given to nutri- 
 tion, and every means should be taken to diagnosticate the disease early. 
 
 Prognosis and Mortality. — In this connection an interesting topic might 
 be discussed as to whether one attack of influenza protects from subsequent 
 attacks. I do not think that this question at present can be fully answered, 
 but the general statement can be made that many families particularly afflicted 
 
EPIDEMIC INFLUENZA. 219 
 
 in 1889 did not develop the disease in 1890 or 1891. There are those who 
 are immune from the disease, and others in whom it has developed three con- 
 secutive years. 
 
 The mortality is different in different epidemics, and the character of the 
 epidemic must be considered, as in all other infectious and contagious diseases. 
 In some epidemics children are particularly liable to contract the disease, while 
 in others adults seem to be selected. And again in a more general epidemic 
 it has been noticed, as I can personally attest, that children often are not 
 attacked until the disease has prevailed for some time. When the attack is 
 moderately severe, I regard it a dangerous malady for a child, particularly if 
 he has anaemia or any vicious constitutional tendencies. Death has taken place 
 in twenty-four hours. It may come from almost every complication, but, in the 
 main, exhaustion and bad nutrition bring about the fatal result. Death may 
 come with such rapidity that in summer insolation is suggested, and at other 
 times malignant malaria. In the fulminant variety with rapid death, the severe 
 symptoms will be referable to the nervous system, while throughout the entire 
 history of other cases the poison selects the respiratory or gastro-intestinal 
 tract, and death comes as it does in those diseases when not complicated with 
 influenza. But it must be remembered that there is always a tendency to col- 
 lapse and a prostration out of proportion to other symptoms. 
 
 The length of time consumed in convalescence from this disease is wonder- 
 ful. The pains and general weakness do not disappear for weeks ; and I may 
 add that many of the sequelae remain for years, and not only produce suffer- 
 ing, but shorten the life of the individual. 
 
 Treatment. — I have no particular remedy or combination of remedies to 
 suggest. I think, however, that care should be taken to prevent the contagious 
 element from spreading and gaining a hold on the community, and, in view of 
 the great mortality and the immense money loss which this disease causes, it 
 appears to me that the time will come when it will be regarded as the duty 
 of all municipal authorities to assume such control of the disease as science 
 suggests. 
 
 Let the people understand that it is a contagious disease, and instruct them 
 how to prevent its spreading by contact. All handkerchiefs and cloths used 
 by the patient must be immersed in some antiseptic fluid, and all cuspidors and 
 articles of furniture which come in contact with the germs of the disease should 
 be carefully disinfected. 
 
 A generous diet must be insisted upon, some stimulation, and a conservation 
 of all the strength of the patient observed from the outstart. 
 
 For the general pain which pervades the entire system, which sometimes is 
 the first and most prominent symptom, nothing has given me such good results 
 as phenacetin and salicylate of sodium. The catarrh of the respiratory tract 
 which speedily prostrates young children should be early treated with stimu- 
 lants, including the ammonia preparations and the ordinary expectorants. The 
 gastro-intestinal catarrh must not be neglected, but should receive attention 
 from the first. It is a clinical fact, which must have been observed by many, 
 that in some of the neglected cases there is just as profound and general col- 
 lapse from the copious diarrhoeal discharges and vomiting, which we sometimes 
 see in this form of the disease, as from those which take place in severe cases 
 of cholera infantum. They should, then, have attention from the very first. 
 For the extreme fatigue and depression not only alcoholic stimulants, but the 
 effervescing waters with quinine, should be administered. If the stomach is 
 particularly irritable, let the quinine be administered by inunction or by the 
 rectum. Children take eagerly and with good results whipped egg-albumin 
 
220 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 
 with sterilized water and a little stimulant and sugar. Champagne is excel- 
 lent for the depression which is so evident among these little people. When 
 there is great prostration following the involvement of any of the three systems 
 we have mentioned, the carbonate of ammonium, camphor, and musk, fortified 
 by the conjoint use of digitalis and nux vomica, are indicated. 
 
 When the patient begins to pass out from the more painful and acute mani- 
 festations of the disease, in addition to a generous diet a tonic composed of the 
 compound syrup of hypophosphites, extract of malt, and pepsin cordial, equal 
 parts, with a very small amount of elixir of bark, iron, and strychnine, acts 
 efficiently. 
 
ERYSIPELAS. 
 
 By FREDERICK A. PACKARD, M. D., 
 
 Philadelphia. 
 
 Erysipelas is an acute, specific, contagious, inflammatory disease of skin 
 and mucous membranes, accompanied by marked general symptoms, and cha- 
 racterized by peculiar local lesions at the seat of inoculation, by its tendency to 
 spread, and by the presence in the affected area of a micrococcus that is capable 
 of reproducing the disease in other individuals. 
 
 The word " erysipelas " is probably derived from ipudpoz, red, and neXXa, 
 sJcin. Numerous qualifying words have been used to signify the point of 
 involvement, the course of the disease, the appearances presented by the local 
 lesion, the age at which the disease occurs, etc. The terms " traumatic " and 
 " idiopathic " have been used to distinguish cases wherein there is or is not an 
 antecedent obvious wound of the skin at the seat of the local lesion. No 
 qualifying words should be used as implying an essential difference in the pro- 
 cess, as it is a disease sui generis, no matter under what circumstances it may 
 occur. 
 
 History. — Erysipelas has been known from the time of Hippocrates, but 
 the descriptions of the disease given by most writers prior to those of the last 
 century show that many diverse diseases were included under this name. 
 When humoral pathology occupied men's attention, this, in common with many 
 other maladies, was supposed to be the outward expression of morbid humors 
 in the body. At a later date it was looked upon as a simple dermatitis; still 
 later, as a simple lymphangitis. The contagiousness of the disease was pointed 
 out by Lorry in 1777. A microbic origin was first suspected by Martin in 
 1865. The question of priority in demonstrating this origin is still a matter 
 of dispute. Between 1868 and 1870, Nepveu and Hueter described the occur- 
 rence of microscopic organisms in connection with the disease. It need only 
 be stated here that the description given by Nepveu corresponds more closely 
 than does that of Hueter to the micro-organism now established as the cause 
 of the disease. Since 1870 many observers have studied the disease from a 
 bacteriological aspect, but it is especially to Fehleisen that we owe our present 
 knowledge of the life-history and etiological role of the micrococcus described 
 by him in 1882. 
 
 Etiology. — The disease is limited in its occurrence to no part of the civil- 
 ized world, but its favorite habitat is the temperate zone. It but rarely occurs 
 in the tropics, being less rare in regions far removed from the equator. In 
 Greenland, for example, occasional widespread epidemics have occurred. 
 
 The predisposing effect of season can be readily seen by the accompanying 
 chart (Fig. 1). It will there be found that by far the greater number of fatal 
 cases in Philadelphia occur during the latter part of the first and the early 
 portion of the second quarter of the year ; that is, during the early spring 
 months. Allen analyzed 566 cases applying for treatment, and obtained 
 practically the same result. 
 
 221 
 
222 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 It appears to be most prevalent among the poorer classes. This may be 
 due to several causes — the greater liability to injury, frequency of chronic 
 
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 Chart showing the Number of Fatal cases of Erysipelas in Philadelphia occurring in different seasons 
 
 from 1874 to 1891. 
 
 superficial inflammatory troubles, lack of cleanliness, want of ordinary sanitary 
 precautions, and neglect of proper isolation amongst those attacked. 
 
 The question of age as a predisposing factor is difficult to determine, as 
 only fatal cases appear in the reports of boards of health. Of 12,556 fatal 
 cases of the disease in England between the years 1862 and 1868, there 
 occurred under one year of age 31 per cent. ; under five years, 5.9 per cent. ; 
 under fifteen years, 2.9 per cent. ; under twenty-five years, 4.2 per cent. ; under 
 forty-five years, 12.4 per cent. ; under sixty-five years, 20.9 per cent. ; above 
 eighty-five years, 1.4 per cent. In Philadelphia, during the period between 
 1874 and 1891, there occurred 1253 deaths from erysipelas. Of these, 380 
 were in children under one year of age, 35 between one and two, 23 between 
 two and five, 25 between five and ten, 6 between ten and fifteen, the remain- 
 ing 784 cases occurring in those past the latter age. All that can be said, 
 therefore, is that no age is exempt. The large number of fatal cases occurring 
 in the first year of life may be due to the almost uniform fatality of the disease 
 during the early part of that period, and cannot be taken as an index of the 
 actual number of cases occurring in infants. 
 
ERYSIPELAS. 223 
 
 What part filth and defective drainage may play in its production has not 
 been definitely settled. In the older hospitals of Europe frequent epidemics 
 have occurred ; but it is not alone in these that erysipelas appears, new and 
 apparently sanitary institutions being also the scene of its occurrence. A 
 well-known and oft-quoted instance of the effect of polluted air is that which 
 occurred in the Middlesex Hospital, where a defective drain was on two 
 occasions the apparent cause of an outbreak of the disease, starting in 
 the bed nearest to its position in the wall. It is said to be frequent in the 
 immediate neighborhood of badly-kept stables. 
 
 The most important etiological factor is contagion. The contagious principle 
 has but a limited area of influence, as is shown by some of the histories of 
 local epidemics within hospital wards, wherein patients upon one side of a 
 ward have been affected seriatim on both the right and left of the individual 
 first attacked. Those in attendance upon a case are apt to contract the disease. 
 One attack seems rather to predispose to, than to protect against, a recurrence, 
 due probably to the fact that some breach of the surface produced by a chronic 
 affection admits the poison. 
 
 The contagious principle is the streptococcus erysipelatis. Although pre- 
 vious investigators had discovered micrococci in the local lesion, the most 
 careful and conclusive work upon the subject was performed by Fehleisen, hence 
 the micro-organism is frequently spoken of as the streptococcus of Fehleisen. By 
 him it was found in the lymphatic vessels and spaces of the skin and subcu- 
 taneous cellular tissue, and in the superficial layers of the corium. It occurs 
 as a single cell or in the form of diplococci or chains of various length. The 
 individual cell measures about 0.3// in diameter. It is readily cultivated upon 
 gelatin and blood-serum, where the colonies form as dull-white, round points, 
 closely marginated or fusing at points of contact. It grows well at the tem- 
 perature of the human body, is facultatively aerobic, and develops well in vacuo. 
 Not only has the inoculation of pure cultures been successfully practised upon 
 animals, but the disease has been inoculated upon human beings as a therapeutic 
 measure. 
 
 In order that the parasite may gain access to the lymph-spaces, it is essen- 
 tial that some breach of the surface should exist. This means of entry may be 
 supplied by some wound accidentally received or purposely inflicted, by the 
 unhealed navel of the new-born, scarifications made for purposes of vacci- 
 nation, the local lesion of vaccinia, the ulcers of varicella, solutions of continuity 
 produced by eczema, intertrigo, ecthyma, or pemphigus, or by ulcers resulting 
 from chronic inflammation of the mucous membranes of the mouth or upper 
 air-passages. It is owing to the frequency of lesions at the points of union of 
 skin and mucous membrane that the local manifestations frequently begin at 
 those situations. 
 
 Pathological Anatomy. — After death the body-heat is maintained for a 
 long time, and, according to Eulenburg, there is a post-mortem rise of tempera- 
 ture to a point .9° C. (1.5° F.) above that observed before death. 
 
 At the seat of the local lesion the vivid color gives place to a mere yellow- 
 ish discoloration, and much of the swelling observed during life disappears. 
 When the skin is incised there exudes a varying quantity of more or less 
 discolored serum. The skin and subcutaneous tissue are somewhat thickened 
 and cannot be readily separated. Microscopical examination of the affected 
 skin shows that beyond the peripheral margin there are numbers of micrococci 
 in the lymphatic vessels. As sections are made from without inward, the 
 greatest histological changes are seen at the visible margin of the patch, where 
 there are much serous infiltration separating the cells, and infiltration by round 
 
224 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and wandering cells, many micrococci being contained in the latter. From 
 this point the alterations progressively diminish as the part earliest attacked is 
 reached, until complete restitutio ad integrum is found to have occurred. 
 The hair-shafts are unaltered, but there is serous and cellular infiltration of the 
 root-sheath, and micrococci may b'e found in the space between the latter and 
 the root. In lately-developed vesicles upon the surface no micro-organisms are 
 to be found, but in those of longer existence various forms abound. In phleg- 
 monous erysipelas there is an admixture of the staphylococcus pyogenes with 
 the streptococcus erysipelatis. 
 
 The mucous membranes that are affected show the same appearance as does 
 the skin, save for the normal structural differences in the tissue. Attacking 
 the larynx, the disease produces marked swelling in the parts around the 
 glottis. (Edema of the rima glottidis may be present. The trachea and 
 bronchi may be of a brillant red color, w T ith paler areas corresponding to the 
 cartilaginous rings. Three forms of pulmonary lesion may be found : (1) an 
 accidental croupous pneumonia, with the ordinary appearances of that lesion ; 
 (2) intense congestion, either general or limited to diseased branches of the 
 bronchial tree, with scattered areas of red or gray hepatization within the 
 congested area; (3) an acute infective interstitial pneumonia from bacterial 
 embolism, with subsequent dissemination of micrococci in the interlobular 
 connective tissue. In cases where the disease has spread from the air-passages 
 the alveoli contain large numbers of leucocytes and many micrococci, instead 
 of the fibrin and epithelial cells seen in croupous and catarrhal pneumonia. 
 
 Inflammation of the pleura may be found from extension of the disease 
 through the chest-wall or as secondary to subpleural pulmonary lesions. The 
 pleural cavity may contain serous or purulent exudate. The streptococcus has 
 been found in pleural exudate. Suppurative anterior mediastinitis has been 
 observed. Pericarditis is rarely seen, but endocarditis, affecting chiefly the free 
 borders or the whole of a leaflet of the valves of the left side, is occasionally 
 present. Granular degeneration of the myocardium also occurs, due doubtless 
 to the elevation of temperature. The endothelium of the blood-vessels has been 
 found to be swollen, granular, and with indistinct nuclei. Tutschek reports a 
 case of thrombosis of the abdominal aorta. The streptococcus has been found 
 in the blood of the skin, subcutaneous adipose tissue, and in the capillaries of 
 the lungs, liver, spleen, and kidneys. 
 
 The stomach may exhibit marked engorgement of its vessels, the intestinal 
 tract patchy redness. Multiple minute duodenal ulcers have been seen. In 
 the large intestine the typical erysipelatous local lesions may be found in cases 
 where the disease has spread from the perineum through the anus to the rectal 
 mucous membrane. 
 
 The liver may be large and congested in rapidly fatal cases ; in those of 
 longer duration it is more often pale, soft, and the seat of fatty degeneration. 
 Many observers have found the streptococcus within the organ. 
 
 By most authors the spleen is said to be increased in volume, as would 
 be expected from the frequency of its enlargement during life in non-fatal 
 cases ; but Denuce found it small, soft, and hypergemic. 
 
 Peritonitis is comparatively rarely found, most instances of its occurrence 
 being in the new-born, where the abdominal wall has been the seat of the 
 primary process. 
 
 In spite of the prominence of cerebral symptoms during life, there are but 
 seldom found any marked structural alterations within the cranium. The 
 membranes may be anaemic or their vessels intensely engorged with blood. 
 Actual meningitis is rarely seen. An instance is reported by Osier of menin- 
 
ERYSIPELAS. 225 
 
 gitis and thrombosis of the lateral sinus in a fatal case of facial erysipelas 
 wherein the process could be traced along the trunk of the fifth cranial nerve. 
 
 From the frequent presence of albuminuria it is to be expected that in 
 fatal eases the kidneys would show structural alterations. In five cases 
 examined by Demice* these organs showed nephritis in degrees varying with the 
 duration of the case. Langer has reported a fatal case of erysipelas of the scalp 
 occurring in a seven-weeks-old boy, and complicated by hemoglobinuria, 
 wherein the kidneys showed infarcts and miliary abscesses. In the articular 
 inflammatory exudate that sometimes occurs Schuller found the streptococcus. 
 
 Symptoms. — In spite of the fact that in six cases purposely inoculated 
 by Fehleisen the initial chill occurred in from fifteen to ninety-one hours, the 
 incubation for cases accidentally inoculated may be reckoned as requiring a 
 period of from three to seven days. 
 
 The onset may be sudden, the first symptom being a chill with rigor. In 
 other cases feelings of languor and vague discomfort in the part that later 
 becomes the seat of the local lesion may precede the occurrence of chill. In 
 young children the occurrence of an initial convulsion is not infrequent. The 
 attack may begin with severe inflammation of the upper air-passages or throat, 
 the skin lesion not appearing for twenty-four or thirty-six hours after the first 
 signs of illness. The temperature rises rapidly to 102°, 103°, or even 105° F. 
 The affected area soon becomes the seat of burning, smarting pain. The local 
 appearances at this time may merely amount to slight redness and glossiness. 
 In a short time there is slight elevation of this reddened area above the sur- 
 rounding healthy surface, the color deepens in shade, and there are pitting and 
 pain upon pressure. The color is readily dispelled by pressure, but quickly 
 returns upon the withdrawal of the finger. The pain becomes more intense, 
 and there is a sensation of stinging and stretching in the affected part. The 
 tongue is coated, there is anorexia, thirst may be marked, varying degrees of 
 cephalalgia are present, while nausea is a frequent source of complaint. Vomit- 
 ing is not frequent in cases of ordinary severity. At this stage the pulse is 
 usually full, bounding, and rapid. Upon the second day the temperature-chart 
 shows a slight morning remission. The redness and swelling extend from the 
 original site to cover a larger area ; the eyes may be invisible from swelling of 
 the lids, the ears swollen and distorted, and the lips thickened. Cephalalgia 
 becomes intense, especially if the scalp be invaded ; insomnia and delirium 
 frequently appear. Albuminuria, with a copious deposit of amorphous urates, 
 will usually be found after the first few days. On the second or third day the 
 local appearances of the part first attacked reach their highest degree of devel- 
 opment. Thereafter the redness and swelling of that part subside. Meanwhile 
 the local process may have steadily advanced from the point of its original 
 appearance until large areas of skin are involved. When extension ceases the 
 temperature rapidly falls, the pulse becomes less bounding and its frequency 
 diminishes, pain lessens, the associated symptoms rapidly subside, and the 
 patient enters upon convalescence. During convalescence the affected skin has 
 a faint yellowish discoloration and is the seat of desquamation, the epidermis 
 separating in branny scales or in large flakes, and in cases where the scalp has 
 been invaded the hair falls. Albuminuria may persist in lessening degree for 
 several days after the cessation of other symptoms. 
 
 Important variations from this ordinary type occur and require separate 
 consideration. 
 
 Erysipelas of the new-born begins either at the navel or at a point nearer 
 to the symphysis pubis. Thence extension rapidly occurs until the skin of the 
 whole abdomen, that of the extremities, or even larger portions of surface, may 
 
 15 
 
226 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 be involved. The infant exhibits extreme restlessness and has high fever, may 
 vomit frequently, and soon passes into an asthenic condition that speedily ends 
 in death. In other cases the process extends along the still patulous umbilical 
 vein, reaches the liver, and may lead to fatal peritonitis. After the early days 
 of infancy are passed the disease shows the same characters in children as in 
 adults. 
 
 Where the mouth, tonsils, pharynx, or nares are primarily attacked, the 
 local appearances are those of an intense inflammation of the part affected, but 
 swelling is more marked than usually occurs with ordinary inflammation, and 
 the tendency to spread to adjacent structures and the skin is a peculiarity of 
 great diagnostic importance. From the nares it may extend to the lachrymal 
 duct and attack the skin near the internal canthus. From the upper air- 
 passages the process may extend to the bronchi or to the lungs, producing the 
 symptoms and physical signs of an intense bronchitis or pneumonia. In the 
 primarily laryngeal form hoarseness begins early, and may be rapidly followed 
 by symptoms of suffocation due to the intense swelling of the mucous 
 membrane. 
 
 The eruption exhibits certain peculiarities worthy of further study. Exten- 
 sion usually takes place most rapidly in one direction, but not in an even line, 
 as flame-like tongues of redness frequently jut out in advance. The area of 
 redness and swelling is bounded by an abrupt fall to the level of the healthy 
 surface. Extension from the face usually occurs upward, reaching the hairy 
 scalp or even passing backward to the nape of the neck or to the trunk. 
 From the trunk it may spread to the extremities or head, and vice versa. One 
 striking peculiarity of the eruption is its liability to terminate at natural 
 boundaries — the borders of the hairy scalp, the various folds of the face, the 
 groin. Where the underlying bone is close to the surface the eruption is fre- 
 quently absent ; thus the chin may be spared, while the rest of the face is 
 much swollen. Conversely, where the skin is but loosely attached to under- 
 lying structures — as in the scrotum, labia majora, and eyelids — swelling is very 
 marked, and gangrene may occur from interference with the circulation. 
 Besides redness and swelling, other appearances are usually present in the 
 affected area of skin. Vesicles, or even bullae with clear or muddy contents, 
 are apt to form. Pustules are rarely seen, but in some regions with resisting 
 skin a verrucose appearance may be presented from cellular infiltration. 
 Minute points or quite extensive areas of gangrene may occur. The bursting 
 of the vesicles and bullae causes the formation of yellowish or brownish 
 crusts. After the active process in a part has subsided the surface is covered 
 with bran-like scales, large flakes of detached epithelium, and crusts of varied 
 hue. The hair may fall very rapidly, leaving the scalp bare, smooth, and 
 shining. 
 
 The temperature-curve follows quite accurately the extension and subsidence 
 of the local process. After the latter has entirely subsided there may remain 
 an elevated temperature, owing to the presence of irritation or actual inflam- 
 mation of various organs. Cavafy has reported five cases, and I have seen one, 
 of erysipelas of the face without pyrexia. 
 
 Not only may the urine contain albumin and an excess of urates, but hya- 
 line and granular tube-casts may also be present. These disappear after the 
 cessation of the disease in the majority of cases. Their presence may be the 
 evidence of the rekindling of a pre-existing disease of the kidneys, in which 
 case they will usually persist or even increase as time passes. 
 
 Complications and Sequelse. — The lung is perhaps the most frequent 
 seat of complication in erysipelas. Pneumonia of the ordinary type is of not 
 
ERYSIPELAS. 227 
 
 infrequent occurrence, or the specific process may attack the lung-structure. 
 Pleurisy (with or without effusion), empyema, peri- and endo-carditis at times 
 occur. Pleurisy occurred twice in eight cases purposely inoculated by Fehleisen. 
 Previously-existing nephritis is apt to be awakened into activity, and uraemia 
 may be the immediate cause of death. Haemoglobinuria may be a compli- 
 cation, as in the case reported by Joseph Langer. In facial erysipelas suppu- 
 rative inflammation of the orbital connective tissue is much to be dreaded, and 
 is frequently fatal from extension to the cerebral meninges through the optic 
 foramen or sphenoidal fissure. Amblyopia or complete amaurosis may result 
 from pressure upon the optic nerve or vessels of the eyeball. Obstinate vomit- 
 ing is at times a serious complication. Diarrhoea frequently occurs, and the 
 stools may contain blood. After the active signs of disease have disappeared 
 superficial abscesses frequently form. 
 
 Erysipelas is, according to Gowers, rarely followed by paralysis. Optic 
 neuritis, optic atrophy, or thrombosis of the retinal vessels may follow com- 
 pression of the optic nerve and ophthalmic blood-vessels in cases of orbital 
 cellulitis. Amblyopia may be due to retinal haemorrhages, detachment of the 
 retina, or opacities in the vitreous. In 9209 cases of adventitious deafness 
 analyzed by W. B. Post, erysipelas was the alleged cause in 36. 
 
 Diagnosis. — In ordinary cases the diagnosis is readily made. The sudden 
 onset of marked constitutional symptoms coincidently with or rapidly followed 
 by the red, elevated, painful lesion of the skin, the peculiar qualities of the 
 latter, and, in particular, the tendency to spread, sufficiently stamp the disease. 
 When the mucous membranes are first attacked it may be impossible to make 
 a positive diagnosis until the skin becomes affected ; but here also the rapid 
 and continuous spread of the disease along the mucous membrane, together 
 with the intense swelling and brilliant redness of the part, should suggest the 
 erysipelatous nature of the inflammation. 
 
 Where the poison has entered through the lesions produced by eczema of 
 the hairy scalp, such as is so frequently seen in the neglected children of the 
 poor, the cause of the constitutional symptoms may be only discovered upon 
 the extension of the local process to the forehead, neck, or ears. 
 
 From simple erythema the diagnosis is made by the tense swelling, the 
 sharply-defined border, the more marked ambulatory character of the lesion, 
 the fever, and other marked systemic symptoms of erysipelas. 
 
 From angeio-neurotic oedema this affection differs in all points save the fact 
 of the presence of swelling. From ordinary urticaria it may be distinguished 
 by the rapid appearance and reappearance of " hives," and by the occurrence 
 of the eruption simultaneously in different portions of the body. 
 
 The local appearances of acne rosacea sometimes closely resemble those 
 of erysipelas, but the clinical history, the rapidity of extension, and the 
 constitutional symptoms of the latter disease clearly differentiate the two 
 affections. 
 
 From malignant oedema the diagnosis must be made by the method of 
 spreading and the local appearances peculiar to the two diseases. Malignant 
 oedema more frequently occurs at points where the skin is particularly thin 
 than does erysipelas. 
 
 Prognosis. — In uncomplicated cases the usual result is in complete and 
 rapid cure. In the new-born (that is to say, in those under the age of fifteen 
 days) the disease is practically always fatal, owing in part to the lack of resist- 
 ing power in those so young, in part to the ease with which extension occurs, 
 and in great part to the liability to the occurrence of phlebitis of the umbilical 
 vein and of peritonitis. In older children complete cure usually results. 
 
228 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Among especially unfavorable occurrences may be mentioned suppuration 
 in the orbital space, gangrene, signs of inflammation of the lung, pericardium, 
 or endocardium. When optic neuritis, optic atrophy, or thrombosis of the 
 retinal arteries occurs, the prognosis as to return of vision is unfavorable. 
 Permanent baldness but seldom results, in spite of the complete alopecia that 
 often is present immediately after the attack. 
 
 Treatment. — In this disease the same rules in regard to isolation should 
 be followed as in other contagious diseases, save only in the degree to which it 
 should be practised. Occurring in the medical wards of a hospital, it may 
 not attack other individuals, providing that the beds are in not too close appo- 
 sition. The contagiousness of erysipelas is not sufficient to warrant the exclu- 
 sion of cases from medical wards that are properly separated from the surgical 
 and obstetrical departments. It is sufficient that the patient be so placed that 
 he may be surrounded by those having no breach of cutaneous or mucous sur- 
 faces. In surgical and obstetrical wards cases of erysipelas should be excluded, 
 and the occurrence of an attack should be the signal for immediate isolation. 
 
 No safer means for the prevention of the disease exists than the use of 
 thoroughly antiseptic methods as regards the wards, the operating-room and 
 its appurtenances, the persons of operators and assistants, and the dressings 
 employed. Where attacks recur in an individual any existing lesion that may 
 give entrance to the poison should receive careful and prompt treatment. 
 
 In the case of a self-limited disease, and one that rapidly subsides without 
 warning, deductions as to the efficacy of any particular line of treatment must 
 be most carefully drawn. The methods employed in erysipelas are too numer- 
 ous to be here enumerated ; suffice it to mention a few of those that have stood 
 the test of prolonged use by various observers. 
 
 A mercurial purgative is advantageous in the early stages and before the 
 institution of any line- of treatment. But two drugs deserve mention as hav- 
 ing any effect upon the course of the disease — tincture of the chloride of iron 
 and jaborandi. After prolonged trial the first of these seems to have some 
 influence in modifying the severity and shortening the course of the attack. 
 It is best given in large doses, 5 to 15 drops, every three or four hours accord- 
 ing to the age of the child. Under its use there is usually found a rapid cessa- 
 tion of extension of the local process and subsidence of the general symptoms. 
 Jaborandi, or its alkaloid pilocarpine, was first recommended by DaCosta, and 
 has had numerous advocates since the announcement of its value in erysipelas. 
 In children, however, it must be given with caution and in doses carefully 
 graduated to the age of the child, the object being to give by hypodermic 
 injection an initial dose of pilocarpine sufficient to produce a pronounced 
 sweat, and thereafter to give every four hours doses of the fluid extract of 
 jaborandi sufficient to maintain a gentle diaphoresis. In adults the method is 
 decidedly beneficial, but in children its use requires caution and careful watch- 
 ing by an intelligent attendant. 
 
 The almost purely mechanical rules that govern the extension and limita- 
 tion of the local process have led to various attempts to substitute artificial 
 boundaries for those of nature. For this end pressure applied in advance of 
 the lesion has been extensively employed by means of tight bandages of elastic 
 material, by the application of strips of adhesive plaster, and by collodion. In 
 many situations no form of pressure is practicable save that by collodion ; but 
 the depth to which the constriction by collodion reaches is too slight to offer 
 any obstacle to the spread of the process. Where the other methods are avail- 
 able the application of constricting bandages sufficiently tight to accomplish 
 the object in view is apt to be too painful for their long continuance. As, 
 
ERYSIPELAS. 229 
 
 however, this does not preclude the employment of other methods of treat- 
 ment, it should be tried wherever practicable. 
 
 Attempts have been made to stay the spread of this specific inflammation 
 by the production of simple inflammatory exudation. For this purpose incis- 
 ions were made or the solid stick of nitrate of silver was applied to the skin 
 beyond the affected area. Scarification of the healthy skin beyond the edge 
 of the patch has been, and is still, used by some for the same purpose. Hueter 
 first introduced the injection of 2 per cent, carbolic-acid solution under the 
 skin threatened with attack. In some cases it seems to have limited the pro- 
 cess, but the method is not always successful. It is, however, rational. 
 
 As applications to the diseased area many materials have been recommended, 
 such as flour, lycopodium, or other bland powders, white paint, lead-water and 
 laudanum, cold water, vinegar and water, turpentine, and tar. These are now 
 but seldom used, except white paint and lead-water and laudanum. The exclu- 
 sion of air of itself seems to relieve much of the discomfort and pain. On this 
 account any emollient application is agreeable. To the fatty base various sub- 
 stances may be added. One of the most agreeable is the hydrochlorate of 
 cocaine in the proportion of 16 grains to the ounce. This usually relieves 
 pain very markedly. Resorcin in the strength of a drachm to the ounce may 
 he used. Koch recommends the application, by means of a bristle-brush, of 
 a mixture of creolin 1 part, iodoform 4 parts, and lanolin 10 parts. Spraying 
 of the affected surface with a solution of corrosive sublimate has been recom- 
 mended, but greater relief of discomfort, with more likelihood of reaching the 
 deeper parts, can be obtained by the use of constant applications of emollient 
 preparations. 
 
 The diet should be nourishing and easily digestible. Milk should consti- 
 tute the basis during the acute stage of the disease, but eggs, broths, and soft 
 milk foods may be given, except when fever is so great as to interfere with the 
 process of digestion. In all cases occurring among the debilitated, and par- 
 ticularly in very young children, stimulants will be almost invariably required. 
 The amount to be given depends upon the age and condition of the patient. 
 
 For extreme elevation of temperature the application of cold externally by 
 means of sponging with cool or cold water, the wet pack, or the cool bath 
 should be employed. Where the hyperpyrexia resists these measures, or where 
 they cannot be properly applied, antipyrine, acetanilid, or, better still, phena- 
 ■cetin, may be cautiously tried. The drugs mentioned should only be employed 
 with extreme care and in minimum effectual doses. 
 
 For delirium bromide of potassium or sodium may be given, either by 
 mouth or rectum. Cold applications to the head may be sufficient to mode- 
 rate the symptom. Opiates are to be used only as a last resource and with 
 great circumspection, not only because of the danger attending their use in 
 childhood, but also because of the liability to insufficiency or actual inflam- 
 mation of the kidneys in this disease. 
 
 Impending suffocation from swelling of the rima glottidis may require tra- 
 cheotomy. Any purulent collections that may form should be promptly 
 released by the knife. 
 
 After the subsidence of the disease tonics with haematinics will be required. 
 The alopecia that occurs in some cases usually requires no special treatment. 
 but friction of the scalp and the use of cantharidal preparations will hasten 
 the growth of the hair. 
 
 Therapeutic Use. — A few words must be added regarding the use of ery- 
 sipelas as a therapeutic measure. For many years back there are to be found 
 reports of cases wherein an intercurrent attack of erysipelas was followed by 
 
230 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 an amelioration or complete subsidence of the primary affection. The fre- 
 quency of this phenomenon led to the intentional inoculation of erysipelas 
 for the cure of various affections that were resistant to other measures of 
 treatment, were inaccessible to the surgeon's knife, or whose existence was 
 incompatible with that of erysipelas. Among the affections alleged to have 
 been cured by such an attack of erysipelas or by the intentional inoculation 
 of the streptococcus of Fehleisen may be mentioned various lymphosarcomata, 
 epitheliomata, lupus, and various other chronic superficial ulcerations, keloid, 
 neuralgia, various psychoses, acute polyarthritis, and pulmonary tuberculosis. 
 The antagonism between erysipelas and diphtheria has led to the inoculation 
 of the former upon the latter disease. 
 
 While many favorable reports as to the action of erysipelas in the reduction 
 or complete removal of sarcomatous and carcinomatous tumors are to be found, 
 there are others where either no result has been obtained or where recurrence 
 of the growth has taken place, or even death has been brought about by the 
 erysipelatous attack. The cases of neuroses and neuralgia that are found to 
 have been relieved by an attack of the disease can be duplicated by those 
 wherein cure has resulted after many different mental or physical impressions. 
 
 In regard to the superficial skin lesions, the favorable action of erysipelas 
 may be explained by the local influence of the inflammation produced as part 
 of the latter. As to the favorable result in a case of pulmonary tuberculosis 
 reported by Chelmonsky, it can only be said that further evidence must be 
 brought forward before any definite curative influence of erysipelas upon this 
 pulmonary lesion can be acknowledged. 
 
 Attractive as is the theory of the antagonistic action of the bacterial products 
 in one disease upon its own micro-organisms or upon those of another malady, 
 it seems as yet unjustifiable to purposely add to the existing affection a disease 
 which, while usually ending in recovery, not only may of itself prove fatal, 
 but which is often observed as the final and fatal complication of many long- 
 standing cases of incurable disease. 
 
CHOLERA ASIATICA. 
 
 By EDWARD O. SHAKESPEARE, A. M., M. D., 
 
 Philadelphia. 
 
 This disease would be most properly designated as cholera infectiosa epi- 
 demica, for in this term a definite idea of its chief characteristic and of its 
 most marked tendency would be included. 
 
 Cholera Asiatica is an exceedingly dangerous specific human disorder, pri- 
 marily of the digestive tract, occasioned directly by the ingestion, entrance into 
 the small intestine, and exuberant multiplication there of special minute vege- 
 table parasites, the spirilla cholerse Asiatics, the so-called "comma bacilli" 
 of Koch. The special poison elaborated by the growth of the parasites in the 
 intestines attacks the epithelial lining of the latter, ultimately reaches the cir- 
 culation and the nerve-centres, and causes the complex phenomena which cha- 
 racterize the disease. 
 
 The intestinal contents, the vomit, and the stools of the attacked contain 
 these specific parasites in enormous numbers, and they are infectious so long as 
 the latter retain their vitality and power of reproduction ; so long as their 
 infectious quality persists they are capable, under favorable circumstances, of 
 causing an attack of the same disorder in another exposed, susceptible person, 
 and of giving rise to a local or widespread epidemic of the same disease. For 
 the latter reason does the danger to the public always outweigh in magnitude 
 even that to the individual attacked. 
 
 Cholera Asiatica is endemic in the lower two-thirds of the presidency of 
 Bengal, roughly corresponding to the delta of the Ganges and the Brahma- 
 pootra ; it becomes epidemic in other parts of Hindostan and of the world only 
 periodically, after more or less irregular intervals of entire absence. During 
 the intervals of epidemics, except as scattered cases shortly preceding or fol- 
 lowing such visitations, and as an essential part of the latter,, it does not exist 
 outside the endemic area : it has no more affiliation with or relation to our 
 somewhat common so-called summer cholera — otherwise termed cholera nostras, 
 cholera morbus — than it has with some acute attacks due to arsenical poison- 
 ing, to ptomaine-poisoning from ingestion of decomposed food, or to acute per- 
 nicious malaria, or to still other very different disorders, all of which, never- 
 theless, not infrequently present very similar symptoms and terminations. 
 
 Etiology. — Although abounding filth of the surroundings — that is, of 
 the district or the locality, of the domicile, of the home-life, and of personal 
 habits — favors infection and the subsequent development of an individual 
 attack, and the initiation, continuance, and spread of an epidemic of cholera 
 Asiatica, neither a personal seizure nor an epidemic outside that endemic area 
 which is the natural home of this disease can occur (not even when the person 
 or population wallow in every sort of reeking abomination), unless the special 
 infection be first introduced. In other words, no amount of filth is capable of 
 producing a spontaneous generation of the specific infection which is the active 
 
 231 
 
232 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cause of this disease ; nor, without the activity of this specific cause, is any 
 other agency or influence capable of producing the disease. 
 
 The active specific cause of cholera Asiatica is the presence and multipli- 
 cation in the intestinal canal of the subject of numbers of very minute vege- 
 table parasites, certain well-defined species of bacteria known as the spirillum 
 cholera Asiatics discovered by Koch in 1883, and because of their usual 
 resemblance under the microscope to the written comma, and of the name of 
 its discoverer, commonly called the " comma bacilli of Koch." 
 
 The term "bacillus" as applied to this vegetable micro-organism is, how- 
 ever, a misnomer, for the species is now regarded by nearly all competent 
 authorities as a member of the group of spirilla. As commonly encountered 
 in the intestinal contents or vomit of a victim of the disease, and in artificial 
 culture media when growth is recent and rapid, if a fresh preparation be 
 placed under a microscope of very high power and excellent definition, this 
 micro-organism is usually so actively mobile as to defy distinct vision. If the 
 fresh preparation has been made from a recent pure culture, and there be plenty 
 of fluid under the thin cover-glass, the movements of the comma bacilli 
 remind one of the rapid, darting, zig-zag movements of the individuals of a 
 swarm of small flies, and of the impossibility of distinct vision of any one of 
 the swarm. If, however, a smear-preparation from such a culture be made, 
 and after drying and flaming in the usual manner, this be properly stained, 
 mounted, and examined, it will be seen that each form is more or less curved — 
 a few almost imperceptibly so ; a few others nearly as much as a semi-circle ; 
 the greater number having a curvature representing an eighth or a quarter 
 of a circle. The length may vary from one-seventh to one-fourth the average 
 diameter of the red blood-corpuscle of man, the width being about a fourth 
 its length. Examined critically it can often be seen that, instead of form- 
 ing a segment of a circular ring, the individual form is in reality a portion 
 of a spiral. The ends are blunt but rounded, sometimes slightly tapering, then 
 presenting an outline similar to the fennel-seed. When proper methods of stain- 
 ing are used each end of the " comma bacillus " is found to be furnished with 
 one or more flagella, which act as motive organs. Cultivated in bouillon by 
 the hanging-drop method, besides the above-described forms there are usually 
 seen a variable number of more or less long and complete spirilla. Old cul- 
 tures in bouillon, in gelatin, in agar, and in other media nearly always contain 
 the comma and spiral forms, and intermingled with these are frequently other 
 shapes, which many authorities regard as involution forms. Chief among the 
 latter are spherules of a diameter from that of a cross-section of the comma to 
 that of a red blood-corpuscle of man, and even greater. It is pretty certain 
 that neither the comma nor the spirillum forms contain spores ; vacuoles have 
 been mistaken for them. In the vomit and intestinal contents of the attacked 
 the comma forms are always present for a number of days, and short and 
 incomplete spirils may sometimes be demonstrated in smear-preparations. 
 
 The comma bacillus of Koch multiplies commonly by two modes, each of 
 which, however, constitutes essentially a process of fission : a, the comma 
 doubles its length, and then divides into two ; b, before dividing the comma 
 continues its elongation into a longer or shorter spiril filament, which ulti- 
 mately becomes segmented in order that finally the segments may separate to 
 form new and separate commas. Of these two processes of multiplication, the 
 former is by far the more rapid. Elongation and division of the one comma 
 into two have been actually observed under the microscope to take place in 
 twenty minutes. With such a rate of multiplication demonstrated, one can 
 easily form some adequate conception of the otherwise inconceivable rapidity of 
 
PLATE VIII. 
 
 .- v -* i 
 
 \^ * 
 
 
 
 Fig. 1. Photo-micrograph : Smear preparation from pure culture of comma bacillus of Koch. \ V1W. 
 Fig. 2. Photo-micrograph: Smear preparation from (old) pure culture in gelatin of comma bacillus of 
 
 Koch, showing oogonia of Ferran or involution forms of other authors. \ 1200. 
 Fig. 3. Photo-micrograph : Gelatin-plate colony of comma bacillus of Koch. \ 50. 
 Fig. 4. Photograph: Gelatin tube-culture of comma bacillus of Koch, 72 hours old, surface inclined. 
 
 Natural size. 
 
CHOLERA ASIATICA. 233 
 
 propagation and enormous power of dissemination in river-water of the specific 
 infectious principle of Asiatic cholera contained in the discharges from the bowels 
 of a few cases, numerous examples of which the history of this disease affords ; 
 one of the most striking being the most recent — namely, that of the river Elbe 
 in 1892. Of other possible modes of multiplication, only two may be merely 
 mentioned here : that by intervention of so-called arthrospores of Htippe, who 
 claims that these reproductive bodies approach the tenacity of life and the 
 power of resistance of genuine spores ; and that of so-called " oogonia " of Fer- 
 ran — both modes being a form of multiplication by budding. 
 
 The multiplication of the comma bacillus of Koch in artificial culture 
 media has been found to vary greatly under different constitution of media 
 and varying conditions of temperature, etc. During the development and 
 continued growth of these organisms in artificial culture media, chemical com- 
 binations are split up and various new chemical products formed, as the neces- 
 sary accompaniment of the nutrition, life, or death of the microbes ; and these 
 resultant new chemical products vary in quantity or composition, or both, with 
 the varied chemical and physical complexion of the culture media, the external 
 conditions of temperature, moisture, free oxygen, light, etc. Thus it seems to 
 be now pretty clearly established that in artificial culture, among many other 
 characteristics, the cholera microbe will not develop at a temperature below 57^-° 
 F. or above 107f ° F. ; that freezing, unless it be prolonged, does not kill this 
 microbe, but places it in a state of hibernation, as it were, ready to resume 
 again all its vital and pathogenic functions with the return of sufficient heat ; 
 then, on the contrary, when a temperature of 107f° F. is exceeded the vital 
 functions of the microbe are more and more inhibited permanently, if the tempera- 
 ture be continued, until a point is reached, at about 140° F., where the life of the 
 microbe is destroyed absolutely in a very few minutes ; that multiplication is more 
 rapid in fluid media of suitable constitution ; that the culture fluid, as a rule, 
 possesses more virulence when the inoculated microbes are very recently obtained 
 from an active case of cholera than when a long time has elapsed ; that the pres- 
 ence of peptone in the culture medium seems to materially increase the develop- 
 ment of the virulent power of the microbe, especially when free oxygen and 
 light are excluded ; that there is scarcely any fluid or solid moist nutrient 
 material of animal or vegetable composition, of a neutral or slightly alkaline 
 reaction and not containing a substance possessing antiseptic properties, upon 
 or in which it will not grow ; and there are at the same time many fruits and 
 vegetables upon the pulp or surface of which the microbes of cholera will not 
 only live for hours and days, but will multiply there even when the object gives 
 a slightly acid reaction. This microbe will live and multiply enormously for a 
 time in pure water, in foul water, even in sewerage, and in sea-water ; it will 
 live for a considerable time and multiply enormously in milk, whether fresh or 
 previously sterilized ; it is capable of living and multiplying for a time in vari- 
 ous common beverages and on various common articles of food. It will retain its 
 vitality, sometimes multiply exuberantly, on various textile fabrics of vegetable 
 or animal nature for days, and in some cases weeks and even months, if they be 
 not thoroughly desiccated or exposed to the sun's rays, and contain no antisep- 
 tic susbtance ; if such fabrics be kept decidedly damp or wet, the germ is capa- 
 ble of enormous multiplication, and of retaining its infectious and reproductive 
 power to a virulent degree for indefinite periods, lasting for weeks or months, 
 provided the sunlight does not fall upon it. If, however, these fabrics are 
 thoroughly dry before the microbe is placed upon them, and remain or quickly 
 become thoroughly dry afterward, it soon dies — more quickly still if exposed 
 to the sunshine or bright reflected light. Whilst the propagative power of the 
 
234 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 
 cholera microbe outside the human body, under favorable circumstances, is so 
 enormous as to be almost incredible, fortunately for man it is, of all the dangerous 
 pathogenic microbes known, the most susceptible to restraining or destructive 
 influences. Whilst it is too often true that an individual, a community, a city, 
 a "whole nation, or even a continent, presenting favorable conditions for the 
 free propagation of the infection, oftentimes suifers consequences which in 
 their swiftness, gravity, and manifold relations may be appalling, yet there is 
 no infectious epidemic disease which can so certainly and so easily be warded 
 off or arrested as can Asiatic cholera. 
 
 Mention has already been made of the ingestion, entrance into the small 
 intestine, and exuberant multiplication there of the " comma bacillus of Koch " 
 as necessary conditions precedent to an attack of Asiatic cholera. Even with 
 these it is probable that there must be one more condition before a serious attack 
 follows — namely, susceptibility to the disease on the part of the individual. 
 Since desiccation is one of the sure and rapid means of killing the microbe of 
 cholera, and since the comma bacillus does not exist in the lungs or intestinal 
 organs, in the blood, lymph, or muscular tissue, or in the nervous system of a 
 person suffering an attack of cholera, it is obvious, a priori, that the active 
 infection of this disease is neither inhaled nor does it enter through the cuta- 
 neous surfaces. But in this matter we are not obliged to rely upon inductive 
 reasoning, for there is not a single example known of either mode of infec- 
 tion in the clinical history of cholera or in laboratory experience with this dis- 
 ease. The cholera microbe must be swallowed and pass from the stomach into 
 the small intestine alive and endowed with vigorous powers of propagation 
 and pathogenesis, before cholera can be naturally produced in man. 
 
 There are various means and modes by which the infection of cholera may 
 be introduced into the oesophagus of man. It may be conveyed by various 
 fluids imbibed, such as water, milk, beer, weak tea, etc. ; by various articles 
 of food, such as raw vegetables, bread, butter, fruits, meats, etc. ; by contact 
 of the mouth with hands in some way soiled through careless handling of 
 objects contaminated with numbers of the microbe, such as the clothing worn 
 by the sick, the bed-linen used by them, the vessels containing the vomit or 
 stools, etc. ; by water used for lavatory purposes or the washing of dishes or 
 other food-receptacles ; by water used for washing the mouth and teeth, etc. 
 The corollary of all this is that Asiatic cholera is not acquired by inhalation 
 or mere contact with persons suffering from the disease, or with things contam- 
 inated with the infectious principle. Moreover, there seems to be a natural 
 insusceptibility on the part of many to an attack of cholera, although they 
 be undoubtedly exposed to the infection. Numerous examples of this personal 
 immunity are furnished by every great epidemic, especially when the outbreak 
 has been caused by contamination of the common supply of drinking-water. 
 Furthermore, there is incontrovertible evidence to prove that there is an 
 acquired immunity of variable duration following a natural attack of Asiatic 
 cholera, whether the latter have been grave or mild. Indeed, it is pretty cer- 
 tain that a natural attack so light as to have escaped recognition is capable of 
 producing such an immunity. That an immunity can be acquired artificially 
 by means of inoculations of various kinds and in various ways now seems to 
 be an established fact. I need only mention in this connection the pioneer 
 work of the Spanish physician, Dr. J. Ferran in 1884 and 1885, and after 
 him the investigations of Petri, Brieger, Wasserman, and Kitasato, Klemperer, 
 Klebs, and Haf kine, which with those of others constitute a body of experi- 
 mental data so convincing as to leave but little, if indeed any, room for rea- 
 sonable doubt. Whether or not an attack of cholera follow introduction of the 
 
CHOLERA ASIATICA. 235 
 
 special eontagium vivum into the stomach of man may depend upon one or more 
 of several conditions. The acid gastric juice of the stomach is, when present 
 in sufficient quantity relative to the number of cholera microbes, capable 
 of quickly killing them. Hence at times when the stomach is properly func- 
 tioning and the number of the cholera bacilli swallowed is not excessive, 
 there is far less probability of these microbes passing the pylorus alive and 
 still retaining their vigorous pathogenic powers than when either there is 
 little or no acid in the stomach or but little relative to an excessive number of 
 comma bacilli introduced. Then, again, the factor of personal susceptibility 
 — or, if we prefer its complement, we may say the factor of personal immu- 
 nity — may intervene (after the cholera microbes have passed into the small 
 intestine alive, virulently pathogenic and in sufficient numbers, with certain 
 limitations), either to render an attack of cholera more certain of development 
 and more violent, or to prevent it entirely, or to render it milder, respectively, 
 as the case may be. Thus there is strong reason to believe that in Asiatic 
 cholera as in other infectious diseases, whether the degree of susceptibility or 
 the degree of immunity of any person be great or little, the dosage of the 
 infectious material is a matter of importance for the generation or the violence 
 of an attack. Any degree of immunity can be overwhelmed by an excessive 
 dose, and any degree of susceptibility can be rendered insufficient by too small 
 a dose. These considerations explain why it is that of so many exposed to the 
 infection of cholera only a comparative few suffer an attack which is recognized 
 as such. They also explain why a few foolhardy persons, whose skepticism 
 seems to be greater than their power of discrimination, have ostentatiously 
 swallowed voluntarily, in former times, some of the intestinal discharges of 
 cholera victims, and in later times, some quantities of pure culture of the 
 cholera microbe, and have lived to preach their false doctrine. 
 
 When a sufficient number of vigorous pathogenic cholera microbes is intro- 
 duced into the stomach and passes with vital properties unimpaired into the 
 small intestine of a susceptible person, an attack of infectious cholera may be 
 developed. In such a case the cholera microbes multiply enormously, and 
 often with great rapidity, in the small intestine. With their growth there, 
 under favorable conditions not yet well determined, a virulent specific chemical 
 poison is generated. Whether this poison be essentially a ptomaine analo- 
 gous to the highly-poisonous vegetable alkaloids, as some contend, or a species 
 of virulent albumose, as others maintain, or a special pathogenic enzyme, as 
 a few affirm, or possess other characteristics, or be a combination of two or 
 more of these, it would be unprofitable to discuss in this place. Whatever 
 the nature of this specific chemical poison may be, it is pretty certain that 
 when generated in sufficient quantity it attacks primarily the epithelium of 
 the mucous membrane of the small intestine, exciting in it the phenomena 
 of irritation and degeneration in varying degrees — according to the concen- 
 tration of the poison and the susceptibility of the person — from initial cloudy 
 swelling all the way to complete fatty degeneration and desquamation. The 
 irritant poison penetrates beyond the epithelium and excites in a susceptible 
 person a round-celled infiltration of the connective tissue underlying the epi- 
 thelium ; it may even exert its irritant powers upon the submucous layer of 
 connective tissue, and sometimes its influence may even extend outward into 
 the muscular and subserous coats of the intestine calling forth in them vary- 
 ing inflammatory phenomena. Klebs pointed out that autopsies of rapid 
 cases of cholera showed invariably the inner surface of the small intestine to 
 be covered with a very tenacious coating of mucus, and the experience of 
 most observers confirms him. Another characteristic is that the serous mem- 
 
236 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 brane of the small intestine is likewise the seat almost always of a viscid cover- 
 ing, consisting mainly of degenerated and proliferated endothelium. The 
 inflammatory action in the mucous and submucous coats of the small intes- 
 tine may become so intense as to result in more or less extensive necrosis. 
 Very generally the mucous membrane is hypersemic. This hyperemia may 
 be very diffuse or it may be limited to larger or smaller areas. It is usually 
 most marked in the region of the ileo-csecal valve and around the Peyer's 
 glands. The Peyer's glands and the solitary follicles are usually infiltrated 
 and prominent, and this is so common that some French authors have regarded 
 cholera as a specific psorenteritis. The infiltration of these glands may in some 
 instances be so intense as to end in necrosis and ulceration. Notwithstand- 
 ing the fact that the chemical poison of cholera attacks locally, first, the intes- 
 tinal epithelium, and then the subjacent layers of connective tissue, sometimes 
 even to the point of denudation and limited destruction of the latter, the cholera 
 microbe itself never penetrates the coats of the intestine except when they are 
 denuded, and then does not pass beyond the most superficial portion of the 
 exposed connective tissue : it never enters the lacteals or reaches the general 
 circulation. The chemical poison, however, which is produced in the intesti- 
 nal canal by the growth of the cholera microbes therein, does not limit its 
 action to a local attack upon the intestinal epithelium or upon the subjacent 
 tissues ; but it is taken up by the intestinal absorbents or the capillaries of the 
 villi, and enters the general circulation of the blood to be distributed to every 
 organ and tissue in the body, to develop in the susceptible its secondary or 
 constitutional action. It may be said, therefore, that cholera infectiosa epi- 
 demica is essentially a specific "systemic intoxication. It may not always hap- 
 pen that the whole or the greater portion of the specific poison which pro- 
 duces an attack of Asiatic cholera has been generated within the intestinal 
 canal of the victim ; there is strong reason for the belief that exceptionally, at 
 least, the offending material ingested already contains, before swallowing, a 
 sufficient quantity of the specific chemical poison of cholera to produce an 
 attack of the disease. It is probable that at least some" of those attacks with 
 a violent onset in a very few hours after exposure to the infection have resulted 
 in such a manner, especially if the autopsy show, as it sometimes does, very 
 little alteration of the intestinal mucous membrane. I can conceive, for 
 example, how milk diluted with water contaminated with cholera dejecta, and 
 then allowed to stand for several hours in a warm place, can act as a quick 
 and fatal poison when swallowed in large quantities. In such a case it w T ould 
 matter not if the bacteria were killed in the stomach by the action of the gas- 
 tric juice ; the preformed chemical poison of cholera when absorbed from the 
 intestine and circulated in the blood might, if in sufficient quantity, still be 
 capable of causing a violent, and even a mortal, attack of cholera. The 
 stools from such a victim of the cholera poison might still contain some quan- 
 tity of that poison, but could not, in the absence from them of the living 
 pathogenic comma bacillus of Koch, be infectious. In other words, from 
 such a victim a new case of cholera could not arise, much less an epidemic. 
 Furthermore, although the symptoms, course, termination, and post-mortem 
 appearances observed in such a case would naturally be those characteristic of 
 cholera, yet a culture test of the stools would necessarily be negative in result, 
 and therefore misleading as to the origin of the attack, if not, indeed, of its 
 nature. A priori, it is just among young children, who consume habitually 
 large quantities of milk, that we should look for the largest proportion of 
 such toxic non-contagious attacks of cholera. 
 
 Symptoms. — For convenience of description in part, and in part also 
 
CHOLERA ASIATIC A, 237 
 
 because the common course of the attack furnishes the basis of the division, 
 clinical writers have been in the habit of discussing the symptoms of Asiatic 
 cholera under four periods :. a, the prodromal period ; b, that of serous evacu- 
 ation : t\ that of algidity or collapse ; d, that of reaction. 
 
 a. The prodromal period, or period of incubation, varies in duration from 
 a few hours to perhaps five days. Probably its average length may be most 
 accurately reckoned at forty-eight hours. It is the time which elapses between 
 the ingestion of the infectious material and onset of pronounced symptoms. 
 During the early part of the period, sometimes during the whole of it, the 
 subject is apparently in his accustomed health, whilst in the latter part of it, and 
 occasionally throughout its entire length, and increasing in severity toward its 
 transition into the next period, there may be a general feeling of distress in the 
 abdomen, or even a tendency to nausea, with or without tenderness, restlessness, 
 rumbling, and increased peristaltic movement of the intestines sometimes visi- 
 ble or palpable through the abdominal walls ; laxness of the bowels or decided 
 diarrhoea, with colored semifluid, feculent, or decidedly fluid, usually painless, 
 sometimes copious, evacuations. All of these symptoms may be present, or 
 only one of them, or they all may be absent. There is nothing at all dis- 
 tinctive in their character which is in any way suggestive of their special 
 nature. They excite suspicion only when it is known or suspected that the 
 person may have been exposed to the infection of cholera, or when the disease 
 is present in the locality. There is no indication of systemic intoxication dur- 
 ing this period. The cholera microbe has merely reached the small intestine, 
 and is more or less quietly gathering its forces for the active attack. It is 
 engaged in multiplying itself and in generating its specific poison. The 
 assault on the epithelial lining of the small intestine may have actually 
 begun, and some breaches in its integrity have been accomplished ; sufficient 
 of the chemical poison may have been generated for the production of some 
 hyperemia of the mucous membrane, or even for the excitement of some infil- 
 tration of the subepithelial connective tissue ; but there has been as yet no sys- 
 temic absorption of the specific chemical poison ; the action of the special 
 poison is still local, although there may be experienced a degree of prostra- 
 tion out of all proportion to the diarrhoea present. 
 
 b. The period of serous evacuations may be regarded as that of sys- 
 temic intoxication, and its duration may last from a few hours to a day or two. 
 The prodromal diarrhoea, if it have existed, now usually assumes more gravity. 
 The discharges become more frequent, copious, and fluid. Often, .but not 
 always, every trace of color disappears from the stools. The latter now fre- 
 quently present the well-known rice-water aspect : they are thin, very watery, 
 and hold in suspension more or less minute whitish flakes or shreds in 
 great numbers ; they look like a watery gruel, in fact closely resemble the 
 aspect of barley-water or macaroni-water. They may sometimes still be 
 slightly colored, and they are not infrequently frothy or somewhat bloody. 
 In fact, there is many a case of cholera Asiatica where the stools are bilious 
 or lack entirely the familiar rice-water appearance. Often the desire to evacu- 
 ate the bowels is sudden and absolutely uncontrollable, and the contents of the 
 lower colon and rectum are sometimes expelled with great force without pain 
 and in enormous quantity, saturating the bed and covering, or deluging the 
 clothing if the patient be still up and moving around. Nausea and vomiting 
 are now usual accompaniments. At first the vomit may be bilious ; later it 
 assumes the rice-water or gruel aspect. The amount of fluid discharged from 
 the anus and mouth is often excessive. Prostration quickly becomes extreme, 
 and thirst intense. The cry for water is constant, yet it is rejected by the 
 
238 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 stomach almost immediately after it is swallowed. The enormous exudation of 
 fluid into the intestinal canal reduces correspondingly the volume of the lymph 
 in the tissues and organs, and of the blood in the circulatory system. The tis- 
 sues become abnormally dry and shrunken, and the blood markedly thickened. 
 The number of the corpuscles of the blood is relatively much increased per 
 cubic centimetre ; it is sometimes nearly doubled. The heart has not of itself 
 the power to propel this thickened fluid with sufficient vigor to prevent venous 
 stagnation. At first the pulse is very frequent for a time ; indeed, palpitation 
 may add to the general distress and anxiety of the patient ; besides being 
 accelerated, the pulse is usually at the same time small, feeble, and soft. Later the 
 heart's action becomes more and more enfeebled, until the pulse is nearly or 
 quite lost at the wrist, whilst the apex-beat may also nearly or quite disappear, 
 and the heart-sounds themselves decidedly change their character — the systolic 
 sound being greatly weakened, or even replaced by a faint blowing murmur, 
 and the second sound lost entirely. The loss of fluid is shown in the deeply 
 sunken orbits, glazed corneae, the pinched expression of the face, the wrinkled 
 condition of the palmar -surface of the hands and feet — the washer-woman's 
 hands — and the general emaciation, which often becomes extremely marked. 
 The impeded circulation of the blood is evidenced by the more or less lividity, 
 which is most marked around the eyes, the ears, the lips, and the ends of the 
 fingers. The surface temperature sensibly falls below the normal, sometimes 
 markedly ; on the contrary, the rectal temperature is usually considerably 
 above the normal. The temperature under the tongue is commonly subnormal, 
 and the tongue itself often feels cold to the touch. Whilst the cutaneous sur- 
 face is objectively cold, the patient himself will frequently complain of intense 
 internal heat. The voice becomes w T eak, hollow, and husky. The intellect 
 may be clear or clouded. Sometimes there is great restlessness and jactita- 
 tion ; at other times there may be entire calm and hebetude approaching to 
 stupor. Oftentimes cramps in the extremities and trunk may be absent or 
 mild and fleeting, or they may be so violent as to cause agonizing pain to the 
 patient. In the early part of this period there is marked diminution of urine 
 associated with albuminuria, and frequently, granular tube-casts. Very soon, 
 however, secretion of urine is completely suppressed. While the blood is 
 robbed of chloride of sodium and serum by the exudation into the intestinal 
 canal, it is overladen with urea, which the kidneys fail to remove, and there 
 is proportionately more of its salts in the central nervous system than anywhere 
 else in the body. 
 
 We have said that this period should be regarded as that of systemic 
 intoxication. The specific chemical poison elaborated in the small intestine 
 during the enormous multiplication of the comma bacillus of Koch, has at 
 at length been taken up by the intestinal absorbents or has entered the net- 
 work of intestinal capillaries, and has reached the general circulation of the 
 blood. From this moment the scope of its action is no longer localized in 
 the small intestine, but is now extended throughout the whole system. 
 The presence of this specific poison in the blood of the susceptible, works 
 changes in the complexion of this vital fluid, some of which are readily vis- 
 ible. We have already spoken of the relative increase of the corpuscular ele- 
 ments due to loss of fluid. There is, however, a material change in the red 
 corpuscles, probably due to the effect of the special chemical poison : many of 
 the red corpuscles are much paler than normal, and also much smaller ; some 
 have been broken up into very small particles, which by reason of their form 
 and frequent arrangement in pairs and chaplets have been mistaken for micro- 
 cocci. The specific gravity of the blood is much increased ; there is little or 
 
 . 
 
CHOLERA ASIATIC A. 239 
 
 no tendency of the red corpuscles to adhere together, and there is little ten- 
 dency to the formation of large clots when allowed to stand ; if there be any 
 separation of serum, it is very slight. The blood when drawn from the veins 
 is very dark, almost black in color and tarry in consistence. 
 
 This abnormality of the blood does not, of course, reach its height at once 
 with the commencement of this stage, but progresses with the continuance and 
 severity of the exudation of the fluids into the intestinal canal during this 
 period. The blood becomes so thick and the heart's action so weak that the 
 flow in the veins becomes exceedingly slow or seems to be arrested entirely 
 toward the end ; it sometimes will not flow from an incision. The left side 
 of the heart may contain but little blood, and the large arteries, which are 
 often spasmodically contracted, are nearly empty. The right side of the heart, 
 on the contrary, is full oftentimes to over-distention. The lungs are usually 
 found, post-mortem, to be quite pale, bloodless, and retracted well against the 
 spinal column. In the mesenteries the arteries are much contracted, while the 
 veins are greatly dilated, and there is usually also capillary engorgement. In 
 fact, this condition of strong contraction and emptiness of the calibre of arteries, 
 wide dilatation and fulness of the veins and capillaries, is observable nearly 
 everywhere. There are often also small ecchymoses, aud sometimes rather 
 extensive extravasations, particularly at the mucous surfaces. (Edemas, how- 
 ever, are not to be met with ; notwithstanding the numerous stagnations of the 
 blood-current in veins and capillaries, the flow of fluids of the blood into the 
 intestinal canal is so great, and the consistency of the blood has become so 
 thick, that everywhere else than at the mucous surface of the intestines the 
 tendency to fluid exudation has been completely arrested. The ecchymoses 
 above mentioned are more abundantly scattered over the mucous and serous 
 surfaces than elsewhere, although they may exist even in the muscular tissue. 
 
 The toxic influence of the specific chemical poison in the blood is probably 
 most marked upon the central nervous system (including the sympathetic gang- 
 lionic system), and upon the liver and kidneys, especially the latter. The 
 mechanical results of loss of such an enormous qauntity of body fluid may in 
 some part account for the seriousness and severity of the symptoms of this and 
 the following period ; but doubtless the action of the chemical poison in the blood 
 upon the nervous system, the liver, and the kidneys is even superior. The first 
 onslaught of the poison upon any important internal organ after reaching the 
 blood naturally falls upon the liver. This organ is generally smaller than 
 normal, flaccid, and anaemic, and contains less glycogen than normal. The 
 outlines of the lobules are more or less indistinct ; the interlobular network of 
 blood-vessels may or may not be dilated and filled with blood ; the radiating 
 cellular trabeculse of many lobules are decidedly narrowed, while the inter-tra- 
 becular blood-capillaries of some portions of acini are dilated and filled with 
 blood-corpuscles. The hepatic cells of many acini are granular and difficult 
 to stain. Some investigators contend that there is actually some atrophy of 
 the liver. The gall-bladder, the cystic and common ducts are distended with 
 a thin brownish or greenish fluid, whilst the interlobular biliary network is not 
 appreciably altered. Whilst the biliary ducts and gall-bladder are full, the 
 intestinal end of the ductus communis choledochus is usually practically imper- 
 meable, and the intestines rarely contain any bile. The spleen is contracted 
 and often flabby. Next to the intestinal lesions in cholera the kidneys show 
 the greatest pathological changes. The effect of the cholera poison in the 
 blood falls heavily upon these emunctories. Granular degeneration of the se- 
 cretory tubules of the cortex soon becomes marked, but is irregularly distri- 
 buted at first. After this pathological process has continued for some time, 
 
240 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 fatty degeneration of the tubular epithelium becomes general and intense, and 
 associated sometimes with parenchymatous inflammation. The suppression of 
 urine is therefore not alone due to the mechanical effects of thickening of the 
 blood. 
 
 c. The period of algidity or collapse may follow after a few hours of con- 
 tinuance of the period of serous evacuations, and may last for some or many 
 hours until death or reaction ensues. In this desperate condition prostration 
 is extreme ; the voice is gone ; respiration is very feeble, shallow, and fitful ; 
 the pulse has vanished and the heart almost ceases to beat ; so also the nausea, 
 vomiting, and cramps, the frequent enormous forcible evacuations of the 
 bowels, whilst, instead of the latter, the contents of the intestines dribble away 
 from the anus, whose sphincter is inactive. Profound stupor or coma is the 
 rule. The general lividity is intense ; the coldness of the skin is like that 
 of marble. The vital forces are nearly overwhelmed by the great losses of 
 fluid sustained, by the effete substances which are accumulated, and by the 
 special cholera poison. During this period the vital spark flickers very 
 faintly ; life hangs trembling in the balance. The pathological conditions 
 are essentially those of the previous period, intensified. 
 
 d. The period of reaction may be short or prolonged, and directly follow 
 either of the three preceding. It may last from three or four days to as many 
 weeks. When it follows immediately upon the prodromal period, convalescence 
 is usually rapid and short, and the wonted health is soon perfectly re-established. 
 In such a case there is, after all is over, of course, great doubt that the attack 
 was choleraic at all. The finding of the comma bacilli of Koch in the 
 stools is the only certain criterion of what its true nature has been. When 
 the period of reaction immediately follows the period of serous evacuations, it 
 is usually the more definite the more serious the symptoms and pathological 
 lesions during the latter period have been. If there have been great altera- 
 tions of the mucous membrane of the intestines, profound general intoxica- 
 tion, with great destruction of the red elements of the blood and marked de- 
 generations in the liver and kidneys, we may expect to witness a more or less 
 prolonged, complex, and dangerous period of reaction. In fact, as a rule, 
 more patients die during than before reaction, when the latter follows immedi- 
 ately the period of serous evacuations. The gravity of the symptoms and 
 general condition of the patient may slowly ameliorate or quickly improve, or 
 one set of alarming symptoms may simply be substituted by another set, which, 
 although not so frightful to the laity, will be regarded by the experienced phy- 
 sician as only a prolongation of the critical struggle between the very evenly 
 balanced forces of life and of death. The evacuations from the stomach and 
 bowels decidedly lessen in frequency and copiousness ; the stools lose their 
 barley-water aspect ; the bile reappears in them, and they assume gradually 
 the common characteristics of an ordinary diarrhoea, sometimes stained with 
 blood ; or if the local destructive effects of the cholera poison have been 
 drastic, there may be grafted upon the diarrhoea a more or less pronounced 
 dysenteric condition with bloody stools and tenesmus. The characteristic aro- 
 matic sperm-like odor of the rice-water stools may now change to the foul, 
 stinking odor of decomposition, and the flatulence which was absent during 
 the preceeding period may become annoying. The voice becomes stronger, 
 respiration more steady and fuller. The heart gradually regains its lost 
 powers ; the pulse begins again to be felt at the wrist ; the surface tempera- 
 ture again goes toward the normal and quickly passes above it ; the shrunken 
 countenance begins to discard the Hippocratic expression, the sunken orbits 
 to fill up and the glazed eyes to brighten ; prostration becomes less marked, 
 
CHOLERA ASIATICA. 241 
 
 thirst less intense ; the secretion of urine is slowly re-established, at first con- 
 taining much albumin, granular casts, and large quantities of urea ; appetite 
 and digestion are slowly recovered as a rule. In fortunate cases the restora- 
 tion to health and to the proper exercise of all the bodily functions may 
 be rapid and complete. But in other cases anaemia, due to the great injury 
 to the elements of the blood, may be protracted ; or the functions of the 
 much-damaged kidneys may be slow of re-establishment ; or the destruction 
 of intestinal epithelium may leave denuded patches in the subepithelial layers 
 of connective tissue, and thus occasion prolonged irritation and even serious 
 derangement of the processes of digestion, and at the same time furnish 
 numerous points of entrance for various septic micro-organisms. In truth, 
 a secondary septic fever, as the result of systemic invasion in this manner, 
 is not at all uncommon in this period : it is vulgarly called the typhoid stage 
 of cholera. 
 
 When the patient passes through the period of serous evacuations and 
 that of algidity or collapse, the period of reaction usually differs only in 
 degree from the condition above described. It can be now readily understood 
 why almost as many victims succumb during the period of reaction as during 
 the periods of specific action of the cholera poison. Even after convalescence 
 has been established impaired health may persist for a long time, evinced by 
 chronic anaemia, stubborn disorders of the digestive apparatus, and easily dis- 
 turbed bowels. Before convalescence is fully confirmed, and even for some 
 time afterward, imprudences of diet sometimes precipitate a dangerous relapse. 
 
 Special Phases of Cholera. — In a virulent epidemic of cholera the cases 
 of very sudden and violent attacks, which do not seem to have been preceded 
 either by a prodromal period or the one described in section 5, are sometimes 
 numerous, and they are most frequently encountered near the commencement 
 of the outbreak. These attacks have been variously named foudroyant, toxic, 
 asphyxic. In description of these foudroyant attacks we cannot do better 
 than quote the recent language of Dr. N. J. Simpson, the health officer of Cal- 
 cutta : " On these occasions the suddenness of the attack, the number affected, 
 and the virulence of the disease would incline one to think that the specific 
 organisms had already elaborated outside the human body a strong poison 
 which acted on the victim almost immediately after being swallowed. Under 
 the most favorable conditions for the elaboration of such a poison there will 
 not, as far as can be ascertained, be the usual twelve to forty-eight hours' 
 period of incubation ; on the contrary, patients will be brought into hospital 
 in a dying state, though taken ill only a short time previously ; some will die 
 before reaching the hospital ; and the ratio of mortality is likely to be 75 to 
 85 per cent. The description given by Dr. Jamieson in 1817 seemed to me 
 until some time ago somewhat exaggerated, when the cases seen during an 
 outbreak at a large pilgrimage convinced me of the correctness of Jamie- 
 son's accounts as applied to exceptional outbreaks. He says : ' Sometimes 
 there was no vomiting, sometimes no purging, sometimes no spasm throughout, 
 sometimes all these symptoms were simultaneous, and the vomiting and purg- 
 ing took place together, as if caused by sudden contraction of the alimentary 
 canal in its whole extent. In some rare cases the virulence of the disease 
 was so powerful as to prove immediately destructive to life, as if the circula- 
 tion were at once arrested and the vital powers wholly overwhelmed. In these 
 cases the patient fell down as if struck by lightning, and instantly expired. 
 Others, again, sank after making one or two feeble efforts to vomit and draw- 
 ing a long and anxious inspiration ; some recovered from the insensibility pro- 
 duced from the first shock, and afterward went through the regular course of 
 
 16 
 
242 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the disease.' In these and similar cases a virulent poison is the best expla- 
 nation of the symptoms and apparent absence of the period of incubation, 
 and of the destructive nature of the disease." Another phase of cholera still 
 more rarely met with is what has been termed cholera sicca. In this there is 
 no vomiting, no purging, but the other symptoms may be little different from 
 those already described. The autopsy shows, however, that there has never- 
 theless been great exudation of fluid into the intestinal canal, for the latter is 
 greatly distended with it from end to end. 
 
 Special Complications of Cholera. — I have already spoken of frequent 
 occurrences of ecchymoses, especially on the mucous and serous surfaces. 
 Cutaneous petechia and eruptions are not uncommon in the period of reaction ; 
 they appear less frequently during that of serous evacuations or algidity. 
 These eruptions, more often observed on the face, neck, and forearms than 
 elsewhere, are usually more or less punctate, the puncta being slightly elevated 
 and having a tendency at times to aggregate into irregular groups. These 
 spots vary somewhat in color, but most frequently the points are dark or black. 
 In some rare cases the vitality of the skin seems to be in a degree impaired, 
 as indicated by a disposition to ulcerate upon small provocation ; for example, 
 bed-sores may sometimes develop early and become an exceedingly trouble- 
 some complication. The cause of these eruptions is unknown, but if we were 
 to express a mere conjecture, it would be that they may be due to innumer- 
 able minute thrombi and emboli — small clots which have formed during 
 stasis of the blood. 
 
 Diagnosis. — The differential diagnosis of Asiatic cholera by means of its 
 symptoms alone is, during the absence of an epidemic of the disease, one of 
 the most difficult feats the clinician is ever called upon to perform. Indeed, 
 it is held by some of the most- skilful and renowned clinical diagnosticians in 
 the world to be an utter impossibility to make a certain diagnosis ; and it is, 
 and always has been, the common experience of the whole world that the 
 saddest, and for the public health the most deplorable, mistakes are very 
 often made even by the most experienced. And yet there is no single one of 
 the whole category of diseases with respect to which a mistake in diagnosis of 
 a first case may, and sometimes does, entail such an endless series of incalcula- 
 ble public calamities. There is not one of the symptoms, and of the groups 
 of symptoms, met with in some period of an attack of Asiatic cholera, which 
 does not perfectly resemble those of some disease which is more or less 
 common. Among these commoner affections for which Asiatic cholera may be 
 mistaken clinically are cholera morbus, arsenical poisoning, pernicious inter- 
 mittent fever, and poisoning from consumption of various articles of food in 
 special states of decomposition or fermentation. 
 
 Of course during the prevalence of an epidemic in a locality, the physician 
 of that place will wisely regard and treat every case presenting the symptoms 
 common in Asiatic cholera as an undoubted case, and will not hesitate to 
 handle it as such ; for the community will unquestionably uphold him. It is, 
 however, just when the physician is most uncertain — namely, in dealing with 
 those doubtful cases which precede and follow the epidemic — that the real 
 interests of the community and of the general public demand the greatest cer- 
 tainty of diagnosis ; but then, as a rule, the people are unwilling to submit to 
 restraints. Fortunately, through the discovery of Koch in 1883 and 1884, 
 we now possess the means of making an absolutely certain differential diagnosis 
 of cholera infectiosa epidemica, and without reliance upon clinical symptoms, 
 which may be misleading, or upon trustworthy knowledge of the previous history 
 or relations of the patient, which may be difficult or impossible to obtain. The 
 
CHOLERA ASIATICA. 243 
 
 presence or absence in the stools of the suspect of the comma bacillus of Koch 
 promptly and definitely settles the matter. This can be determined within forty- 
 eight hours by resort to the microscopic and biological tests. These tests, 
 however, should never be relied upon when made by a tyro. They are too 
 difficult of application to be trusted to the inexperienced. To describe here 
 the methods of procedure would therefore be useless, for the experienced bac- 
 teriologist does not need such instruction, whilst the unskilled would need 
 much more to be rendered capable. During times of great danger of the 
 introduction of Asiatic cholera into a locality all cases presenting the symp- 
 toms of cholera should be handled as suspicious until a differential diagnosis 
 by means of the microscopic and biological tests be made by a thoroughly 
 competent and experienced bacteriologist. 
 
 Prognosis. — The outcome of an attack of cholera depends very much 
 upon what period of the seizure medical advice is had, very much upon the 
 slowness or rapidity with which grave symptoms appear and persist, very 
 much sometimes upon the period of the epidemic at which the attack happens, 
 and very much upon the constancy of intelligent care in handling the case 
 from first to last. Wise and prompt treatment of the first stage usually aborts 
 the attack almost in the beginning, and is followed by scarcely any mortality. 
 In the vast majority of such cases the attack never gets beyond the stage of 
 premonitory diarrhoea, and convalescence is usually rapid and complete. The 
 prognosis of a seizure which has passed into the second period, or that of pro- 
 nounced serous diarrhoea, is grave ; the mortality varies greatly, from 25 to 60 
 per cent, of attacks, by reason of the varying susceptibility of patients, vary- 
 ing doses of the specific poison, varying promptness, persistency, and wisdom 
 of treatment. The prognosis of an attack of Asiatic cholera in the period of 
 algidity or collapse is truly desperate, and the mortality has usually been 
 frightful, not infrequently having reached 80, 90, and sometimes 100 per cent. 
 The prognosis of an attack which has reached the period of reaction varies 
 greatly according to the damage which may have been done the intestinal lin- 
 ing, the secretory elements of the kidneys, the glandular elements of the liver, 
 and the elements of the blood, and in proportion to the accumulations of effete 
 material and of specific poison in the blood and tissues. It is sufficiently 
 serious to require careful nursing and wise medical direction ; where septic 
 poisoning has been engrafted upon the cholera attack, it is often grave. 
 Speaking generally, the mortality of epidemics of Asiatic cholera is usually 
 greatest in the early course of the outbreak in the locality, and is limited 
 almost entirely to those who neglect to invoke the aid of the physician until 
 the attack has become exceedingly grave. The general mortality among the 
 attacked may vary between 20 and 80 per cent., according to the virulence 
 or mildness of the type of the disease, the total average being nearly 50 per 
 cent. If the patient is seen early and is promptly, judiciously, and constantly 
 cared for, the danger of a fatal issue is usually not great. 
 
 Treatment. — Although the gross number of attacks of Asiatic cholera 
 and the wide spread of pandemics of the disease among civilized nations have 
 lessened considerably, thanks to better hygiene and improved methods of pre- 
 vention, yet the percentage of deaths to attacks remains about the same 
 now as it was many decades ago, and is not very materially lower under mod- 
 ern and civilized systems of therapeutics than it has been under antiquated 
 and semi-civilized or barbarous modes of management. Knowledge of efficient 
 methods of treatment of cholera has by no means kept pace with that of 
 the etiology and prophylaxis of the disease. In the early stages of this 
 disease the skilful physician is all powerful ; in the latter stages he is almost 
 
244 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 impotent. Hence the paramount advantage of prompt and judicious medical 
 treatment. 
 
 Treatment in the Premonitory Period. — During the prevalence of 
 Asiatic cholera in a locality, every disturbance or derangement of the ali- 
 mentary canal should be corrected without loss of time. Indigestion or 
 abdominal distress should receive without any delay the careful attention of 
 the physician, who should not fail to impress upon his clientele the urgent 
 necessity of scrupulous obedience to his instructions. The first thing to do is 
 to remove any apparent cause of the disturbance ; place the patient upon a 
 lighter diet, fluids by preference ; absolutely interdict any exercise which tends 
 to overheat or fatigue ; insist upon clothing during the day which will keep the 
 trunk and extremities warm, and, during the night, which will prevent chilling 
 of the abdomen and the legs. One article of clothing should consist of a broad 
 flannel binder around the abdomen and loins next the skin, kept on day and 
 night. The first appearance of diarrhoea should be the signal for active treat- 
 ment. One or two stools during the twenty-four hours more than the usual num- 
 ber habitual to the individual when in health, or a single copious watery stool, 
 should require the patient to be put to bed at once and kept recumbent, not only 
 during the continuation of looseness of the bowels, but for a day or two after this 
 condition has entirely disappeared. All solid food should be rigidly interdicted, 
 and nothing but broth, bouillon, or whey, allowed to be eaten. In fact, an 
 approach to abstinence is far more desirable than risk of overfeeding. The 
 looseness of bowels or diarrhoea must be arrested as soon as possible, but in 
 doing this it is much better to avoid powerful astringents and strong opiates if 
 it can be done without them. In the choice of the remedy it should be borne 
 in mind that the nature of the disturbance is that of a specific infection of the 
 small intestine by the comma bacilli of Koch, associated with, and greatly 
 favored by, a rather decided alkalinity of the intestinal fluids. The rational 
 treatment would therefore seem to be the administration of some combination 
 of acids, disinfectants, and sedatives. Of the acids which may be employed 
 in proper doses are sulphuric, hydrochloric, lactic ; of the intestinal disin- 
 fectants, naphthaline, salol, calomel, salicylate of bismuth ; of the sedatives, 
 paregoric, Hoffman's anodyne. Aromatic sulphuric acid and paregoric in 
 proper doses may be given and repeated p. r. n. This may be alternated or 
 not with naphthaline or salol, alone or in the same powder with salicylate of 
 bismuth, or with naphthaline and calomel together. It will be found in 
 the great majority of cases that this simple treatment will prove effective. 
 Instead of the mineral acids, lactic acid is preferred by many. Dujardin- 
 Beaumetz uses — 
 
 Jfy. Lactic acid prts. 10, 
 
 Syrup " 20, 
 
 Tinct. of citron ........ " 2, 
 
 Water . ..:..," 1000.— M. 
 
 Sig. For the adult three teaspoonfuls, with or without 20 drops of pare- 
 goric added, at intervals of a half hour, or longer as the case may require. 
 
 As a drink instead of water, it is well to use an acid lemonade with a view 
 to lessening the alkalinity or rendering acid, if possible, the reaction of 
 the contents of the small intestine, in order to inhibit the growth therein of 
 the specific microbe. Sulphuric, hydrochloric, or lactic acid — say, one part to 
 the thousand of sterilized water, sweetened — may be employed for this pur- 
 pose. 
 
CHOLERA ASIATICA. 245 
 
 Should the diarrhoea persist or increase in severity in spite of the simple 
 treatment above mentioned, recourse must be had without loss of time to more 
 active medication. Stronger anodynes and decided astringents are called for. 
 Chlorodyne may be used, or Lausedat's drops, as follows : 
 
 1$;. Tr. valerians aether TTLc 
 
 Tr. opii TTLxx. 
 
 Essentia menthse piperit gtt. v. 
 
 Spts. setheris comp TTLc. — M. 
 
 Sig. Five to eight drops for a child of six years. 
 
 Or something like the following may be tried : 
 
 3^. Acid, tannici 
 
 Plumb i acetat da gr. iij. 
 
 Pulv. opii gr. ss. 
 
 Oleoresinae capsici . gr. ij. — M. 
 
 Ft. pil. No. XII. 
 
 Sig. One pill every one to four hours, p. r. n., at the age of six years. 
 
 On the principle of clearing the bowels of irritants and altering the secre- 
 tions, some begin the treatment of this period with a large dose of calomel, 
 followed in a few hours by castor oil combined with naphthaline. 
 
 Treatment of the Period of Serous Diarrhcea or Systemic In- 
 toxication. — Although such early treatment as indicated above will, as a 
 rule, prove effective in the prevention of full development of an attack, there 
 are some cases which seem to be doomed, in spite of prompt and judicious 
 attention, to advance into the period now under consideration. Moreover, it 
 it is usually not until this period that the physician is called. The conditions 
 now to be contended with are those which have already been pointed out. 
 
 For the vomiting and thirst cracked ice and sinapisms to the epigastrium ; 
 for the coldness, envelop the whole person in hot flannel blankets, with bottles 
 of hot water next the skin, and immersion in a hot bath for fifteen or twenty 
 minutes at intervals of two to four hours ; for the cramps, friction by rubbing 
 with the palms of the hands : if the pain be violent it may be allayed by inha- 
 lations of ether ; for the prostration and restlessness, cardiac stimulants and 
 nervous sedatives ; for the purging, chiefly intestinal antiseptics and correc- 
 tives ; for the loss of fluid, hypodermatic or intravascular injections of saline 
 fluids ; as against the special poison in the intestinal canal, irrigation of the 
 colon with large injections of saline fluids. 
 
 Among the legion of remedies which have been tried and often been found 
 wanting, the favorite East Indian compound called chlorodyne has been about 
 as useful as any. Lausedat's drops, already mentioned, may take the place of 
 chlorodyne. The remedies mentioned in treating of the prodromal period, es- 
 pecially the acids and antiseptics, may still be useful in the early part of the 
 stage now under consideration. A powder which has been often used in former 
 epidemics to combat coldness, prostration, and collapse has the following com- 
 position : 
 
 ty. Bismuthi subnitrat. 3J- 
 
 Plumbi acetat. gi'. iij . 
 
 Camphorae . . . . . gr. ij. 
 
 Oleoresinae capsici gr. j . — M. 
 
 Divide in chart. No. XII. 
 Sig. One every hour or two. 
 
246 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Macnamara, the great Anglo-East-Indian authority on cholera, says : " I 
 think water, though urgently demanded by the patient, should be refused 
 (cracked ice is recommended instead). I would restrict the opium to three 
 grains ; it is unwise to give more, although we are wellnigh certain that much 
 
 of it has been vomited If the vomiting is very severe, a single 
 
 dose of twenty grains (for the adult) of calomel will sometimes relieve this 
 symptom. A mixture may be added, each dose of which contains two grains 
 of acetate of lead and fifteen drops of dilute acetic acid, to be taken every 
 second hour, and fifteen drops of dilute sulphuric acid in water every alternate 
 hour, so that the patient should take a draught of first one mixture and then 
 the other every hour. In this way the alkaline stools become acid, and perhaps 
 destroy the cholera organism in the intestinal canal. However this may be, 
 
 these acids seem to be beneficial in the treatment of cholera I 
 
 believe that alcohol is positively harmful in any stage of cholera." 
 
 Unfortunately, in this stage of cholera medication by way of the stomach 
 is always impeded, very often rendered almost useless, sometimes quite impos- 
 sible of effecting an impression, by reason of the vomiting and the failure of 
 absorption in the intestines. If the little that is not rejected by the stomach 
 succeeds in reaching the intestine, it so often happens that none of it is 
 absorbed ; powerful drugs may lie and accumulate in the latter, to cause actual 
 harm when the stage of reaction is ushered in, and with it restoration of the 
 function of intestinal absorption. Neither can ordinary rectal injections of 
 medicine be depended upon, for the same reason. The sluggishness, sometimes 
 practical stagnation, of the little lymph still remaining in the tissues, after the 
 continuous drain of copious watery evacuations from the bowels, usually lessens, 
 often quite nullifies, the customary results of hypodermatic medication. When 
 such a condition arises, as it unhappily too often does, what other resources has 
 the physician left to him ? There are still three which, used judiciously and 
 skilfully, are powerful to restore marvellously — at least for a time, sometimes 
 permanently — the suspended functions. I refer to intestinal, to hypodermatic, 
 and to intravascular irrigation. 
 
 Enter ocly sis, first introduced by the late Prof. Cantani of Naples during 
 the former cholera epidemic in Italy as a means of treating all stages of the 
 disease, consists essentially in irrigating the rectum, colon, and, if possible, 
 also the small intestine, with large quantities of a warm, astringent, antiseptic, 
 sedative fluid. The following is Cantani's formula for an adult : 
 
 ^ Boiled water or infusion of chamomile . . 2 quarts. 
 
 Tannin 1-1- to 21 drachms. 
 
 Laudanum 30 to 50 drops. 
 
 Powdered gum-arabic 1J ounces. 
 
 The temperature of this mixture when introduced should be sufficiently 
 above the normal to aid in restoring heat to the body. Of course the quantity 
 injected should vary according to the age of the patient and other circum- 
 stances in the judgment of the physician. The best time for administration 
 is immediately after an evacuation. 
 
 Hypodermoclysis, also first introduced by Prof. Cantani as a means of 
 treating especially the stages of serous diarrhoea and of algidity or collapse, 
 consists essentially in the introduction hypodermatically of a large quantity 
 of warm saline fluid for the purpose, primarily, of replacing the fluid lost 
 through the intestinal drain ; secondarily, of washing out from the blood 
 and tissues much of the effete material and specific poison which have accumu- 
 
CHOLERA ASIATIC A. 247 
 
 lated in them. Cantani's formula for an adult consists of 2 quarts of boiled 
 •water, '1\ ounces of pure sodium chloride and a drachm and a half of sodium 
 carbonate. The quantity to be injected each time varies according to age, the 
 apparent amount of fluid lost, and other circumstances. The amount for an 
 adult is one to two and a half quarts. The temperature of the solution when 
 injected should be 100J-° F., unless that of the rectum be very low, in which 
 case it has been sometimes raised as high as 109^° F. The most successful 
 time for resort to hypodermoclysis is at the first indications of insufficiency of 
 water in the body, such as Hippocratic countenance, wrinkling or discoloration 
 of the skin, cramps, coldness, etc. 
 
 Intravascular injections of saline fluids, a procedure as old as the history 
 of cholera in Europe, has had a renewed trial during the present visitation 
 of the disease. Injection into veins and into arteries has been practised 
 especially at Hamburg, and each method of procedure has its champions. 
 Some variations in the constitution and proportions of the saline fluid used 
 occur, but the following may be regarded as a standard : sodium bicarbonate 
 1 part, sodium chloride 6 parts, boiled water 1000 parts. The temperature of 
 the fluid when injected varies according to circumstances from 100J- F. to 
 104° F., more frequently the latter. The quantity administered has sometimes 
 been very considerable, averaging for the adult one to two quarts. The injec- 
 tion may be repeated in a half hour to four hours, as the condition of the 
 patient demands. 
 
 Of the relative advantages and disadvantages of the hypodermatic and 
 intravascular irrigations, it may be said that the former is slower and usually 
 more permanent in its action than is the latter. There may occur occasions, 
 however, in the treatment of the algid period, when the matter of time will 
 decide which method shall be tried first. It seems to me that it is mainly in 
 rapidly-sinking cases in that period, that intravenous injection should be given 
 the preference, to be followed at the second injection by hypodermoclysis. The 
 hypodermoclysis has the further advantage of being far simpler of application. 
 Only one skilful person is required for this operation ; indeed, the attendants 
 can readily be instructed to perform it very safely in the absence of the physi- 
 cian. On the contrary, the physician requires at least one skilled assistant 
 to safely perform the intravascular injection. In all these operations strict 
 antiseptic or aseptic precautions must be observed. 
 
 For enteroclysis there is needed a large fountain syringe with a long flex- 
 ible tube with a cock, to which a moderately stiff but flexible terminal portion 
 two or three feet long is attached. The tube, quite full of the fluid, must be 
 passed up into the colon and worked along its interior as far as possible ; the 
 fluid should be let flow slowly, avoiding very sudden distention of the gut, 
 and should be retained as long as possible. 
 
 For hypodermoclysis a fountain syringe with a long flexible tube, furnished 
 with a cock, answers the purpose ; with another shorter tube, one end attached 
 to the cock, the other having a needle-pointed canula, a little longer, stronger, 
 and with a somewhat wider calibre than the ordinary hypodermic needle. The 
 tube and canula are first perfectly filled with the fluid, and then the canula 
 is inserted well in between the skin and deep fascia of the flanks, buttocks, 
 or interscapular region. The fluid should be made to flow slowly, allow- 
 ing fifteen to twenty minutes for the introduction of one quart. The slight 
 tumor should be made to disappear, as it will, by gentle kneading or 
 massage. 
 
 For intravascular injections of saline fluids any good transfusion apparatus 
 suffices. 
 
248 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Lavage of the stomach to stop vomiting is a most effective procedure, and 
 sometimes succeeds in arresting this distressing symptom when nothing else 
 will do it. Indeed, .it would seem to be a very useful associate of enteroclysis, 
 for it seems that to clear the stomach of the offending rice-water fluid is only 
 second in importance to washing it out from the intestine. Boiled water hold- 
 ing in solution boracic acid has been satisfactorily used for this purpose. 
 
 Treatment in the Period of Algidity or Collapse. — In this stage 
 of the disease, where absorption is practically suspended, little is useful beyond 
 enteroclysis and hypodermoclysis or intravascular injections of fluids, and 
 efforts to communicate heat. The vast majority of cases in this stage 
 die in spite of every effort of the physician, but there is certainly more 
 success to be expected of this mode of treatment than of any other at 
 present known. 
 
 Treatment in the Period of Reaction. — The treatment in this stage 
 is essentially expectant and symptomatic. Each condition enumerated in the 
 sections on Symptomatology and Etiology will suggest to the experienced the 
 particular line to be followed. One of the most important things to avoid is 
 pointed out forcibly by Macnamara, whom I can do no better than to quote in 
 conclusion : " When reaction comes on, we must be careful not to fall into the 
 error of over-feeding the patient under the mistaken idea of supporting his 
 strength ; he will not die of exhaustion if small quantities of milk and arrow 
 root are administered frequently for two or three days, together with warm 
 beef-tea enemas. But enteritis may certainly be induced if food beyond the 
 simplest and smallest quantities be allowed. The patient requires rest and 
 the most careful nursing after a severe illness like cholera." 
 
 Prevention. — Whilst the physician is often impotent in the treatment of 
 cholera, in prevention he may be, if he will, all-powerful. It is not our pur- 
 pose to discuss this subject from the standpoint of a state or community; we 
 shall consider the matter solely from the side of the individual : First, what 
 those ministering to the sick should do to prevent the spread of the disease ; 
 second, what the individual who may be exposed to the infection should do to 
 safeguard himself from an attack of cholera. 
 
 1. The Duties of those Attendant upon the Sick. — I wish to say in the 
 beginning that, whilst there is scarcely any infectious epidemic disease which 
 is so capable as cholera of working great injury in various ways to the com- 
 munity, if the attendants upon the sick are ignorant or careless in applying the 
 principles of prevention, yet there is no such disease which can so easily and 
 certainly be limited to those attacked if only these principles be constantly and 
 scrupulously applied. As I have said elsewhere, Asiatic cholera can be dwelt 
 with and handled with absolute impunity if only the proper precautions be 
 never once forgotten or neglected. There is, therefore, not the slightest danger 
 in administering to the sick if carefulness be the rigid rule. It has already 
 been pointed out that it is only the evacuations from the stomach and bowels of a 
 person suffering an attack of Asiatic cholera that contain the original infection. To 
 promptly and thoroughly disinfect these and everything soiled by them or contain- 
 ing them is to render the spread of the disease from the person attacked impossible. 
 The evacuations should without any delay be treated in one of the following 
 ways : a, water that is. boiling should be poured upon them carefully, so as not 
 to splash, in such amount that the volume of the water is four times that of the 
 evacuations, or a strong solution of potash soap may be used in the same 
 way; b, or fresh milk of lime (white wash), of twice the volume of the 
 evacuation, should be poured upon the latter and the mixture gently stirred ; 
 c, or a similar quantity of a freshly-prepared solution (5 per cent, strong) 
 
CHOLERA ASIATIC A. - 249 
 
 of chloride of lime may be used in the same way ; d, or a similar volume 
 of 5 per cent, solution of carbolic acid may be thus employed. Which- 
 ever one of these means be chosen, it is essential that the vessel be im- 
 mediately covered from the flies and allowed to stand fifteen or twenty minutes 
 before emptying ; and it is also essential that the disinfected evacuations be 
 emptied into a pit in the earth, the bottom of which is covered with a layer of 
 quicklime, and be covered immediately with another layer of the same mate- 
 rial, care being taken that the location of this pit does not jeopardize water- 
 courses, springs, or wells. Clothing or other textile fabrics soiled by the 
 evacuations should be disinfected as soon as possible. They should be at first 
 soaked in a disinfectant solution — say, a mixture of strong potash soap and 
 carbolic acid of 5 per cent, strength — for an hour or more, and then boiled. 
 It is better to burn bedding rather than attempt its disinfection. The floors 
 of the sick-room should first be sprinkled with chloride of lime, and then 
 mopped over with a cloth moistened in a chloride-of-lime solution. Any 
 article of furniture which may have been contaminated should be carefully 
 disinfected. Finally, it would be well to disinfect the room itself, after all is 
 over, by means of sulphur fumes, 3 pounds to the 1000 cubic feet of space, for 
 eight to ten hours. No one should be allowed in the sick-room except the 
 necessary attendants, who under no consideration should eat or drink in this 
 room. The patient should be fed from a set of dishes which should be disin- 
 fected immediately after use, and kept separate from those of the rest of the 
 household; the remains of the patient's meal should be disinfected and 
 destroyed. After handling the patient or anything that he has soiled, the 
 attendants should immediately first disinfect and then carefully wash their 
 hands : this thorough ablution should be performed invariably immediately 
 before eating. After vomiting or an evacuation of the bowels the mouth and 
 the parts around the anus should be wiped with a cloth wet with solution, 
 1 : 2000, of corrosive sublimate. If convalescence supervene, the patient should 
 be kept isolated for a week, and the stools should be disinfected during that 
 time. If death occur, the corpse should at once be enveloped in a sheet soaked 
 with corrosive sublimate, 1 : 500, and cremated or buried without delay or 
 funeral cortege. Finally, promptly notify health officials of every suspect or 
 known case of cholera. 
 
 2. Individual Precautions for the Exposed. — No water or milk should 
 be used or consumed, which could by any possibility be contaminated, unless 
 recently boiled. No cold or uncooked food should be eaten which could 
 possibly become contaminated. Such things as salads should be avoided. 
 Unripe or over-ripe fruit should be eschewed. Alcoholic stimulants are per- 
 nicious. In fact, excesses of all kinds predispose to an attack. Regularity 
 in eating, sleeping, exercise, and all other habits, contributes to safety. Keep 
 all the bodily functions well regulated ; avoid fatigue and chills. The use of 
 a broad flannel waist-bandage next the skin day and night is beneficial in 
 guarding against abdominal congestions. Quickly correct the slightest intesti- 
 nal disorder. 
 
DIPHTHERIA. 
 
 By DILLON BROWN, M. D., 
 
 New York. 
 
 Diphtheeia is an acute, contagious, and infectious disease, the most 
 characteristic and constant feature of which is a pseudo-membranous exu- 
 date on, or a superficial necrosis of, a mucous membrane or some part of 
 the skin which has been denuded of its epithelium. Although a comparatively 
 recent disease in this country, it threatens to be the scourge of the large cities. 
 Less than a century ago but few isolated and poorly-understood cases were 
 seen, but the disease has spread very rapidly during the past fifty years, and 
 in New York City alone the mortality from diphtheria and croup has exceeded 
 fifty thousand in twenty-five years. And this number does not include many 
 cases which were reported as deaths from pneumonia, nephritis, heart failure, 
 etc., which were really complications of diphtheria. 
 
 There is no guide to the virulence of diphtheria. It is one of the most 
 dreaded, one of the most fatal, and one of the most common diseases of child- 
 hood. At the onset it is impossible to say whether the disease will be mild or 
 malignant. A case beginning with high fever and profound constitutional 
 disturbance may go on to a rapid recovery ; while, on the other hand, an 
 apparently mild case will grow depressed and weak, and slowly die. Neither 
 does the amount nor character of the exudate give any certain prognosis. 
 Indeed, the clinical symptoms vary to such an extent that many mild cases are 
 not even recognized unless some post-diphtheritic complication ensues ; but, 
 although these mild cases may be of small danger to the individual, they 
 are all diphtheria and all equally contagious, and may be the origin of the 
 most malignant ones. 
 
 Etiology. — It has been well recognized that certain cases of croupous 
 inflammation are not true diphtheria. This list includes the chronic membra- 
 nous exudates seen in certain forms of fibrinous bronchitis, cystitis, enteritis, 
 etc., the acute superficial necrosis of the mucous membranes due to direct 
 heat, as a scald, or an intense irritation from the application of ammonia. 
 However, excluding these, there remain many doubtful cases ; but modern 
 bacteriological research seems to have solved this problem, and proven beyond 
 much doubt that there are at least two forms of pseudo-membranous inflam- 
 mation, the one a true diphtheria, due to the Klebs-Loeffler bacillus, and the 
 other, which may include several varieties, a pseudo-diphtheria, due usually to 
 a streptococcus. 
 
 True diphtheria is the product of the Klebs-Loeffler bacillus, either alone 
 or associated with other bacteria, and it is primarily a local disease with many 
 secondary manifestations, due to the absorption of the ptomaines or poisons 
 which result from the growth of this micro-organism. The following obser- 
 vations seem to establish these propositions as fairly well proven : 
 
 1. This bacillus is present, usually in large numbers, in the false membrane 
 
 250 
 
DIPHTHERIA. 251 
 
 of all typical cases of infectious diphtheria, and is rarely or never found in 
 other inflammations of the mucous membrane of the throat or in the healthy 
 throat. 
 
 2. This bacillus is always found at the place of local infection, and never 
 found in the blood or any of the internal organs, even though they may be the 
 seat of marked secondary changes. On the contrary, streptococci and other 
 bacteria may be found in the blood and internal organs. 
 
 3. Pure cultures of this bacillus when injected into the mucous membrane 
 of susceptible animals produce a typical diphtheritic inflammation, even to 
 paralyses and organic lesions. 
 
 •i. Inoculation of animals with the toxalbumin of this bacillus produces 
 the sepsis, the paralysis, the visceral lesions, and all the secondary constitu- 
 tional symptoms of diphtheria, without the membrane. 
 
 5. Clinically, surface diphtheria, without participation on the part of the 
 lymph-vessels, is apt to exhibit little or no fever ; the disease does not run a 
 typical course ; one attack does not offer security against its recurrence in the 
 future ; and whenever the diphtheritic infecting agent finds a foothold on the 
 body — as, for example, by inoculation — it always excites a local affection at 
 the point of entrance ; and from this local infection the general infection will 
 develop, the extent and rapidity of which depend upon the anatomical rela- 
 tions of the affected parts, their characteristics, and their power of absorption. 
 
 The hypothesis that diphtheria is at first a general disease of the blood, 
 with secondary manifestations on the mucous membranes, is hardly tenable in 
 face of the foregoing facts. The chief arguments brought forward in support 
 of this theory are its similarity to certain of the infectious diseases ; its epi- 
 demic occurrence ; the fact that constitutional symptoms may be present for 
 hours and days before local symptoms are discovered; the marked susceptibility 
 of children ; the great disproportion often seen between the general symptoms 
 and the apparently trifling local changes ; the multiplicity of the localizations, 
 and the fact that efforts to conquer the disease by destroying the pseudo-mem- 
 brane with strong caustics have been for the most part without result. However, 
 these observations simply prove that diphtheria may be a general infectious 
 disease, but they do not explain how this infection takes place. Neither clin- 
 ical observations nor post-mortem examinations have ever been able to present 
 enough facts to settle this question ; but, fortunately, modern bacteriological 
 research, with inoculation experiments on living animals, has determined it 
 very conclusively. 
 
 Besides true diphtheria, we frequently meet with an allied pseudo-mem- 
 branous inflammation which cannot be distinguished from it clinically, except 
 that it runs a milder course. Bacteriologically, however, the Klebs-Loeffler 
 bacillus is always absent, and streptococci, and often other bacteria, are 
 found in great abundance, not only in the exudate, but even in the blood and 
 internal organs. The differential diagnosis is very important, as a knowledge 
 of which disease w r e have to deal with modifies somewhat the treatment, and 
 greatly the prognosis. 
 
 Not only do we have a croupous inflammation which is not a true diph- 
 theria, but we can have a true diphtheria in which the membrane covers so 
 little space that there is apparently no fibrinous exudate. This was clearly 
 demonstrated by Jacobi in his article on " Follicular Amygdalitis ;" and every 
 observer must have seen cases in which an apparently catarrhal follicular 
 amygdalitis quickly proved itself to be a diphtheritic one, or, after recovery, 
 showed its true nature by a characteristic diphtheritic sequel — a paralysis of 
 some muscle or group of muscles. 
 
252 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Accepting the microbic origin of diphtheria, we must still take into 
 account the many conditions that materially modify the course of this affec- 
 tion, which is one of the most variable and uncertain of all the contagious 
 diseases. It is doubtful if a normal mucous membrane can be infected by the 
 bacillus, and it is certainly true that a lesion favors its development. This 
 also applies to the toxalbumin of the bacterium, large amounts of which can be 
 swallowed without danger by susceptible animals that have healthy and intact 
 mucous membranes. 
 
 Age is ordinarily an important factor in influencing the occurrence of the 
 disease ; and, though it may occur at any time of life, it is essentially a disease 
 of childhood. 
 
 Individual or family predisposition has some influence. It occurs by 
 marked preference in connection with those diseases which produce lesions of 
 the mucous membranes. Cold and dampness favor its occurrence, partly by 
 their tendency to excite catarrhal affections and thus offer an opportunity for 
 infection, and partly by the more favorable conditions for the growth of the 
 bacillus which are present during such weather. All the windows and other 
 sources of ventilation are shut, and the rooms, especially in tenements, where 
 the disease is most common, are stifling and hot. Insanitary conditions un- 
 doubtedly favor the development of this germ. 
 
 Klebs-Loeffler Bacillus. — In the membrane of true diphtheria this 
 bacillus is always found, either alone or associated with other bacteria. It is 
 rarely or never found in the blood or internal organs, although the strepto- 
 coccus, which is often associated with it, may appear in the blood, the 
 lymphatics, or the viscera. On the surface and the most superficial portions 
 of the exudate the bacillus is found mixed with numerous other micro- 
 organisms. In the middle or deeper portions the only organisms present are 
 the Klebs-Loeffler bacilli, either alone or associated with streptococci. In the 
 deeper layers there are only a few bacilli, and in the mucous membrane, as a 
 rule, none. 
 
 These bacilli are " moderate-sized rods, usually slightly bent, averaging 
 nearly as long as the tubercle bacilli, but twice as broad, and usually with 
 rounded ends. According to the rapidity of growth, the soil, and other con- 
 ditions, the form and size of the micro-organisms vary, and the differences are 
 striking. The bacteria are sometimes enveloped in a more or less capacious 
 membrane ; sometimes the contents divide into a number of pieces, separated 
 by transverse divisions ; one end of the rod is frequently thickened like a 
 club, or both ends may be clubbed, or one or both pointed. The bacilli are 
 immobile and have no spores. The best staining agent is Loeffler's alkaline 
 methyl-blue. Some forms stain uniformly, others in various irregular ways, 
 the most common being the appearance of deeply-stained granules in a 
 slightly-stained bacillus or of darkly-stained ends with a paler centre. The 
 bacilli are very often in pairs, never in chains ; they are semi-anaerobic, and 
 thrive at a somewhat high temperature, 20° to 42° C." 
 
 "The Loeffler bacilli can be cultivated upon all the ordinary culture 
 media, but grow most vigorously on a mixture of blood-serum and nutrient 
 bouillon, as given by Loeffler. On this, solidified, the bacilli grow as large, 
 round, elevated, grayish-white colonies, with the centre more opaque than the 
 somewhat irregular periphery" (Park). 
 
 The most ready method of detecting this bacillus is to detach a small 
 piece of membrane and place it for five minutes in a 2 per cent, solution of 
 boracic acid, then to draw the piece of membrane along the surface of 
 sterilized blood-serum in a test-tube, and maintain it at a temperature of 37° 
 
PLATE IX. 
 
 
 
 3* 
 
 
 
 Fig. 1— Loeffler bacilli. X 650. Fig. 2. -Pseudo-bacilli. X 650. 
 
 Fig. 3.— Involution forms of the Loeffler bacillus. X 650. 
 
 Fig. 4.— A. Pseudo-bacillus. B. True bacillus. C. Pseudo-bacillus. 
 (Natural size.) 
 
 From photographs taken by Dr. Henry Koplik, Carnegie Laboratory, New York. 
 
DIPHTHERIA. 253 
 
 C. for twelve to twenty-four hours. At the end of this time, if the bacilli are 
 present, characteristic small white rounded colonies are visible along the track 
 of inoculation. They can then be stained and examined. To get a pure 
 culture a second or third preparation must be made. To overcome the diffi- 
 culty of obtaining serum for the culture medium, Sakharof suggests the use 
 of slices of hard-boiled eggs placed in sterilized test-tubes, and Johnston sug- 
 gests the use of hard-boiled eggs from which a part of the shell has been 
 removed with ordinary forceps, so that the shell-membrane can be peeled off 
 and the inoculation made at that point. To guard the culture against contam- 
 ination, the egg can be placed upside down in a common egg-cup, the interior 
 of which has been sterilized by allowing a flame to enter it for a second or two. 
 
 The pseudo-diphtheria bacilli is a term applied to a group of micro- 
 organisms which closely resemble the true diphtheria bacilli, both in appear- 
 ance and in producing a pseudo-membrane, but they are without pathogenic 
 properties in guinea-pigs, and they do not grow on gelatin at ordinary 
 temperatures. However, for bedside diagnosis it is wiser to consider all cases 
 as true diphtheria that give colonies of bacilli resembling the Klebs-Loeffler. 
 
 The ptomaine, or poison, produced by the diphtheria bacillus is of a proteid 
 nature, precipitated by alcohol and soluble in water. When pure, it is a 
 white amorphous mass and extremely poisonous. It is not at all, or but 
 little, absorbed by healthy and intact mucous membranes ; but when inoculated 
 into a susceptible animal it produces all the symptoms of a diphtheria without 
 the exudate. 
 
 Mode of Infection and Propagation. — There is no doubt that in the 
 vast majority of cases the inoculation takes place through some lesion of the 
 mucous membrane or of the skin. Therefore, it would be hard to over- 
 estimate the value, as a prophylaxis, of attention to all lesions, no matter 
 how slight, of the mucous membrane of the upper air-passages. Every 
 catarrhal condition should receive prompt and efficient treatment, and bad 
 teeth, accumulated secretions, or any other source of local irritation should be 
 removed as soon as possible. 
 
 The germ is usually propagated through the surrounding air, and brought 
 in contact with the mucous membrane during respiration. Less frequently 
 the disease may be propagated by the direct deposition of diphtheritic matter 
 by inoculation or through some article of food. It has been known to have 
 been communicated from some of the domestic animals. The contagion may 
 be spread by contact with the person or clothes of those suffering from the 
 disease, and may also be spread by bed-clothes, furniture, and other articles in 
 the sick-room. Too much care cannot be taken to prevent those surround- 
 ing the sick from spreading the disease, and there is no doubt that phys- 
 icians themselves frequently carry the disease from one patient to another. 
 This is clearly shown from the large number of cases which occur in their 
 own families. 
 
 Incubation. — In experimental diphtheria the duration of the incubation 
 period is short, varying from twelve hours to three days ; but when diphtheria 
 is contracted in the usual way — by inhaling air which contains the contagion 
 — this period may be much longer, varying from one day up to twenty. How- 
 ever, in the latter case this only means the interval between exposure and the 
 appearance of the disease, for there is no means of knowing exactly when the 
 contagion entered the mucous membrane, and how long it had remained harm- 
 lessly upon it, waiting for the development of some lesion through which to 
 infect it. It is obvious, therefore, that all observations based upon the inter- 
 val between exposure and the appearance of the disease must be uncertain. 
 
254 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 This period also depends not only upon the quality and quantity of the 
 infecting material itself, but also upon the structure and texture of the tissues 
 and their power of resistance — a power which is often greatly modified by strep- 
 tococci and other bacteria which may be associated with the true diphtheria 
 bacilli. When the Klebs-Loeffler bacilli are implanted upon a normal mucous 
 membrane, they do not grow, but these associated streptococci produce an 
 acute purulent discharge, with redness and swelling. Thus they prepare the 
 lesion for infection by the Klebs-Loeffler bacilli. 
 
 Anatomical Changes. — The local pathological changes of this disease occur 
 on a mucous membrane or some abraded portion of the skin. The changes 
 found on the inflamed mucous membrane are as follows : The surface becomes 
 hypeneraic and swollen, and presents the usual manifestations of a catarrhal 
 inflammation. After a short time, usually a few hours, it is covered with a 
 whitish or yellowish layer, which forms the pseudo-membrane so characteristic 
 of the disease. This membrane may represent a fibrinous exudate which can 
 be easily peeled from the surface beneath, or it may represent a true necrosis, 
 so that the exudate is an integral part of the mucous membrane and cannot 
 be separated from it. Many of its characteristics depend upon its anatomical 
 position and the type of epithelium upon which it is located. It looks to the 
 naked eye like coagulated fibrin, but under the microscope it is seen to consist 
 of proliferated epithelial cells held together by a fibrinous network. In its 
 physical and chemical properties it closely resembles fibrin. The surface 
 beneath the exudate may show all grades of inflammation, from a mild catar- 
 rhal to an ulcerated one. The false membrane is found oftenest on the tonsils, 
 uvula, soft palate, and back of the pharynx, the nasal passages, the larynx, 
 and trachea ; less commonly on the conjunctiva, at the border of the anus, or 
 in the vagina ; rarely in the bronchi as a primary affection, but not uncom- 
 monly as an extension of the same process from the larynx and trachea ; and 
 very rarely in the oesophagus, the intestinal tract, or the ear. 
 
 Besides these local pathological changes other organs of the body may 
 become affected as the result of the absorption of the toxalbumin. 
 
 The adjacent lymph-nodes are swollen and inflamed, but they rarely become 
 the seat of a suppurative inflammation ; the surrounding tissues are infiltrated 
 with serum containing scattered pus-cells. 
 
 The lungs show areas of intense congestion, with hemorrhages into their 
 tissue. They may exhibit oedema, broncho-pneumonia, catarrh, atelectasis, 
 emphysema, ecchymoses, and large infarctions ; and the bronchi may be lined 
 with false membrane as far as the smaller branches. These changes, however, 
 are mostly observed as complications of laryngeal diphtheria. 
 
 The pleura may be hyperaemic and inflamed, with haemorrhages, and in 
 many cases the pleural cavity will contain an excess of fluid. 
 
 The kidneys, in experimental cases, are moist and hyperaemic, and the 
 adrenals are congested and may be haemorrhagic. Fatty changes occur in the 
 epithelium of the tubes and glomeruli, and hyaline alterations in the glomer- 
 ular capillaries and in the smaller arteries. Haemorrhages, parenchymatous 
 and interstitial nephritis, are common lesions observed in the kidneys in albu- 
 minuric cases. 
 
 The spleen and the liver may be enlarged and congested, with haemorrhages 
 into the capsule and tissue. There may be present smaller or larger masses of 
 necrotic cells, and in some cases there is a fatty degeneration, and occasionally, 
 in protracted cases, a hyaline or a waxy one. 
 
 The heart may show in the substance of the muscle large and small 
 haemorrhages and ecchymoses. When death is due to asphyxia without 
 
DIPHTHERIA. 255 
 
 general poisoning of the whole organism, the muscular substance of the 
 heart itself may be normal ; but when there has been a general poisoning 
 it has usually undergone a granular and fatty degeneration, and there may be 
 other septic changes, as, for example, an endocarditis. 
 
 In both the parietal and visceral layers of the pericardium there may be 
 small and large haemorrhages and ecchymoses ; there may be an excess of fluid 
 in the pericardial cavity ; and in rare cases there may be an emphysema of 
 the pericardium as a consequence of the extension of a subpleural emphysema 
 into the loose cellular tissue between the folds of the mediastinum. 
 
 The blood, as in most severe forms of septicaemia and poisoning, is but 
 slightly coagulable, sticky, brown, or rather livid, and the blood-vessels contain 
 a greatly increased number of leucocytes. 
 
 The mucous membrane of the intestinal tract and of the bladder may 
 rarely become directly infected, and under such circumstances they present the 
 characteristic pseudo-membrane and other changes which take place in th© 
 pharynx, etc. However, when secondary changes occur in consequence of 
 general infection, cell-infiltration and haemorrhages are the usual ones, and in 
 one reported case such extensive haemorrhage from the great omentum occurred 
 that a considerable quantity of free blood had collected in the peritoneal cavity. 
 The layers of the peritoneum may be injected and be the seat of ecchymoses, 
 and the peritoneal cavity may contain an excess of serous fluid. 
 
 The fibres of the muscles show degenerative changes, and the thyroid may 
 be congested and ecchymotic. 
 
 The earliest change in the brain and spinal cord is venous hyperaemia, 
 both in the vascular linings and in the substance itself. Later in the disease 
 come extravasations, with the subsequent softening of the surrounding tissue, 
 and finally various degenerative changes. Extravasations into the substance 
 of the spinal nerves have been seen, as well as granular degeneration of the 
 nerves of the soft palate and other parts that have suffered from a diphtheritic 
 paralysis. 
 
 Symptoms and Diagnosis. — The characteristic feature of the disease is 
 the pseudo-membrane. There are cases of pseudo-membranous inflammation 
 which are not diphtheria ; but, excluding the chronic cases and those due to 
 great heat, as a scald, and to the application of an intense irritant, like am- 
 monia, it is often impossible to distinguish between the true and the false 
 diphtheria, except by a bacteriological examination. The only positive test is 
 the presence of the Klebs-Loeffler bacillus, either alone or associated with 
 streptococci or other bacteria. In a certain proportion of cases it is very 
 difficult to distinguish between the true and the pseudo-bacillus ; and in all 
 doubtful cases, at least for the present or until inoculation experiments can be 
 made, it is wiser to consider them as true diphtheria. Clinically, cases of 
 follicular amygdalitis are frequently diagnosticated as simple catarrhal or puru- 
 lent inflammations, when they are really diphtheritic. All such cases should 
 be isolated and treated in every respect as true diphtheria until the diagnosis 
 is made certain either by a bacteriological examination or the appearance of 
 new evidence which will show the true nature of the disease. 
 
 The diagnosis, even of a membranous inflammation, may be obscure from 
 its location. It may be confined to the posterior nares, the larynx and 
 trachea, or even the intestine, the bladder, or other positions where the local 
 changes cannot be seen. 
 
 The constitutional symptoms which are the result of the poisoning due to 
 the absorption of the toxalbumin produced by the specific bacilli vary greatly, 
 and depend not only on the amount and rapidity of the absorption, but also 
 
256 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 upon the susceptibility and condition of the patient. In simple and uncom- 
 plicated cases there is usually little or no fever. The symptoms may vary 
 from this to evidences of the most profound poisoning. The temperature may be 
 high and irregular, the pulse rapid or, in certain very fatal cases, abnormally 
 slow. There is languor and loss of appetite, and an amount of prostration out 
 of proportion to the fever and the local inflammation ; the skin dry and hot ; 
 and, according to circumstances, typhoid symptoms may show themselves, or 
 there may be delirium with great restlessness. Relapses are frequent, and one 
 attack does not protect against a subsequent one. 
 
 The lymph-nodes which are in anatomical relation with the local process, 
 as well as their surrounding tissues, may be swollen and tender, but they 
 seldom undergo a suppurative change. The degree of enlargement and inflam- 
 mation depends upon the amount of absorption, and of course this depends 
 not only upon the character of the local process, but also upon its relations 
 with the neighboring lymphatics. 
 
 The heart's action is usually rapid, and may be feeble, during an attack of 
 diphtheria; and this condition often continues for some time after the disap- 
 pearance of all local evidences of the disease. The pulse may be irregular both 
 in force and rhythm. Another condition, usually appearing late in the disease, 
 and often when the local process is apparently improving or has entirely cleared 
 up, is for the feeble pulse to become progressively slower until the beats num- 
 ber less than forty, sometimes less than thirty, to the minute. These cases, 
 which are nearly always fatal, together with those having the feeble, rapid pulse 
 of profound sepsis and exhaustion, may be classed as examples of slow heart 
 failure. But there is still another condition which usually appears after all the 
 alarming symptoms are gone ; that is, a sudden failure or paralysis of the heart. 
 Endocarditis most frequently involving the mitral valve may occur, and is 
 accompanied by fever, precordial pain, attacks of syncope, a systolic murmur, 
 and ante-mortem heart-clots, which may become free and enter the circulation, 
 producing the usual phenomena. In most cases there is a rapid destruction of 
 the red corpuscles of the blood, and a relative increase of the white corpuscles. 
 Hence the anaemia which appears early and rapidly increases as the disease 
 advances. 
 
 Albuminuria is a common complication, and appears usually on the third 
 to sixth day, but may rarely appear as early as the first day or as late as the 
 fifteenth. The amount of albumin varies greatly, from a slight cloudiness, 
 on boiling, to complete consolidation. The urine usually appears normal, 
 but it may be scanty and dark, and in rare cases dark-colored or smoky 
 from the presence of blood. There may also be present in the sediment gran- 
 ular, hyaline, epithelial, and blood casts. The duration of the renal complica- 
 tion varies from a day or two to a week or two, but it may occasionally become 
 chronic. It is seldom attended with oedema, but vomiting and other ursemic 
 symptoms are not so rare. It is impossible to distinguish between the albu- 
 minuria of true and of false diphtheria, but in diphtheria there are some 
 characteristics which distinguish it from the same complication of scarlet fever. 
 
 The tonsils are the most frequent location of the disease, and when confined 
 to them it runs a mild course, because they have little or no connection with 
 the lymphatic system, and they do not contain a large number of blood-vessels. 
 The chief difficulty in diagnosis is to distinguish between a simple follicular 
 amygdalitis and a diphtheritic one. The secretion from a catarrhal amygda- 
 litis may cover the tonsils with a coat which closely resembles pseudo-mem- 
 brane, but it can be easily washed away with a syringe, and in most cases a 
 careful examination will show its true character. 
 
DIPHTHERIA. 257 
 
 The pharynx, soft palate, and mouth may be involved ; and here it is a 
 more serious condition than when confined to the tonsils. The lymph-vessels 
 are very numerous : those of the uvula connect with the deep facial glands ; 
 of the tongue, with the deep cervical and the submaxillary glands ; and of the 
 floor of the mouth, with the submaxillary glands. The differential diagnosis 
 lies between true diphtheria and false diphtheria, exudates as the result of an 
 intense heat or irritation, ulcerative and gangrenous stomatitis, or occasionally 
 herpes and aphthae. The main differential symptoms pointing to diphtheria 
 are, besides the history, the characteristic pseudo-membrane, the thin, brown- 
 ish, acrid discharge, the sweetish and musty fetor, the glandular swellings, the 
 tendency to haemorrhages, the slight fever and marked prostration, the albu- 
 minuria, and the sequel of paralysis. In doubtful cases the only positive dem- 
 onstration is the presence of the pathognomonic bacilli. 
 
 In the nares diphtheria is very serious on account of the abundant lymph- 
 and blood-supply, and the consequent increased facilities for absorption of the 
 poison, and on account of the conformation of the nasal passages, which inter- 
 feres with their thorough drainage when swollen and inflamed, and which 
 makes thorough local treatment very difficult. The greater supply of lymph- 
 vessels is in the inferior portion of the nasal cavities, and these vessels con- 
 nect with the deep facial and posterior submaxillary glands. It is often very 
 difficult, and may be impossible, to see the pseudo-membrane in the posterior 
 nasal cavities in children. Theoretically, it is very simple to use a rhino- 
 scope, but practically it is quite another matter, and it is often impossible and 
 usually impracticable, even in a tractable child. The symptoms which help 
 to a diagnosis are the thin, acrid discharge more or less stained with blood, the 
 evidence of nasal obstruction, the enlarged cervical glands, the bad odor to the 
 breath, the tendency to haemorrhage, and the frequent signs of general poi- 
 soning. 
 
 When the epiglottis, larynx, and trachea are involved, the main danger comes 
 from the mechanical obstruction to respiration and the extension of the disease 
 to the bronchi. Constitutional symptoms are usually absent, partly on account 
 of the protection afforded by the very numerous mucous glands, and partly on 
 account of the absence of lymphatic glands and the scant supply of lymphatic 
 vessels. These vessels connect with the bronchial glands. After death from 
 laryngeal diphtheria these glands are found more or less enlarged. 
 
 The diagnosis by means of the laryngoscope would be very valuable if it 
 were practical. In the vast majority of cases it is not only impossible, but it 
 is unnecessary and cruel. There is undoubtedly a membranous laryngitis 
 which is not diphtheria, but the differential diagnosis cannot be made either 
 from the symptoms or the character of the membrane. It can only be made 
 by a bacteriological examination, which will show the presence or the absence 
 of the Klebs-Loeffler bacillus. 
 
 The differential diagnosis lies between a membranous laryngitis and a 
 catarrhal or a spasmodic one ; and while this is not usually so very difficult, 
 certain cases will present phenomena which keep the diagnosis obscure, unless 
 the membrane is actually seen through the laryngoscope or is coughed up. 
 Again, cases which, in the beginning, are catarrhal and run a typical course, 
 may later become infected and run the usual course of a membranous inflam- 
 mation. Again, confusion may be caused by those rather rare cases in which 
 the membranous inflammation begins below and ascends to the larynx. 
 
 In the uncomplicated cases of membranous laryngitis, excluding the 
 ascending ones, there is little or no fever ; the onset of the disease is gradual, 
 and it grows progressively worse ; there is hoarseness, and after a time complete 
 
 17 
 
258 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 aphonia; the stenosis is, at first, slight and only on inspiration, but after 
 a while, usually two to four days, the stenosis becomes extreme, and attends 
 both inspiration and expiration ; the respiration and the cough, which in the 
 beginning may be noisy and croupy, gradually become more husky and sup- 
 pressed. Spasmodic attacks may occur in connection with the disease, but 
 this is not a prominent feature of its clinical history. 
 
 The cases of ascending diphtheria of the trachea and larynx are very fatal, 
 and, fortunately, uncommon. There are no constitutional symptoms, and the 
 only evidence of sickness which can be detected is a slight bronchial or 
 tracheal catarrh, until the process reaches the subglottic division of the larynx 
 or the chink of the glottis, when laryngeal symptoms are seen, and stenosis 
 appears and increases so rapidly that the patient becomes cyanotic within an 
 hour or two, and soon dies unless immediate relief is given by intubation or 
 tracheotomy. Even after operative interference the patient, in most cases, 
 dies from extension of the disease to the bronchi, and usually within two 
 days. 
 
 In doubtful cases the appearance of membrane in other locations, or the 
 existence of an epidemic of diphtheria, favors the diagnosis of a membranous 
 laryngitis. If with this the temperature is low, not high ; the stenosis 
 increases progressively, not spasmodically ; the onset is gradual, not sudden ; 
 the laryngeal symptoms are of long, not short duration, — the diagnosis of 
 membranous laryngitis is very clear. 
 
 There are numerous evidences of stenosis of the larynx besides the noisy 
 respiration, as this latter symptom may be present in many other conditions. 
 The most characteristic features of laryngeal obstruction are the deep reces- 
 sions of the soft parts of the chest in inspiration, the blue or leaden hue of the 
 skin and mucous membranes, the aphonia, the restlessness, and the abnormal 
 frequency of the respirations ; but none of these symptoms are constant. The 
 soft parts of the chest-walls may project and make the chest barrel-shaped if 
 the obstruction is greater on expiration ; the skin and mucous membranes may 
 appear blue if the stenosis increases rapidly, but this color becomes a leaden 
 white if the obstruction is of slow progress ; the voice may be clear in sub- 
 glottic cases ; and in advanced cases the restlessness is supplanted by a con- 
 dition of stupor from carbon-dioxide poisoning. The only constant and reliable 
 guide as to the presence and the amount of laryngeal obstruction is obtained 
 by auscultation of the chest and listening to the respiratory sound. This 
 gives an accurate guide as to the amount of air entering the lungs. 
 
 The other diseases which should be considered in making a diagnosis are 
 abscess of or about the larynx, tumors of the larynx, retropharyngeal abscess, 
 certain cases of naso-pharyngeal obstruction, foreign bodies in the air-pas- 
 sages, etc. ; but the diagnosis should not be difficult if a careful examination 
 is made. 
 
 In the bronchi a membranous inflammation is rarely or never primary, but is 
 secondary to a similar one in the larynx or trachea. It may extend to the finer 
 bronchial tubes, or even into the air-cells themselves, and result in a broncho- 
 pneumonia, with pulmonary collapse or emphysema. Its symptoms are, in 
 a case of laryngeal diphtheria, a sudden rise of temperature — often very high 
 — rapid respiration, marked dyspnoea, and cyanosis ; and, although the phys- 
 ical signs in the chest are often obscure and masked by the laryngeal disease 
 and pulmonary complications, there is less air entering the lung on the affected 
 side, and. the respiratory sound is dry and " boardy." 
 
 Diphtheria of the conjunctiva, the ear, the intestinal tract, the genito- 
 urinary organs, abraded portions of the skin, and wounds has occurred, usually 
 
DIPHTHERIA. 259 
 
 as a secondary process, but occasionally as a primary infection. The symptoms 
 are those of an ordinary inflammation in those parts, to which are added the 
 pseudo-membrane and other characteristics of this disease. 
 
 Diphtheria may, of course, complicate any disease, but the most frequent 
 association is with scarlet fever, measles, and those diseases which present 
 a catarrhal condition of the mucous membranes, and thus favor a fresh in- 
 fection. 
 
 The skin eruptions which occur in diphtheria are septic manifestations, and 
 may be of three kinds. The mildest and most transient closely resembles a 
 scarlet-fever rash, but disappears more rapidly and does not desquamate. The 
 second type is a purpura hemorrhagica, and is usually associated with septic 
 and grave forms of the disease. The last type, also seen in scarlet fever, 
 usually follows a purulent septic infection, and occurs in cases which have a high 
 mortality. There is an increase of temperature and the invasion is gradual. 
 The eruption appears as red or dark-pink blotches, with sharply-defined mar- 
 gins. The color fades on pressure with the finger, but quickly returns. It 
 appears first over the prominent bony points, such as the ankles, finger-joints, 
 elbows, outer sides of the feet, etc., but always has a tendency to become gen- 
 eral. Its disappearance is followed by a profuse desquamation, and usually this 
 is quickly followed by a return of the eruption. 
 
 Sequelae. — Besides the chronic catarrh which is left at the site of the 
 pseudo-membranous inflammation, and the anaemia, the most frequent and char- 
 acteristic sequel of diphtheria is paralysis, which develops from one to five 
 weeks after all evidence of the acute disease has gone, though it may make its 
 appearance during the course of the primary affection. It is a true multiple, 
 peripheral neuritis, and resembles very closely, both clinically and pathologic- 
 ally, the neuritis of alcohol, lead, and other poisons. The duration of the 
 paralysis usually varies from two to six weeks ; it may last several months, and 
 in exceptional cases has persisted for years. It is more frequent in adults than 
 in children, and the severity of the original disease seems to offer no guide as 
 to the severity of the paralysis or the probability of its appearance. Recovery 
 usually takes place, and, while the location and the order of involvement differ 
 greatly, the course is usually as follows: The soft palate and pharyngeal 
 muscles, giving a nasal tone to the voice and a tendency to regurgitation of 
 food through the nose during deglutition ; the muscles of the tongue, lips, 
 and face: the ocular muscles, as shown by strabismus and disturbances of 
 vision; the lower extremities; the upper extremities; the larynx, recognized 
 by modifications in the character of the voice or by obstruction, usually on 
 inspiration ; the muscles of the neck, with inability to control the position of 
 the head; the muscles of the trunk, with loss of power over the body; the 
 intercostal muscles,, the diaphragm and other muscles of respiration, with inter- 
 ference with their function ; the heart, usually fatal, but may not be ; the walls 
 and the sphincter of the intestines or bladder. There has also been observed 
 paralysis of the special senses, giving temporary amaurosis, deafness, and im- 
 pairment of taste and smell. 
 
 The paralysis of diphtheria may be divided into two classes ; first, a true 
 multiple neuritis, with loss of tendon reflexes as the result of poisoning by the 
 toxalbumin ; and second, other types of paralysis, as a result of haemorrhages 
 or degenerative changes in the brain or spinal cord. The first type occurs 
 only in true diphtheria ; the second may occur in true or false diphtheria or as 
 a result of many other septic conditions. 
 
 Prognosis. — The prognosis is always better when the Klebs-Loeffler bacillus 
 is absent. In 159 observations on cases of pseudo-membranous inflammation 
 
260 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 made by Park at the Willard Parker Hospital of New York, the Loeffler 
 bacillus was found in 54 cases, and in the other cases streptococci were the 
 most abundant bacteria, and often the only ones. The mortality in true 
 diphtheria was 46J per cent. ; in pseudo-diphtheria, 5f per cent. ; intubation 
 in diphtheria, 71J per cent. ; intubation in pseudo-diphtheria, 28J per cent. ; 
 adults in diphtheria, 36 per cent. ; adults in pseudo-diphtheria, 2 per cent. 
 
 The prognosis varies, not only according to the age and condition of the 
 patient, to the symptoms, and to the anatomical location of the disease, but 
 also according to the character of the prevailing epidemic. The danger is 
 greater the larger the surface involved and the more the exudate approaches a 
 septic or gangrenous type, as shown by broken-down masses of exudation, the 
 sweetish foul odor from the mouth, the yellowish or brownish secretion from 
 the mouth and nose, which is both fetid and acrid, and the swelling and tender- 
 ness of the lymphatic nodes and the surrounding cellular tissue. However, the 
 prognosis must always be a guarded one, since the subsequent course of the 
 disease can never be predicted ; and even after it has apparently terminated in 
 recovery a relapse may take place, the infection may extend to the larynx or 
 nose, or sudden death may result from paralysis of the heart. Another class of 
 cases result in death, after all local manifestations of the disease have disap- 
 peared, from a slow exhaustion. Such a condition might be called diphtheritic 
 marasmus, the chief characteristic of which is the distaste for all food and the 
 progressive and extreme emaciation. 
 
 The prognosis in nasal cases is more serious, for reasons already given, while 
 in laryngeal cases the prognosis is very grave from the great danger of 
 asphyxia ; and, even if this be overcome, from the ease and frequency with 
 which the membranous inflammation extends into the bronchi. 
 
 Unfavorable prognostic signs are pallor, prostration, vomiting, haemor- 
 rhages, marked weakness of the pulse, with excessive rapidity or slowness, 
 fetor, purpura hemorrhagica and septic blotches on the skin, persistent high 
 fever, restlessness, delirium, and anorexia. The importance of albuminuria 
 depends upon its character and the gravity of the symptoms which are asso- 
 ciated with it. Diphtheritic paralysis usually ends in recovery, and is danger- 
 ous only when it involves the heart or the muscles of respiration or degluti- 
 tion ; and even in these cases its danger depends upon its degree. 
 
 Prophylaxis. — The first requisite, after the appearance of the disease, is 
 complete isolation of the patient, either in a hospital devoted to contagious 
 diseases or in a separate room in the house, preferably on the top floor, and 
 containing as little furniture as possible. Separate dishes and other utensils 
 should be kept for the sick-room, and everything that it is necessary to return 
 to other parts of the house should be thoroughly disinfected before it leaves the 
 room. All discharges should be received in vessels containing a strong solu- 
 tion of copperas or corrosive sublimate. The clothing, towels, etc. should be 
 put in a solution of sulphate of zinc (4 ounces) and common salt (2 ounces) in 
 boiling water (1 gallon). Water-closets, privies, etc. should be liberally 
 treated with copperas solution (1J pounds to the gallon). During the con- 
 tinuance of the disease it is of great service to keep the room filled with some 
 antiseptic vapor, as carbolic acid, eucalyptus, or turpentine ; but I have found 
 that most good in preventing the spread of the disease is obtained by sub- 
 liming fifteen to thirty grains of calomel in the room every hour. After recovery 
 the patient should be thoroughly cleansed and disinfected, and dressed in clothes 
 that have not been exposed to infection. In any event, as much as possible of 
 the exposed clothing, furniture, etc. should be destroyed, and the rest thoroughly 
 disinfected, either by the methods previously described or by naphtha or super- 
 
DIPHTHERIA. 261 
 
 heated steam. The walls, bed, and furniture should be washed with a strong 
 solution of corrosive sublimate, and then, after closing the room tightly, sul- 
 phur should be burned in it in the presence of an excess of moisture — about 
 three pounds of sulphur to every thousand cubic feet of air-space. After this 
 it is well to advise that four to eight ounces of calomel be sublimed. Other 
 members of the family should be kept from school and church ; they should be 
 removed to a different house if possible, away from the infection, and their 
 naso-pharyngeal cavities and teeth should be kept clean by means of antiseptic 
 washes, sprays, and gargles. At all times, and especially during an epidemic 
 or after exposure to it, the mucous membrane of the respiratory tract should be 
 kept in as healthy a condition as possible by keeping it clean and free of lesions. 
 
 The physician should protect his clothing as much as possible on entering 
 the sick-room by a linen gown, and before seeing another patient, especially a 
 child, all parts exposed to the infection should be thoroughly aired ; or, better 
 still, he should disinfect himself and put on fresh clothes, leaving the dis- 
 carded ones exposed to the open air or to the fumes of subliming mercury. 
 
 One of the chief causes of the spread of diphtheria in New York City is 
 the laxness, and almost criminal carelessness, of the authorities in our dis- 
 pensaries for the poor. It is almost a daily occurrence in the large dispensa- 
 ries for a contagious case to be packed in a small, hot room with a number of 
 other children, most of them ill and in good condition to contract the infec- 
 tion. 
 
 Treatment. — There is no disease in which a greater variety of treatment 
 has been recommended — from the expectant, which lets the patient absolutely 
 alone, to the active treatment, which requires him to be disturbed every few 
 minutes. It is impossible to lay down any routine plan : we have no specific 
 for the disease, and each case should be treated on general principles and 
 according to its individual indications. The general condition and strength 
 of the patient should be improved as much as possible. There should be 
 plenty of sunlight and fresh air in the sick-room, which should be kept at 
 a uniform temperature of about 70° F. The clothes and bed-linen should 
 be kept clean and pure by frequent changing.- The skin should be kept in 
 good condition, and special care should be taken of the digestion and nourish- 
 ment. Great stress should be given in advising the recumbent position and 
 avoiding all exertion, but, of course, this is often impossible in children. 
 
 Internal Treatment. — Alcohol and food are of the greatest value, and too 
 much stress cannot be laid on the importance of their proper use. The diet 
 should, as a rule, be a liquid one, and consist of such food as is easily digested. 
 Cows' milk, pure and fresh, is undoubtedly the best, but to aid digestion or to 
 prevent souring and other fermentative changes it may be peptonized, or lime- 
 water or an antiseptic may be added to it. To give variety to the diet or to 
 meet special indications other wholesome and nourishing articles may be 
 included, as beef juice, eggs, etc. The food should always be given at regular 
 intervals, about once every three or four hours, and in definite quantities. It 
 is always harmful to compel a child to take more food than it can digest, and 
 any drug which interferes with the 'proper digestion and assimilation of the 
 food is positively harmful, and its use should be avoided. 
 
 Alcohol, as brandy, whiskey, champagne, wine, or in some other form, 
 should be given rather freely from the beginning, and there is more danger 
 from giving too little than too much. A three-year-old child can take from one 
 to ten ounces of whiskey in twenty-four hours, and in bad septic cases this 
 amount may be greatly increased with advantage. Other valuable stimulants 
 are carbonate of ammonium, camphor, musk, strychnia, digitalis, and the large 
 
262 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 number of heart stimulants and tonics ; but alcohol, in one of its many forms, 
 is by far the best and safest. 
 
 The remedies which are given internally in the treatment of diphtheria 
 make a long list, but most of them are of doubtful value, and many of them 
 interfere with the digestion or do positive harm in other ways. Tincture of 
 the chloride of iron is the most popular one. Locally it is a powerful astring- 
 ent and antiseptic, but internally it seems to me that the theoretical benefit 
 which it produces is, in many cases, more than counterbalanced by the diges- 
 tive disturbances which follow its use. 
 
 Chlorate of potassium has an excellent effect in healing lesions of the 
 mucous membranes, but internally,- especially in large doses, it is positively 
 dangerous, not only by its irritating effects on the stomach and intestines, but 
 also by its dangerous action on the kidneys and heart. 
 
 The mercurials, especially the corrosive and the mild chloride, are undoubt- 
 edly valuable, but most of the good resulting from their use is obtained from 
 their local effect on the pharynx, and their local effect in the digestive tract by 
 preventing fermentation. The corrosive sublimate should be used in large and 
 frequent doses, and always well diluted. 
 
 Turpentine, chloride of ammonium, iodide of potassium, antimony, the 
 salicylates, bromine, benzoate of sodium, balsam of copaiba, cubeb, quinine, 
 pilocarpine, and many other drugs are enthusiastically advised by different 
 writers ; but in the light of recent knowledge of this disease it is difficult to 
 understand how any benefit could be obtained by their internal adminis- 
 tration. 
 
 High fever should be reduced by sponging and baths, and the antipyretic 
 drugs, antipyrine, acetanilid, phenacetin, etc., should be avoided, because 
 they all increase the depression of the weak and degenerated heart. The bath, 
 if used, should not be cold, but begun at 95° F. and gradually reduced to 
 80°, or even 70° in bad septic cases. Stimulants internally, hot applications 
 to the extremities, and a warm sponge-bath are valuable in overcoming any 
 bad effects of an over-cold bath. However, it is seldom wise to reduce the 
 temperature of the bath below 70° F., and the best antipyretic effects are 
 obtained in this manner. The patient should remain in the bath until the 
 temperature, taken in the rectum, begins to fall, when he should be imme- 
 diately removed and put to bed. In laryngeal cases, and in cases with enlarged 
 and tender lymphatic glands, cold applications, and even the ice-bag, often 
 seem to be of benefit to the local process. 
 
 Exhaustion, reflex vomiting, collapse, diarrhoea, haemorrhages, and other 
 complications should be treated symptomatically and promptly; but their 
 appearance can often be prevented, and every effort should be made to attain 
 this end. For exhaustion and collapse alcohol in large doses, both by mouth 
 and under the skin, is the best remedy, but digitalis, nitro-glycerin, strych- 
 nine, camphor, and musk are useful. In the rapid heart failure of diphtheria, 
 with an irregular and fluttering pulse, nothing is equal to a moderately large 
 dose of morphine, given hypodermatically. It is a powerful stimulant, and 
 quiets and steadies the heart. For the reflex vomiting there is nothing more 
 satisfactory than the oil of wormwood, given as follows : 
 
 3^. Olei absinthii gtt. j to ij. 
 
 Sodii bicarbonatis 3j. 
 
 Aquae menthae piperitae ad f giv. — M. 
 
 Sig. One teaspoonful for a child three years old, every half hour until 
 the vomiting ceases. Shake well before using. 
 
DIPHTHERIA. 263 
 
 "When the vomiting is due to uraemia or to irritation of the stomach other 
 appropriate measures should be taken. For the diarrhoea, when due to local 
 irritation in the bowels, give an active cathartic, by preference calomel or 
 castor oil, to remove from the digestive tract the cause of the irritation, and 
 follow this by an antiseptic to prevent further fermentation. The following 
 answers very well : 
 
 1^5. Hydrargyri chloridi corrosivi gr. j. 
 
 Bismuthi subnitratis 3iv. 
 
 Aquae anisi f^iv. — M. 
 
 Sig. One teaspoonful in water every two hours until the discharges are 
 black and lose their fetor. Shake well. 
 
 In severe haemorrhages, especially from the nose, it may be necessary to 
 apply local astringents or even to plug the nares with cotton. However, this 
 should be avoided when possible, and many cases, being caused by an irregular 
 and weak heart or a passive congestion from a weak right ventricle, can be 
 stopped by the use of alcohol, digitalis, or nitro-glycerin, according to the 
 indications. 
 
 Local Treatment. — It must be acknowledged that the best and most sat- 
 isfactory results in diphtheria are obtained by local treatment. The chief 
 points to be considered in deciding upon a plan of treatment are — 
 
 1. The most convenient method of applying the medication — by spray, 
 irrigation, insufflation, gargle, inhalation in the form of vapor, or by direct 
 application with a swab. This will vary according to the medication employed 
 and the location of the disease. For naso-pharyngeal cases the most satisfac- 
 tory and thorough method is by irrigation with a fountain syringe. Through 
 the nostrils the whole naso-pharyngeal cavity can be most thoroughly cleansed, 
 and with less difficulty than by any other method. The child should be kept 
 in a horizontal position when possible, and a rubber sheet arranged to catch 
 the discharge. At each irrigation it is necessary to use enough of the solution 
 to thoroughly clean the naso-pharynx — about one pint. This should be done 
 every two hours, and in all cases often enough to thoroughly clean the diseased 
 surface and bring the germicide in direct contact with it. In adults it is very 
 satisfactory to use the irrigation through the mouth. In children this is often 
 impracticable, but, when necessary, pass the nozzle of the syringe back be- 
 tween the teeth and cheek, so that the stream will enter the pharynx behind 
 the last molar tooth. If the child be intractable and exhaust himself to a dan- 
 gerous degree by fighting against the treatment, it may become necessary to 
 clean the surface by giving internally plenty of water, either alone or with a 
 weak antiseptic or a mild alkali, and applying the germicide by inhalation in 
 the form of vapor, either by the sublimation of fifteen to forty grains of calo- 
 mel every hour or two, or by keeping the air of the room saturated with steam 
 which is impregnated with turpentine or some of the volatile antiseptics. The 
 following is an excellent combination : 
 
 Tfy. Acidi carbolici foj. 
 
 Olei eucalypti foij. 
 
 Spts. terebinthinae fsviij. — M. 
 
 Sig. Add a tablespoonful every half hour to about a quart of water, 
 which is kept simmering over a flame. 
 
 In laryngeal or bronchial cases, although an application may be made 
 
264 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 directly to the larynx with a swab, the only satisfactory method is by means 
 of the inhalation of a medicated vapor. 
 
 The spray, while of value, usually does not go beyond the oral cavity, and 
 seldom or never reaches the posterior pharynx. Through the nose it does 
 better service. The swab, except in very careful and experienced hands, is 
 liable to be too harsh and tear off membrane, thus opening up fresh avenues 
 for infection ; and in the grave cases, the nasal ones, it is almost useless. The 
 use of the gargle is limited to adults and older children, it is not thorough, and 
 it tires the patient very quickly. 
 
 2. The medication to be employed. There are two indications to be met : 
 (a) the clearing away of debris and dead tissue, which may be the cause of 
 much fetor and secondary septic complications, and which may also prevent 
 the germicide from reaching the bacilli ; and (b) the destruction of the living 
 bacilli and other bacteria which are producing the disease. A third indication 
 would be to neutralize or to destroy any of the unabsorbed toxalbumin which 
 may be present. With our present knowledge of the properties of this poison 
 it would be difficult to decide upon any practical rules, but we may be sure 
 that its mechanical removal by irrigation is of value. We know that it is 
 taken up very slowly from the infected tissues, often giving symptoms of fresh 
 absorption after all the bacilli have disappeared ; therefore the importance of 
 keeping the surface of the mucous membrane clean after all evidence of the 
 disease has gone. 
 
 (a) The most efficient drug for the removal of broken-down membrane, 
 dead tissue, pus, and other debris is the peroxide of hydrogen, although it has 
 apparently no destructive effect on the living bacilli. For this purpose it is 
 certainly superior to any other means, although there are some preparations 
 which are of great value as adjuncts — e. g. a saturated solution of borax in 
 hot water, and the solvents, like pepsin, trypsin, and papayotin. The ordinary 
 fifteen-volume solution of peroxide should be used, either in full strength or 
 diluted with lime-water, which removes some of its acrid and irritating quali- 
 ties without impairing its efficiency. It should be used freely, and in most 
 cases a mixture of one part of the ordinary fifteen-volume solution with two or 
 three parts of lime-water is effective. The best method to apply it is by irriga- 
 tion with a fountain syringe, using about half a pint each time, and often enough 
 to keep the diseased surfaces clean. There are several objections to its use. One 
 is the difficulty of obtaining a fresh and active solution. This objection has been, 
 in a great measure, overcome by Squibb of Brooklyn, who has made it possible 
 to freshly prepare this solution at the time of use. A serious objection to 
 Squibb 's method is the long time required to prepare the solution. How- 
 ever, it is always well to test the activity of the solution before depending upon 
 it. Another objection, and an important one, is its irritating effect upon the 
 mucous membrane. It causes pain, and, as a result, objections to its use on 
 the part of the patient ; it also produces fresh lesions in the healthy mucous 
 membrane, thus offering new places for infection. In my early experience 
 with the drug, these objections and the greatly increased number of cases in 
 which the diphtheritic process extended to the buccal mucous membrane, the 
 gums, the tongue, and lips, seemed to make its use of very doubtful value, and 
 probably harmful. However, these faults can be obviated in a great degree 
 by diluting the solution with an alkaline water, and, after its use, by irrigating 
 the same surface with a saturated solution of borax in hot water. If it is 
 desirable to use the solution of peroxide without diluting it, neutralize the 
 excess of acid with an alkali. 
 
DIPHTHERIA. 265 
 
 (b) To destroy the bacilli almost every caustic, astringent, digestive fer- 
 ment, essential oil, and germicide has been lauded, and brilliant results claimed 
 for each. Unfortunately, most of these reports are not based upon enough 
 observations to be of much value; and it is apparently not recognized that 
 nearly every case of tonsillar, most cases of pharyngeal, and many cases of 
 naso-pharyngeal diphtheria recover under any kind of treatment. 
 
 Of all the germicides, the mercurials seem to have the most destructive 
 effect on the Klebs-Loeffler bacillus, and carbolic acid, either alone or combined 
 with eucalyptus and turpentine, on the streptococci and other bacteria which 
 produce the false diphtheria. As it is often so difficult to distinguish between 
 them — and, in fact, both forms are so frequently combined— it is better to use 
 locally both the carbolic acid and some mercurial preparation. Therefore, 
 always keep the room moderately filled with steam that is impregnated with 
 the mixture of carbolic acid, eucalyptus, and turpentine. In naso-pharyngeal 
 cases, after the thorough cleansing of the surface with the peroxide and the 
 borax solution, use in the cavity a solution of bichloride of mercury, 1 : 1000, 
 either by irrigation, with a swab, or by spray. No metallic utensils should 
 come in contact with the mercury solution, as it corrodes them. If, for any 
 reason, it is impossible to use the irrigation or spray, the local effect of the mer- 
 cury may be obtained by subliming the mild chloride and allowing the child to 
 inhale the fumes. 
 
 In laryngeal cases dependence must be placed upon inhalation, as it is im- 
 practicable and dangerous to use the laryngeal applicator. The inhalation 
 most destructive to the Klebs-Loeffler bacillus is the fumes obtained by sub- 
 liming calomel. The child should be well wrapped up, so that only the face is 
 free, thus exposing the least possible surface of the skin to the action of the 
 mercury. It should then be placed in an ordinary croup-tent, and the calomel 
 sublimed in such a manner as to fill it with the fumes. The best apparatus for 
 this purpose is the ordinary steam-spray, in which the boiler is replaced by a 
 strip of tin upon which the calomel is put. Another good arrangement is to 
 put a small alcohol lamp in the bottom of an ordinary chamber, and cover it 
 with a pie-pan or strip of metal to hold the powder. The same end may 
 be attained with a hot stove-lid, a shovel of red-hot coals, and in other ways. 
 According to circumstances, fifteen to forty grains of calomel should be burned 
 in this manner every one, two, or three hours. It is not necessary to wake the 
 child for treatment, and if the smoke causes much coughing and irritation, sub- 
 lime it less rapidly by lowering the flame of the lamp. It usually takes about 
 ten minutes to sublime fifteen grains, and if care be taken to obtain pure calo- 
 mel, or, better yet, calomel which has been recently sublimed and recondensed, 
 the irritation from the fumes is usually very slight. This treatment does good 
 not only by its local effect in the larynx, but by keeping the bronchi protected, 
 and thus preventing the most common and fatal complication of laryngeal diph- 
 theria — the extension of the disease to the bronchi. This treatment, which 
 was first suggested by Corbin of Brooklyn, is not only of great value after 
 operative interference, by preventing the extension of the disease to the bron- 
 chi, but its early use will in many cases obviate the necessity of an intubation 
 or a tracheotomy. Besides this, it keeps the sick-room disinfected and helps 
 to prevent the spread of the disease. The attendant should be cautioned to 
 inhale the vapor as little as possible, as it is surprising how frequently the nurse 
 becomes salivated and how seldom the patient is at all affected. However, this 
 treatment seems to have a depressing effect on some patients, although there are 
 seldom any other evidences of mercurialization ; but it should be remembered 
 that in infants and young children mercury is not liable to produce salivation 
 
266 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 as in adults. Its effects are shown rather by marked anaemia and depression, 
 with signs of irritation of the intestines and the kidneys. 
 
 The operative treatment of diphtheria will be considered elsewhere, but the 
 following suggestion may be of value in overcoming one of the most serious 
 complications that arises — namely, loose membrane in the trachea or bronchi. 
 Its removal by aspiration, by tubes of large calibre, and by numerous kinds of 
 forceps has been attempted, but with little or no satisfaction. The most suc- 
 cessful method in my own practice is to insert a small laryngeal applicator, the 
 cotton on which is covered with a very sticky substance like Canada balsam. 
 Upon its withdrawal more or less of the membrane remains adherent to it, 
 and after several trials and in many cases the loose membrane is all brought 
 out. 
 
 Antitoxin. — In discussing the value of any treatment for diphtheria it 
 is necessary to consider this disease separately as it involves the larynx 
 and as it involves the naso-pharynx. For all therapeutical purposes we 
 have practically two distinct diseases, although the cause may be the same. 
 In the laryngeal type the danger is from asphyxia, either from laryn- 
 geal obstruction or, when this is overcome, from an extension of the mem- 
 branous inflammation to the smaller bronchi ; and the danger from sep- 
 sis is not great, because of the meagre lymphatic supply in this region 
 and the small area of the surface from which absorption of toxins can 
 take place. 
 
 On the other hand, in naso-pharyngeal diphtheria the danger from 
 mechanical obstruction is slight, and the fatal cases are, almost without 
 exception, the result of the absorption of poisons through the abundant 
 lymph- and blood-supply. This is especially true of the nasal cases, as in 
 this region not only is the blood- and lymph-supply very abundant, but it 
 is almost impossible to obtain good drainage when the nasal mucous mem- 
 brane and the turbinated bones are swollen. 
 
 Again, in laryngeal cases the disease is rarely the result of a mixed infec- 
 tion, but naso-pharyngeal diphtheria, as we see it in practice and not in the 
 laboratory, is frequently due to a mixed infection. The importance of this 
 from a therapeutical point of view is evident when we consider the difference 
 between infection by Klebs-Loffler bacilli and by streptococci. The point is 
 that in streptococcus infection the germ itself finds its way into the blood 
 and viscera, but this is rarely true of the bacillus in Klebs-Loffler infection. 
 In one case you have a toxin only to fight, and in the other you have both 
 the germ and its toxin. 
 
 Although we admit that there are many unsolved therapeutical problems 
 in connection with the antitoxin treatment of naso-pharyngeal diphtheria, 
 there can be no doubt of its almost specific value in the laryngeal form of 
 this disease. The laboratory proof is absolutely convincing as far as it goes 
 — namely, that the serum in proper doses is a specific for preventing the 
 harm which follows the absorption of the toxin of the Klebs-Loffler bacillus. 
 The clinical results confirm this conclusion. 
 
 I can do nothing stronger to uphold this position than to give a short 
 analysis of the cases of laryngeal diphtheria which I have seen during the 
 past twelve years. I have arranged them from September to September, 
 so that the cases of each winter will be kept together. With but few 
 exceptions they have been seen in council with other physicians, and, since 
 the antitoxin days, the diagnosis has been confirmed in nearly every case 
 by a bacteriological examination by the New York or Brooklyn Board of 
 Health. 
 
DIPHTHERIA. 267 
 
 Intubation Cases. 
 
 No. Recovered. 
 
 July, 1SS5, to September, 1886, 37 7 = 18.9 per cent. 
 
 18S7, 65 15 = 23.0 
 
 1888, 89 28 = 31.4 " 
 
 1889, 95 31 = 32.6 
 
 1890, 63 19 = 30.1 " 
 
 1891, 63 23 = 36.5 " Began calomel 
 
 1892, 117 40 = 34.1 " sublimations. 
 
 1893, 84 32 = 38.0 " 
 
 1894, 76 29 = 38.1 
 
 , QQ _ f 13 with antitoxin . 5=38.4 " 
 1 « yo > \ 44 without " . 20 = 45.4 
 
 27 with antitoxin . 17 = 62.9 " 
 3 without " . 0= " 
 
 Sept 
 
 , 1SS6, 
 
 u 
 
 1887, 
 
 u 
 
 1888, 
 
 u 
 
 1SS9, 
 
 a 
 
 1S90, 
 
 a 
 
 1891, 
 
 << 
 
 1892, 
 
 (i 
 
 1893, 
 
 a 
 
 1894, 
 
 u 
 
 1895, 
 
 tt 
 
 1896, to 
 
 
 Total . 
 
 1896, 1 2 g 
 
 a -i ion- / 19 with antitoxin . 18 = 94.7 
 April, 189/,|^ without „ ^_g = _o 
 
 796 284 = 35.6 
 
 The following table shows the results with and without calomel sublima- 
 tions in all cases of laryngeal diphtheria up to September, 1894, or the 
 beginning of the antitoxin treatment, and the results since the antitoxin 
 was used : 
 
 442 cases ; 
 
 intubation ; 
 
 no calomel sublimations ; 
 
 121 recovered = 27.3 per cent. 
 
 295. " 
 
 " 
 
 with 
 
 123 " = 41.6 
 
 59 " 
 
 u 
 
 " antitoxin ; 
 
 40 " = 67.8 " 
 
 50 « 
 
 no " 
 
 no calomel sublimations ; 
 
 all recovered = 100 " 
 
 45 " 
 
 (i a 
 
 with 
 
 = 100 
 
 18 " 
 
 U U 
 
 " antitoxin ; 
 
 = 100 
 
 38 died before my arrival. 
 23 refused operation and died. 
 21 died of sepsis with only slight obstruction. 
 991 cases. 
 
 It is interesting to note the steady improvement in results as our know- 
 ledge of the technique of intubation increased, and as we learned from experi- 
 ence to overcome, with greater success, the dangers and accidents of intuba- 
 tion. The marked improvement after calomel sublimations were used, and 
 the still greater success after antitoxin, are noteworthy. This benefit is seen 
 not only in the larger number of recoveries after operation, but in the in- 
 creased percentage of cases which recovered without an operation. Thus of 
 
 492 cases, no sublimations, 50 recovered without operation = 10.1 per cent. 
 340 " with " 45 " " =13.2 " 
 
 77 " " antitoxin, 18 " " =23.3 " 
 
 Of course even this underestimated the good results, for the percentage of 
 cases under calomel sublimations or the antitoxin treatment which recover 
 without operation is very much larger. Since the introduction of antitoxin 
 many cases recover and are never seen by the consultant which in former 
 years would have undoubtedly come under his notice. 
 
 The apparently bad results after the use of antitoxin from September, 
 1894, to September, 1895, were probably due to two causes — inferior anti- 
 toxic serums and insufficient doses. A careful consideration of the cases 
 during this period fails to show any marked difference in severity between 
 those that received and those that did not receive antitoxin. 
 
 Treatment of Sequels. — The treatment of the sequelae and the albu- 
 minuria of diphtheria requires a few words. The albuminuria of this disease 
 seems to be very little affected by treatment. The best that can be done is to 
 
268 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 put the patient on a proper diet, compel the skin and the intestinal tract to do 
 the work of the kidneys as much as possible, and to give a diuretic mixture — 
 e. g. the infusion of digitalis with acetate of potassium. In bad septic cases 
 the tincture of the chloride of iron seems to be useful ; but marked diminu- 
 tion of urine, especially anuria, with a large amount of albumin, seems to be 
 unaffected by any treatment, and usually ends fatally. 
 
 The anaemia should be treated by improving the nutrition and general con- 
 dition in every possible way, and giving an iron mixture internally, a most 
 satisfactory one being — 
 
 ]^. Tr. ferri chloridi f^iij to xij. 
 
 Glycerini flj. 
 
 Aquae ad f liv. — M. 
 
 Sig. — Teaspoonful three times daily, in water, through a glass tube. 
 
 The chronic catarrh left after the disappearance of the pseudo-membrane 
 should receive prompt and efficient treatment. In most cases the local appli- 
 cation, continued for some time, of a weak solution of nitrate of silver will be 
 all that is needed. But there are cases which may require operative interfer- 
 ence and special treatment; and this treatment is discussed at another place 
 in this work. 
 
 The natural tendency of the post-diphtheritic paralysis is to recovery. This 
 is aided by every means which tends to increase the nutrition and improve the 
 general condition. Therefore, good hygienic surroundings, plenty of easily- 
 digested and nourishing food, iron, quinine, strychnine, and other tonics, are 
 indicated. Strychnine, either hypodermatically or by mouth, seems to affect 
 most beneficially the paralyzed muscles, one-sixtieth to one-thirtieth of a 
 grain being given in twenty-four hours. Besides this, the careful use of mas- 
 sage and electricity does good service in assisting the nutrition and circulation 
 of the affected muscles until the nerve-lesion gets well. 
 
 Synopsis of Treatment. — In brief, the treatment of diphtheria may be 
 summarized as follows: 
 
 1. Put the patient in the best hygienic surroundings, with plenty of fresh 
 air and sunlight. Keep the room at a uniform temperature of about 70° F., 
 and give him an abundance of clean linen and bed-clothes. In protracted 
 cases transfer the patient to a fresh room that has been thoroughly aired and 
 not exposed to the disease, as many cases are undoubtedly liable to rein- 
 fection. 
 
 2. Keep up the strength and nutrition of the patient with plenty of stimu- 
 lants and easily-digested and nourishing food. 
 
 3. Avoid all internal medication unless clearly indicated. The bichloride 
 of mercury is useful, and in certain septic cases the tincture of the chloride of 
 iron. The chlorate of potassium is dangerous. 
 
 4. Remove all broken-down membrane, pus, and other de'bris by irrigation 
 of the diseased surface with a fifteen-volume solution of peroxide of hydrogen, 
 diluted with lime-water. 
 
 5. To destroy the bacilli after the surface has been cleaned apply a solution 
 of bichloride of mercury, 1 : 1000, either by irrigation or spray, and keep the 
 room saturated with the vapor from a mixture of carbolic acid, turpentine, and 
 eucalyptus. When it is impracticable to use the spray or irrigation, either from 
 the location of the disease or the impossibility of managing the child, the best 
 substitute is to make the patient inhale the fumes obtained by subliming 
 calomel. 
 
DIPHTHERIA. 269 
 
 6. The treatment of the albuminuria is very unsatisfactory ; in septic 
 cases the tincture of the chloride of iron, in addition to the digitalis and 
 acetate of potassium, gives the best results. 
 
 7. The sequelae should be treated according to indications — the anaemia 
 with iron and general tonics ; the chronic catarrh by the application of weak 
 solutions of nitrate of silver ; and the paralysis by strychnine, massage, elec- 
 tricity, and general tonics. 
 
 8. Recent studies in immunity have given us a knowledge of an antitoxin 
 which neutralizes or destroys the toxalbumin of the diphtheric bacillus. The 
 following are the excellent rules for its use recommended by the American 
 Pediatric Society at its meeting in 1897 : 
 
 Antitoxin should be given at the earliest possible moment in all cases of 
 suspected diphtheria. 
 
 Quality. — Of the products on the market some have, by test, been found 
 to contain one-half to one-third the antitoxin units stated on the label. Select 
 the most concentrated strength of an absolutely reliable preparation. 
 
 Dosage. — All cases of laryngeal diphtheria, the patient being two years 
 of age or over, should receive as follows : 
 
 First dose — 2000 units at the earliest possible moment. 
 
 Second dose — 2000 units twelve to eighteen hours after the first dose if 
 there is no improvement in symptoms. 
 
 Third dose — 2000 units twenty-four hours after the second dose if there 
 is still no improvement in symptoms. 
 
 Patients under two years of age should receive 1000 to 1500 units, the 
 doses to be repeated as above. 
 
TUBERCULOSIS 
 
 By WILLIAM OSLER, M. D., 
 
 Baltimore. 
 
 I. General Etiology and Morbid Anatomy. 
 
 Infants born dead . . 
 
 . . 0.0 per 100 
 
 From 2 to 3 years . 
 
 From to 4 weeks . 
 
 . . 0.0 " " 
 
 " 3 « 4 <c 
 
 " 5 " 10 " . 
 
 . 0.0 " " 
 
 a 4 a g a 
 
 " 3 " 5 months 
 
 . 8.6 " " 
 
 " 5 " 10 " 
 
 a q « 12 u 
 
 . 18.3 « " 
 
 " 10 " 15 " . 
 
 " 1 " 2 years . 
 
 . 26.8 " " 
 
 
 (a) Incidence of Tuberculosis in Infancy and Childhood. — Altkough 
 it has long been known that, in the quaint language of Sir Thomas Browne, 
 "consumptive and tabid roots sprout early," the appreciation of the wide- 
 spread prevalence of tuberculosis in the early periods of life is due to recent 
 observations. Extremely rare in the new-born and uncommon in the first thre 
 months of life, the cases increase rapidly throughout the latter half of the first 
 year and in the second year. In the creche of the Hopital Tenon of Paris, in 
 the year 1890, it is stated that more than 21 per cent, of the babies died of 
 tuberculosis. Of 2576 autopsies on infants made at Kiel, Boltz found 424 
 cases of tuberculosis. The following table gives the proportions at different 
 ages: 
 
 33.0 per 100 
 29.6 " " 
 31.8 " " 
 34.3 " " 
 
 30.1 " " 
 
 The statistics of the late Professor Parrot embraced 219 cases in children 
 under three years. Of these there were — 
 
 From 1 day to 3 months 23 
 
 " 3 to 6 months 35 
 
 " 6 " 12 " 53 
 
 giving a total of 111 under one year of age, and from one to two years, 108. 
 
 Of 500 autopsies in children at the Munich Pathological Institute, Miiller 
 found tuberculosis in 150. Of 527 infants dead in hospital of various diseases, 
 tubercles were present in 314. 
 
 A set of combined autopsies on 2230 children gave 753 tuberculous and 
 1407 non-tuberculous. The ages of the tuberculous cases are thus grouped: 
 
 From birth to 1 month 10 
 
 Up to 2£ years 138 
 
 From 3 to 5 years 255 
 
 " 6 « 10 " 226 
 
 " 11 " 15 " 124 
 
 270 
 
TUBERCULOSIS. 271 
 
 Analogous statistics are not, to my knowledge, available in this country, 
 but the observations of Northrup at the New York Foundling Asylum show, 
 at any rate, that the- disease must prevail quite as extensively. From the third 
 to the fifteenth year tuberculosis is also very frequent, and its manifestations 
 in the glands, skin, and bones contribute a very considerable percentage of all 
 cases in the out-patient departments of hospitals and in the special infirmaries 
 for children's diseases. 
 
 The mortality, highest in the first year, sinks rapidly throughout childhood, 
 to rise after puberty. Thus of 10,000 living, there die (U. S. Census, 1870) of 
 tuberculosis in the first year 18.5 ; in the second, 10.5 ; in the third, 5.9 ; from 
 the third to the fifth, 2.9; from the fifth to the tenth, 2; from the tenth to 
 the fifteenth, 3.3. The Kiel mortality statistics (Heller) also show this in a 
 striking manner: of 10,000 living, there died in the first year 245; in the sec- 
 ond, 114; in the third, 76; from the third to the fifth, 34: from the fifth to 
 the tenth, 14 ; from the tenth to the fifteenth, 16. 
 
 (b) The Bacillus Tuberculosis. — It is acknowledged by those most 
 capable of expressing an opinion that the essential cause of tuberculosis is the 
 organism discovered by Koch. The bacillus is a short, fine rod from 1 to 5 fi 
 in length, and usually a little curved. In the sputum and in tuberculous 
 tissue the bacilli are often in little clumps, or two lie crosswise at an acute 
 angle. 
 
 For demonstrating the bacilli in sputa the following method will be found 
 satisfactory: The thicker and more purulent parts of the sputum are picked out 
 with a small sharp-pointed forceps and spread over the cover-glass, which is 
 allowed to dry in the air and then passed three or four times through the 
 flame. A few drops of Ziehl's solution of fuchsin— namely, distilled water 
 100 grams, carbolic-acid crystal 5 grams, alcohol 10 grams, fuchsin 1 gram — 
 are placed upon the cover-glass, which is held over the flame until it begins to 
 boil. The glass is then washed in water, and a few drops of Gabbet-Ernst's 
 solution — namely, methylene blue 1 to 2 grams, 25 per cent, sulphuric acid 
 100 grams — are placed upon the glass and allowed to remain there for about a 
 minute. The glass is then washed in water, and mounted either in water or, 
 after drying between filter-paper, in oil or balsam. The tubercle bacilli are 
 stained red, while the nuclei of the cells and any other bacteria are stained blue. 
 
 In sections the following method is pursued at the Pathological Laboratory 
 of the Johns Hopkins Hospital: The tissues should be hardened in absolute 
 alcohol and imbedded in celloidin. After the sections have been cut, the cel- 
 loidin should be removed either with oil of cloves or with absolute alcohol and 
 ether. After this they are passed through strong alcohol (to remove the oil or 
 ether), and then placed in water previous to staining. The most satisfactory dye 
 is the carbol-fuchsin solution of Ziehl. The sections are left for two hours at a 
 temperature of 60° C. (or, if this be inconvenient, they may be stained for six 
 or eight hours in the thermostat at 37° C, or for twenty-four hours at the room 
 temperature). The tissue-elements and the bacilli are thus stained deeply in 
 the fuchsin. A good decolorization solution is the ordinary acid alcohol of the 
 laboratory (acid, hydrochloric. 1, aq. destill. 30, alcohol 70). The decolorizing 
 process must be carefully watched, as too much of the dye may be easily 
 extracted, the tubercle bacilli along with the tissue-elements losing their stain. 
 It is best to remove the sections from the acid alcohol while they still retain a 
 decided pink tint. A counter-stain is then used, the most desirable being a 2 
 per cent, aqueous solution of methylene blue. This removes all remaining fuch- 
 sin color from the tissue-elements and stains them a delicate blue. The tuber- 
 
272 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cle bacilli are stained a bright red. The sections are to be dehydrated in abso- 
 lute alcohol, cleared in oil of cloves or preferably in xylol, and mounted in xylol 
 balsam. It is best to examine with an oil-immersion lens, although if the bacilli 
 are numerous they can readily be made out with a good high-power dry lens 
 (Zeiss 3, or Leitz 7). Tubercle bacilli may be demonstrated in tissues by 
 means of the rapid method used for staining them in sputum, but the results 
 are very unsatisfactory, owing to the distortion of the tissues resulting from 
 the action of the heat and the strong acids. 
 
 The bacillus is aerobic, and, although somewhat difficult to cultivate, may 
 be grown on blood-serum, glycerin agar, or even on potato. The colonies form 
 dry, grayish-white, scale-like masses. In the growth the bacillus forms certain 
 soluble product or toxines, which, if introduced into the body, produce lesions 
 similar to those induced by the bacilli themselves. 
 
 The bacilli are tolerably tenacious, and retain their virulence after freezing, 
 desiccation, and salaison. It is stated that the bacilli have been found alive 
 after burial of the subject for two years. The combined action of dryness and 
 exposure to air is stated to diminish the virulence, but tuberculous sputum 
 exposed to the air for from fifty to one hundred days still retains its virulence. 
 The bacilli are rapidly killed in a few minutes by moist heat, as in boiling ; 
 dry heat is much less effectual. The bacilli are found in variable numbers in 
 all tuberculous structures — the acute miliary nodule, the caseous, fibrous, and 
 fibro-caseous nodules. They are most abundant in rapidly-growing tubercles 
 and in the old ulcerous lesions of pulmonary tuberculosis. They are scanty, as 
 a rule, in the more chronic tuberculous processes of glands and of bones, and in 
 the lesions associated with extensive caseation. When not easily demonstrable 
 by histological methods, inoculation in animals may alone determine the tuber- 
 culous nature of a structure. 
 
 Outside the body the bacillus has been shown to be a very widely-dis- 
 tributed organism, the number in any locality depending upon the number of 
 cases of pulmonary tuberculosis and the carelessness or thoroughness with which 
 the sputa of infected individuals is destroyed. In an ordinary case of pulmo- 
 nary consumption countless millions are thrown out daily and scattered widely 
 in the sputum dried as dust. Cornet found the dust of hospital wards and 
 places occupied by tuberculous patients to be infective in a number of cases. 
 Thus of 118 samples of dust from the wards of hospitals and rooms occupied 
 by tuberculous individuals, 40 proved capable, when inoculated in animals, of 
 producing tuberculosis. The infectiveness of the dust of the medical and sur- 
 gical divisions of a hospital was found to be in the proportion of 76.6 to 12.5. 
 
 (c) Modes of Transmission. — (1) Experimental Tuberculosis. — Much of 
 our knowledge of the disease has been derived from experiments, and we owe 
 to Villemin the demonstration of the infective character of all tuberculous pro- 
 cesses. The receptivity of animals varies very much : the rabbit and guinea- 
 pig are particularly susceptible ; dogs and cats are very resistant. Bovines are 
 very susceptible, and one of the most important facts in the etiology of the 
 disease is the frequency with which the disease occurs in them. 
 
 Subcutaneous inoculation of tuberculous material in a susceptible animal, 
 as a rabbit or a guinea-pig, is followed in a short time by the production of a 
 little nodular growth, which softens, and even ulcerates, and which in time may 
 be absorbed. The corresponding lymph-glands swell, tubercles develop in 
 them, and then caseate. The animal dies in from six weeks to three months. 
 Tubercles are found in the lymph-glands, and there is, as a rule, general tuber- 
 culosis of the organs. The most satisfactory method is the inoculation of 
 
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 material into the anterior chamber of the eye of the rabbit, as used by Cohn- 
 heim. The development of the tubercles, at first a local process, may be 
 watched in the iris. There is afterward generalization, and the animal dies 
 emaciated. In some instances in the rabbit and guinea-pig the lesion produced 
 is entirely local and the animal recovers. If a culture of tubercle bacilli is 
 injected into the veins, the animal dies, as a rule, in a shorter time, with the 
 development of miliary granulations, particularly in the liver and in the spleen. 
 If a larger quantity be injected, the animal may die of a profound infection 
 before the tubercles become visible to the naked eye. 
 
 The transmission by inhalation is more difficult in animals, and the results 
 of causing animals to breathe air charged with tubercle bacilli are discordant, 
 but in some instances undoubted pulmonary infection and general tuberculosis 
 have followed. Experimental infection through the digestive passages has 
 also been demonstrated, particularly in the feeding of animals with the milk 
 of tuberculous cows. 
 
 (2) Hereditary Transmission. — Current opinion on this point may be ex- 
 pressed as follows : While in a few rare cases tuberculosis is transmitted directly 
 from parent to offspring, in the great majority of all cases the heredity does not 
 relate to the transmission of the seed itself, but of a disposition of body, a 
 type of tissue-soil favorable to the development of the disease in case of acci- 
 dental infection. 
 
 Congenital tuberculosis has been observed in some six or eight cases. In 
 the case of Charrin there was generalized tuberculosis in a foetus seven and a 
 half months old, the mother of which died of phthisis. In Berti's case the 
 child, born at term of a phthisical mother, died on the ninth day, and two small 
 cavities were found at the posterior border of the lower lobe of the right lung, 
 which were shown microscopically to be tuberculous. In Merkel's case the 
 tuberculous mother died two days after confinement. The child had tuber- 
 culosis of the palate and an abscess of the left trochanter major. In Jacobi's 
 case the foetus, born at the seventh month, had miliary granulations in the 
 liver, peritoneum, spleen, and right pleura. In the case described by Sabour- 
 aud the child born of a tuberculous mother died on the eleventh day. The 
 liver and spleen were tuberculous. 
 
 In all of the cases reported it was direct maternal heredity. The mode of 
 transmission is not at all certain, but it is probably transmission through the 
 placenta. Tuberculosis of the placenta is very rare. Lehman has recently 
 reported an instance in a woman aged twenty-nine dead of acute tuberculosis in 
 the eighth or ninth month of pregnancy. The foetus was not affected, but on 
 both surfaces of the placenta there were a few grayish nodules, which showed 
 the characteristic structure of tubercle, with bacilli. It has been shown also 
 that the placenta of a tuberculous woman proved infective ; and, indeed, it is 
 stated that the amniotic fluid of a tuberculous subject may produce the disease 
 in a guinea-pig. 
 
 There are several experiments (Landouzy and Martin, Birch-Hirschfeld, and 
 Armanni), which indicate that the virus may be present in the foetus without 
 the presence of actual tubercles, since they found that portions of the viscera 
 of foetuses born of tuberculous mothers were infective to guinea-pigs. 
 
 A modified view of this direct heredity is advocated by Baumgarten, who 
 holds that the virus is directly transmitted, but remains latent, and does not 
 develop until some time after birth. In support of this he quotes the large 
 number of cases of tuberculosis in the early months, the figures illustrating 
 which have already been given. He also lays great stress upon the occurrence 
 of tuberculosis in the bones and the joints of children, regions to which the 
 
 18 
 
274 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bacilli would not be likely to be conveyed in accidental infection. This post- 
 natal development he regards as analogous to syphilis hereditaria tarda, and he 
 suggests that the actively growing tissues of the child restrain or inhibit the 
 development of the germs. 
 
 There is no evidence to show that a tuberculous father can directly trans- 
 mit the disease. The experimental evidence is also negative. Gartner (whose 
 recent article on "Heredity in Tuberculosis" is the most important contribu- 
 tion made to the subject of late years) found that in rabbits and guinea-pigs, 
 with artificially induced tuberculosis of the testes, and whose semen contained 
 bacilli, the embryos were never infected. On the other hand, of 65 female 
 guinea-pigs which had consorted with the tuberculous bucks, 5 presented genital 
 tuberculosis, and of 59 female rabbits under similar conditions 11 became 
 infected. 
 
 In support of the view that tuberculosis is hereditary great stress is laid 
 naturally on the frequency with which a history of the disease is met with in 
 the parents. The estimates of various authors on this point vary from 10 to 
 50 per cent. Of 427 cases at the Johns Hopkins Hospital, there were only 53 
 in which the mother was affected, 52 in which the father had had tuberculosis, 
 and 105 in which sister or brother had had the disease. The fact that the 
 children and relatives of tuberculous individuals are more directly exposed to 
 contagion than other individuals renders it difficult, as Fagge remarks, to draw 
 a clear line between heredity and accidental infection. 
 
 (3) Inoculation. — This is not very common in man, as the skin does not offer 
 a very suitable soil for the development of the tubercle bacilli. This mode of 
 infection is, however, seen in persons whose occupations bring them in contact 
 with dead bodies and animal products. Demonstrators of anatomy are particu- 
 larly subject to a local tubercle on the finger or back of the hand — the so- 
 called post-mortem wart, verruca necrogenica, the "lichen" tubercle of the 
 Germans. Only in very exceptional instances is this followed by serious results. 
 Cases have been reported of infection from the bite of a tuberculous patient, 
 inoculation from a cut by a broken spit-cup and the puncture of a hypoder- 
 mic needle. There is no reliable observation of the transmission of tubercu- 
 losis by vaccination. In the performance of the rite of circumcision children 
 have been inoculated, the infection in these cases being associated with disease 
 in the operator, and occurs in connection with the habit of cleansing the wound 
 by suction. 
 
 (4) Transmission by Inhalation. — The expired air of tuberculous patients 
 is harmless, but the sputa, dried and widely diffused in the form of dust, con- 
 stitute one important medium of transmission in the disease. The investi- 
 gations of Cornet have shown the greater infectiveness of the dust of localities 
 frequented by patients with pulmonary tuberculosis. The frequency with which 
 the disease is met with in the lungs and in the bronchial glands finds here its 
 explanation. 
 
 In institutions the residents of which are restricted in the matter of fresh 
 air and exercise, as in jails and convents, the death-rate from tuberculosis is 
 very much higher than in the general population. Cornet found that in some 
 of the religious communities more than three-fourths of the deaths were due to 
 this disease. The mortality in prisons from tuberculosis is from 40 to 50 per 
 cent., while in the general community it is not more than 15 per cent. Flick 
 has brought forward evidence to show that the distribution of tuberculosis in 
 one of the wards of the city of Philadelphia is more particularly with certain 
 houses in which individuals have died of this disease. There are also some 
 striking local epidemics of tuberculosis : thus Marfan gives an instance of a 
 
TUBERCULOSIS. 275 
 
 place confined and badly ventilated, occupied by twenty-two employees, who 
 were joined in 1878 by two consumptives, who for several years coughed and 
 spat about the floor indiscriminately. The employees arrived at an early hour 
 and breathed the air charged with the dust raised by the morning cleaning. 
 Between 1884 and 1889 thirteen of these persons fell victims to tuberculosis. 
 
 Against these facts, however, are the statements that at hospitals for con- 
 sumptives, as at Brompton, in London, the doctors and nurses are rarely 
 attacked. Dettweiler claims that at his institution in Falkenstein no case of 
 tuberculosis has been contracted. On the other hand, Marfan states that in 
 the Paris hospitals tuberculosis is extremely frequent in the attendants and 
 decimates the lay contingent. At the Hospital Necker half of the attendants 
 are attacked with phthisis, and he notes as a significant fact that it is particu- 
 larly the attendants in the medical wards. 
 
 The danger is enhanced when the contact is particularly intimate, as between 
 a tuberculous mother and her child or between man and wife. In the latter 
 case there are figures which indicate that contagion is not at all infrequent. 
 
 (5) Transmission by the Food. — Experiments have shown that infection 
 may be communicated by ingestion of tuberculous material, and one of the 
 most important problems relates to infection with the milk of tuberculous cows. 
 Experimentally, it has been conclusively demonstrated that such milk is infec- 
 tive, even when the disease is localized in the lungs of the animal, and that 
 it is not necessary that the udder should be diseased. Ernst has shown that 
 the bacilli may be present in the milk when there is no tuberculous mammitis. 
 The danger of infection from this source in children is very urgent, and system- 
 atic sanitary inspection should be made of the cows, and, if necessary, inocu- 
 lation experiments made with the milk. 
 
 The percentage of tuberculous animals in the dairy-stables of our cities 
 is very much larger than has been supposed. The figures in this country 
 for large numbers are not available. It has been stated that from 10 to 15 
 per cent, of the dairy stock in the Eastern States is tuberculous. This is 
 probably a low estimate. 
 
 The virulence is retained in the cream and in the butter. Other conditions 
 than the presence of the bacilli in the milk are probably necessary for infection, 
 and, fortunately, all children who drink tuberculous milk do not become con- 
 taminated. In some instances the gastric juice may destroy the bacilli ; in 
 others, conditions of the tissues may not be favorable to the development 
 of the seed. Experimentally it has been show^n that lesion of the intes- 
 tines itself is not necessary, and infection of the mesenteric glands may take 
 place through a normal mucosa. Possibly the great frequency of mesenteric 
 tuberculosis in children finds here its explanation. In 127 cases of fatal tuber- 
 culosis in children noted by Woodhead these glands were involved in 100. It 
 is not definitely determined whether the milk of a tuberculous woman is viru- 
 lent. 
 
 Infection by meat is probably very much more rare. When the tuberculosis 
 is generalized in the internal organs the flesh should be confiscated. The viru- 
 lence, however, is only marked when the disease is very extensive. It has 
 been shown that the flesh of tuberculous subjects is infective to guinea-pigs. 
 Nocard, however, in a series of experiments found that the juices of the muscle 
 of twenty-one cases with general tuberculosis, when injected into the perito- 
 neum of guinea-pigs, only once produced tuberculosis. 
 
 (d) Conditions influencing Infection. — (1) General — These, dealing 
 specially with the environment of individuals; explain in a great measure the 
 
276 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 frequency of the disease in certain localities. Thus one of the most important 
 is residence in the large centres in which many people are crowded together. 
 The death-rate from tuberculosis is very much higher in towns than in the 
 country, and a very considerable share of the high infant mortality of cities is to 
 be attributed to it. Not only is the air of the large towns less pure, but the 
 chances are very much greater that the dust, blown in all directions, has with 
 it the germs of the disease. The inhalation of impure air in certain occu- 
 pations, which in adults is an important predisposing factor in pulmonary tuber- 
 culosis, does not prevail to any special extent in children. Climate in itself 
 does not influence the conditions materially, but, as a rule, the disease is more 
 common in the temperate regions, largely because in these are found the largest 
 collection of human beings. Soil and locality have an important influence, 
 cold and dampness increasing the personal liability by favoring the develop- 
 ment of catarrhal affections. There are fewer cases of tuberculosis and fewer 
 foci of infection in regions such as the Alps and in elevated plateaux as in 
 Mexico, but altitude itself does not confer immunity, and there are many 
 mountainous regions in which the inhabitants are much affected by tuberculosis. 
 
 More important than these are the factors relating to personal environment, 
 as of the dwellings. The constant breathing of a vitiated air, as in the small 
 crowded rooms in the tenements and narrow alleys of our large cities, and the 
 absence of sunlight, are two of the most important predisposing elements in 
 tuberculosis in children. These influence infection in two ways : first, by 
 favoring the distribution of the bacilli ; and, second, by lowering the nutrition 
 of the individual and leading to conditions favoring the entrance of the bacilli 
 to, or their development in, the body. 
 
 (2) Individual Predisposition. — From the time of Hippocrates it has been 
 thought that there was a certain conformation of body which rendered an indi- 
 vidual more prone to the disease. His words are : " The form of body peculiar 
 to subjects of phthisical complaints was the smooth, the whitish, that resem- 
 bling the lentil ; the reddish, the blue-eyed, the leuco-phlegmatic ; and that with 
 the scapulae having the appearance of wings." In children it may be said that 
 the build and type such as here described is certainly more prone to tuber- 
 culous affections. Two types of conformation have long been recognized as 
 predisposing in some way to infection ; the tuberculous, with bright eyes, oval 
 face, thin skin, and long thin bones, and the scrofulous, with a heavy figure, 
 thick lips and hands, opaque skin, and large thick bones. But, as in adults, 
 well-developed, healthy infants and children may become subject to the disease. 
 In addition to the conformation of the chest, the respiratory capacity, the rela- 
 tion between the volume of the lung and of the heart, a relatively small heart 
 with narrow arteries, and a pulmonary artery relatively wider than the aorta 
 (Beneke), and relatively large-sized viscera, have all been brought forward as 
 causes predisposing to tuberculosis. 
 
 Among others which may be mentioned is race : the negro seems more 
 liable to the disease than the white races, and it is stated that the Hebrews 
 possess a relative immunity. 
 
 More important in children are the local conditions influencing infection. 
 Acute and chronic catarrhal troubles of the throat and upper air-passages, and 
 of the lung, undoubtedly favor infection, either by allowing the freer entrance 
 of the germs or by weakening the powers of resistance. The infectious diseases, 
 particularly whooping-cough, measles, and influenza, act probably in this way, 
 while small-pox, typhoid fever, and syphilis influence the conditions rather by 
 reducing the power of resistance. In institutions the frequency with which 
 tuberculosis follows the infectious disorders is very striking. 
 
TUBEBCULOSIS. 277 
 
 Of local affections of the lungs which predispose to tuberculosis, haemoptysis, 
 which was regarded as an important cause, is now thought to be an indication 
 rather of the existence of the disease. Such disorders as dilatation of the 
 bronchi and pleurisy also heighten the liability to infection, though in the 
 latter case many of the instances believed to be simple are in reality from the 
 outset tuberculous. 
 
 The subjects of congenital or acquired contraction of the orifice of the 
 pulmonary artery usually, as is well known, die of tuberculosis. Prior to the 
 development of the disease many subjects show a marked anaemia, and unques- 
 tionably chlorosis offers favoring conditions for the development of this affection. 
 Diseases of the stomach and intestines, particularly chronic entero-colitis, in- 
 crease the susceptibility to infection. 
 
 Blows and contusions favor in some way the development of tuberculosis, 
 particularly in children, in whom spinal caries and hip disease may follow 
 an injury; less often does trauma play any part in pulmonary tuberculosis. 
 Here, too, may be mentioned the favoring influence of operation : resection of 
 a tuberculous joint is occasionally followed by an acute infection. 
 
 "With reference to infection and the conditions which influence it the follow- 
 ing may be stated : 
 
 (a) In a few cases the disease is directly transmitted from the mother, and 
 appears in the child at birth. 
 
 (b) The primary tuberculosis of the bones, joints, kidney, spleen, liver, etc. 
 of early youth is very possibly associated with a foetal haematogenous infection 
 (Baumgarten, Gartner). 
 
 (c) Direct paternal transmission has not been proved, and experimental evi- 
 dence is strongly against it. 
 
 (d) In a large proportion of cases the infection is post-foetal — through the 
 lungs, intestines, or skin. 
 
 (e) Heredity influences the soil. All are tuberculizable, to use a French 
 expression, and very many of us actually become infected. Whether or not the 
 seed develops depends, firstly, upon the character of the tissue-soil ; and 
 secondly, upon the existence of special favoring circumstances. 
 
 (/) Immunity, a relative condition, enjoyed chiefly in consequence of 
 inherited tissue-resistance, is lessened by all circumstances which depress nutri- 
 tion, such as bad air, bad food, and imperfect hygienic surroundings. Next to 
 the germ, a vulnerability of tissue, however brought about, whether congenital 
 or acquired, is the most important factor in the etiology of the disease. 
 
 (3) The Relations of Tuberculosis and Scrofula. — The lesions known as scrof- 
 ulous are tuberculous, and due to the development of the bacillus tuberculosis, 
 so that the term scrofula is now almost, and may well be entirely, abandoned. 
 Though the so-called scrofulous lesions of glands and bones and skin are bacillary 
 in origin, yet it has been shown that their virulence is not so extreme as that 
 of the tuberculous products in the viscera, the latter, according to Arloing, 
 killing, when injected, both guinea-pigs and rabbits, the former only guinea- 
 pigs. This corresponds with the more protracted course and the more favorable 
 termination of the so-called scrofulous affections. It has been suggested that 
 the scrofulo-tuberculous manifestations are caused by an attenuated virus. An 
 attempt has been made by writers, particularly Marfan, to show that the scrofulo- 
 tuberculous lesions, when recovered from, confer a sort of immunity to pulmo- 
 nary tuberculosis, but the evidence for this is not yet very strong. 
 
 (e) Anatomical Changes produced by the Tubercle Bacilli. — The 
 lesions induced by the bacilli are in the form of small nodules which, fused 
 
278 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 together, may form large infiltrated areas, so that a distinction is often made 
 between the nodular and the diffusely infiltrated varieties. The studies of 
 Baumgarten and others have enabled us to follow accurately the primary 
 changes induced by the bacillus. These are — 
 
 (1) The mutiplication of the fixed tissue-elements by a process of karyokine- 
 sis. The cells of the vascular epithelium, of the ordinary epithelium, and of 
 the connective tissue proliferate, and gradually there is produced from them the 
 large, rounded, cuboidal, or polygonal cells with vesicular nuclei — the so-called 
 epithelioid cells — inside some of which the bacilli are seen. This reaction of 
 the fixed elements of the tissue would appear to be the primary effect. 
 
 (2) Leucocytes, chiefly polynuclear, migrate, and accumulate about the 
 focus of infection. These form the lymphoid cells which were formerly thought 
 to be so characteristic of the tubercle. They do not, however, undergo sub- 
 division. Some believe that they attack and destroy the bacilli. There would 
 appear to be successive invasions of leucocytes at the focus of irritation, and 
 many of them undergo rapid destruction. It is stated, too, that later, as the 
 little tubercle grows, the leucocytes which surround it are of the mononuclear 
 form, or lymphocytes, and that these persist and do not undergo the rapid 
 degeneration of the polynuclear forms. 
 
 (3) A reticulum of fibres is formed in the tubercle by the fibrillation and 
 rarefaction of the connective-tissue matrix, most apparent, as a rule, at the 
 margins of the growth. 
 
 (4) In some, but not in all, tubercles giant-cells are formed by an increase 
 in the protoplasm and in the nuclei of an individual cell, or possibly by the 
 fusion of several cells. The bacilli are usually, but not always, seen in the 
 giant-cells. There seems indeed to be an antagonism between the number and 
 virulence of the bacilli and the giant-cells : thus in joint and gland tuberculosis 
 and in lupus, in which the former are scanty, the latter are abundant ; while in 
 miliary tubercles, and, as a rule, in all lesions in which the bacilli are abundant, 
 the giant-cells are scanty. 
 
 The tuberculous nodule thus formed may undergo necrosis and caseation, 
 or may gradually be converted into a connective-tissue mass. Caseation begins 
 at the central part of the growth, and appears to be owing to the direct action 
 of the bacilli. The cells undergo coagulation necrosis, lose their outline, be- 
 come irregular, and are finally converted into a homogeneous, structureless 
 material in which the cells are no longer distinguishable, and which no longer 
 takes the stain. As this process extends involving several nodular tubercles, 
 they are gradually converted into uniform yellowish-gray masses. No blood- 
 vessels are found in the central portion, but the bacilli are usually abundant. 
 By the union of many of the nodular tubercles large masses may be formed 
 which may undergo either (1) softening or liquefaction with the formation of 
 cavities; (2) fibroid limitation, leading ultimately to encapsulation; (3) in the 
 older caseous masses, particularly when encapsulated, lime salts may be deposited 
 (calcification) ; and (4) sclerosis. There is necrosis of the tissue-elements in the 
 centre, gradual hyaline transformation, with great increase in the fibrous reti- 
 culum, so that the tubercle is ultimately converted into a firm, hard structure. 
 Sometimes increase in the fibrillation and caseation go on together, with the 
 production of fibro-caseous tubercle. 
 
 Diffuse Infiltrated Tubercle. — It was formerly thought that the products of 
 any simple inflammation might become caseous, and the identity of the caseous 
 pneumonia and of scrofulous lesions with tubercle, which Morton (1685) main- 
 tained, and which Laennec laid down as a fundamental proposition, was for a 
 long time disputed, particularly by Virchow. Now, the researches of Koch 
 
TUBERCULOSIS. 279 
 
 have demonstrated that these infiltrated caseous lesions are definitely tuber- 
 culous. 
 
 Infiltrated tubercle results from the fusion of many small nodular foci, too 
 small sometimes to be visible to the naked eye. Histologically, however — in 
 the lungs, for instance — they may be seen to be composed of scattered centres 
 surrounded by zones in which the air-cells are filled with leucocytes and the 
 products of the proliferation of the alveolar epithelium. Under the influence 
 of the bacilli caseation takes* place, usually in small groups of lobules, but 
 occasionally in an entire lobe, or it may be throughout the greater part of a 
 lung. There is really no essential difference between the nodular and the infil- 
 trated tubercle. 
 
 Secondary inflammatory processes accompany the growth and development 
 of tubercle: (1) The exudation of leucocytes and serum about the primary 
 growth is in reality an inflammation, which varies with varying conditions, and 
 which may be limited or very extensive. For example, about the tubercles in 
 the lungs there is always inflammation of the alveoli with infiltration and pro- 
 liferation of the connective-tissue elements of the septa, and changes in the 
 blood- and lymph-vessels. 
 
 (2) The bacilli themselves may induce suppuration, as in joint and bone 
 tuberculosis ; experimentally, the products of the growth of the tubercle bacilli, 
 particularly Koch's tuberculin, produce an active suppuration. In tubercu- 
 losis of the lungs, as well as in other regions, the suppuration is largely the 
 result of a mixed infection, and is due to pus-organisms. 
 
 (3) A slow, reactive inflammation occurs about many tubercles, resulting 
 in the formation of a cicatricial connective tissue, limiting and restricting their 
 growth, and constituting, in reality, the important conservative and healing ele- 
 ment in the disease. 
 
 II. Generalized Forms of Tuberculosis. 
 
 (1) Acute Miliary Tuberculosis. 
 
 Forms of tuberculous infection running a rapid course are decidedly more 
 common in infants and children than in adults. Practically, there is always a 
 focus of local disease in a bronchial or mesenteric gland, a joint, or on the skin, 
 or in superficial lymph-glands. In a few rare instances a miliary tuberculosis is 
 encountered in which caseous foci cannot be discovered. The picture may be 
 either that of an acute infection without definite local manifestations, or of an 
 intense infection with pronounced symptoms pointing to involvement of the 
 meninges of the brain, the lungs, or the serous membranes. In children there 
 is no hard-and-fast line to be drawn between the acute forms in which miliary 
 granulations occur throughout all the organs, and in which the clinical course 
 is from three to six or eight weeks, and forms in which throughout the various 
 organs there are coarser, larger grayish-yellow tubercles, and in which the 
 clinical course is of more subacute character, lasting from eight to twelve or 
 even sixteen weeks. As in the adult, the cases may be divided for convenience 
 into three groups, as the symptoms are those of a general infection, simulating 
 very often typhoid fever, or those of an acute meningitis or of an acute affec- 
 tion of the lungs. These cerebral, general, and pulmonary types cover a major- 
 ity of the cases. There may be mentioned, in addition, an acute affection, 
 occurring in children the subjects of a local tuberculous process, in which, with 
 the symptoms of a profound infection, there is no general miliary tuberculosis. 
 This form, which has been described by several French writers as the fievre 
 
280 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 infeetieuse tuberculeuse suraigue, is not generally recognized, but the cases 
 described by Landouzy and others presented quite minor tuberculous lesions 
 of the lungs or of other organs, with the clinical symptoms of very intense 
 infection, the severity of which was out of all proportion to the local lesion and 
 to the number of miliary granulations found throughout the body. It is thought 
 to be due to the action of the tuberculous toxines. 
 
 The acute tuberculous meningitis will be described separately. We shall 
 here speak only of the typhoid and of the pulmonary types. 
 
 Typhoid Type. — The onset is usually insidious, and commonly there has 
 been an indisposition or slight cough, but prior to the fever the child may 
 have been in good health. The fever is noticed in the afternoon or evening, 
 and with it there is loss of appetite, and the child loses in weight and is list- 
 less and not inclined to play. A bronchial cough is by no means uncommon, 
 but it is to be remembered that the disease may set in quite abruptly in a child 
 believed to be in good health. Within a week, or even earlier, the child takes 
 to bed, and the symptoms of an infection are well pronounced. The tongue is 
 white and furred. The abdomen is distended, sometimes painful on pressure, 
 and there may be diarrhoea. The spleen is usually enlarged, and can be readily 
 felt. The liver may be also distinctly swollen. The gastro-intestinal trouble 
 with the continued fever may be strongly suggestive of typhoid fever, but rose- 
 spots are not detected. There are usually some symptoms pointing to the 
 involvement of the bronchi or the lungs, and the respirations are hurried, only, 
 however, in proportion to the fever, and the physical signs indicate rather a 
 catarrh of the larger than of the smaller tubes ; there is no dulness. There 
 are headache, delirium, particularly at night, and sometimes marked hyper- 
 esthesia of the skin. Albuminuria is often present, and there may be com- 
 plete suppression of urine. The fever varies greatly in intensity, but usually has 
 not the regularity of typhoid, and the daily exacerbations are more marked. It 
 may rise to 104° and 105 ° F. On the other hand, there are cases in which the 
 fever is moderate, not more than 101° or 102°, and very rarely there may be 
 no fever. There are also instances in which there have been rigors through- 
 out the course of the disease. The condition of the child becomes aggravated, 
 and with a dry tongue, delirium, unconsciousness, distended abdomen, and 
 swollen spleen, the similarity to typhoid fever is very close. The course is ex- 
 tremely variable, and while death may occur at the end of the second or begin- 
 ning of the third week, in other cases the disease is prolonged to five or six 
 weeks. In the more protracted cases definite local signs are met with ; thus, 
 with an increase in the dyspnoea and cough bronchitis of the smaller tubes is 
 found, and patches of consolidation at the bases, so that aeration is very defec- 
 tive. The eruption of tubercles on the meninges may intensify the cerebral 
 manifestations, and there may be from the outset severe headache, with a gradual 
 and progressive coma, dilated pupils, and sometimes strabismus. 
 
 Pulmonary Type. — The clinical features are of an intense capillary bron- 
 chitis (broncho-pneumonia). This, the more common variety, is very often 
 mistaken at its onset, and even throughout the course, for simple broncho- 
 pneumonia. The onset may be abrupt, and even with a chill, but, as a rule, the 
 child has been failing in health or is at the time convalescing from some acute 
 illness or is the subject of an acute naso-pharyngeal catarrh. The fever is high, 
 and may reach from 103° to 105°; the pulse is rapid, from 130 to 140. 
 The respiratory symptoms are marked. At first the shortness of breath is slight 
 and proportionate to the fever, but gradually it increases, and the respirations 
 may be from 60 to 70 per minute. The cough is frequent, dry, and very 
 troublesome. As the dyspnoea becomes more marked the color of the face changes, 
 
TUBERCULOSIS. 281 
 
 and there is slight cyanosis. Though the fever is high and the symptoms grave, 
 there are rarely severe cerebral manifestations. There may be slight diar- 
 rhoea, but the abdomen is not specially distended ; the spleen is easily pal- 
 pable. The whole clinical picture is that of an acute broncho-pneumonia. The 
 physical examination shows hurried respiration, and there may be retraction of 
 the lower zone of the thorax ; the percussion note is clear, even hyperresonant, 
 and auscultation at first shows signs of a general bronchial catarrh, chiefly of 
 the smaller tubes. Subsequently, as the case progresses, there are areas in 
 which the resonance is higher in pitch or even tympanitic, and in places distinct 
 blowing breathing may be heard, or even the signs suggestive of cavity. 
 
 The course of the disease in this type is much more rapid, and the child 
 may die at the end of a week, or even earlier, with the signs of an acute suf- 
 focative catarrh — more commonly in from ten to twelve or fourteen days, usually 
 from a progressively advancing asphyxia. 
 
 Diagnosis.— The diagnosis of acute tuberculosis in children may be very 
 easy or beset with the greatest difficulties. The family history should be taken 
 into account ; the surroundings of the case, particularly whether there have 
 been instances of tuberculosis in the same house or occupying the same room. 
 Much more important is the previous history and personal condition of the 
 patient. Inquiries should be made about whooping-cough and measles, 
 diseases not infrequently followed by acute tuberculosis. Sometimes a history 
 of failing health or of protracted catarrh may be obtained. The most evident 
 cases are those in which there are signs of local glandular or bone tuberculosis. 
 Sometimes the acute affection follows an operation on the tuberculous glands of 
 the neck or the opening of a joint abscess, or even of a so-called cold abscess, 
 or, in very rare instances, the tapping of a pleural effusion. In the typhoid 
 type, when the features are well developed, the simulation of ordinary enteric 
 fever may be extremely close. Here, if from the outset a careful temperature 
 record be kept, it will usually be found that the fever is much more irregular 
 in tuberculosis, and early in the disease there may be quite marked morning 
 remissions. As noted before, in a few instances the temperature may be low, 
 even subnormal, in the morning. The general features of infection are much the 
 same in both diseases. The absence of typhoid rash, unless it is there, which is 
 usually present in children, and very distinctive, is a most important nega- 
 tive sign. Expectoration is rarely obtained, but should the child vomit, sputa 
 should be looked for in the vomitus, since it sometimes happens that an acute 
 miliary tuberculosis takes its origin in a small focus of disease in one lung, from 
 which tubercle bacilli may reach the sputum. 
 
 The examination of the urine is important, but Ehrlich's reaction is pres- 
 ent as frequently in acute tuberculosis as in typhoid fever. Pus in the urine 
 should be carefully examined for bacilli, since instances of general infection 
 have resulted from urogenital tuberculosis. 
 
 The profound infection associated with malignant endocarditis may simulate 
 that of acute tuberculosis. The special heart-signs, if present, and embolic 
 features, would be important distinguishing marks. The diagnosis of the 
 catarrhal or broncho-pneumonic type will be more fully considered when speak- 
 ing of the acute tuberculous broncho-pneumonia of infants. 
 
 Prognosis. — The prognosis is always unfavorable. Here, however, may 
 be mentioned a type of acute tuberculosis recognized by Empis, Landouzy, and 
 others, which they call typho-tuberculose or typho-bacillose, and which may 
 be either the first manifestation of the invasion of the organism with the bacilli 
 or the expression of an acute, but aborted, tuberculosis, following some local 
 tuberculous process. The clinical aspect is really that of typhoid fever, and 
 
282 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the temperature curve would not appear to give any definite criterion. Unless, 
 in fact, there is some local tuberculous focus, I do not see how this form can be 
 recognized, and many of the cases reported by Aviragnet in his monograph are 
 not at all convincing. That there may be, however, either early in a tuber- 
 culosis, or as a secondary event in a local process, an infection of the system 
 with the toxines is extremely likely. In adults it is not very uncommon to 
 find a tuberculous focus completely overlooked in a general infection believed 
 to be typhoid fever, and in which the secondary development of miliary granu- 
 lations seems scarcely sufficient to account for all the symptoms. 
 
 (2) Chronic Diffuse Tuberculosis. 
 
 This, one of the most common forms of tuberculosis in children, is charac- 
 terized anatomically by the gradual development of tubercles in many different 
 parts of the body : they are not, however, the miliary granulations of the acute 
 tuberculosis, but coarse, grayish-yellow tuberculous masses, varying in size from 
 a pea to a walnut. In the lungs, for instance, there are caseous tubercles of all 
 sizes, areas of caseous broncho-pneumonia, some of which have undergone 
 softening ; but cavities are not common except in children above four or five. 
 The bronchial glands are often greatly enlarged and caseous, and sometimes 
 present abscesses. The abdominal organs show extensive tuberculosis. The 
 spleen is greatly enlarged, and on section presents numerous grayish-yellow 
 tuberculous masses, varying in size from 2 to 10 mm. The liver is enlarged 
 and may show miliary tubercles on the capsule, but in many instances there 
 are coarser yellowish-gray masses which have developed about the bile-capil- 
 laries, and which, having softened in the centre, present a yellowish-green bile- 
 stained pus. The small intestines may show tuberculous ulceration to a greater 
 or less extent. The mesenteric glands are usually enlarged and caseous. 
 The kidneys may show coarse tubercles, sometimes an intense tuberculous pye- 
 litis. In the brain there may be either an acute terminal meningitis or there 
 are coarse tuberculous nodules scattered throughout the substance, particularly 
 in the cerebellum. The chronic diffuse tuberculosis is much more frequent in 
 infants than in children above the age of two. The symptoms are those of a 
 progressive enfeeblement of the nutrition, as a rule without fever, and with 
 manifestations in different organs varying with the degree of tuberculization. 
 The affection may set in acutely as a bronchitis or a broncho-pneumonia, the 
 symptoms of which gradually subside. Very often the condition follows whoop- 
 ing-cough, measles, or acute gastro-intestinal catarrh. Less frequently it is 
 insidious, and the child presents simply progressive failure in health. The 
 appearance of the child is that of marked cachexia. It is thin ; the skin is loose 
 and pale, sometimes covered with fine scales, and occasionally pigmented. The 
 eyes are large, and the expression often bright and animated. The thorax is 
 thin, the ribs readily noted, and there may or may not be the signs of coexist- 
 ing rickets. The abdomen is usually tumefied, and both the liver and spleen 
 are enlarged. When the abdominal features are marked, the clinical picture 
 is that really of some cases formerly described as tabes mesenterica. The 
 superficial glands may be enlarged and hard. Cough may be present, usually 
 dry, and very rarely there is dyspnoea. The physical signs thoroughout the 
 lungs are either dulness in the interscapular regions or scattered areas of defec- 
 tive resonance with bronchial rales and blowing breathing. The appetite is 
 poor, the digestion feeble, vomiting is frequent, and diarrhoea is common. Not 
 only may there be no fever, but the temperature may even be subnormal. 
 Death usually results from some complication, either a secondary invasion of 
 pneumococci or streptococci, or an acute meningitis. 
 
TUBERCULOSIS. 283 
 
 The diagnosis may present difficulties if one does not constantly bear in 
 mind, in the first place, the frequency of tuberculosis in infants, particularly 
 in institutions ; and, secondly, the fact that this diffuse form, which is very 
 common, may pursue its course without fever, and only perhaps toward the 
 close show signs of active disease, now of the meninges, now of the lungs, or, 
 again, of the intestines. This cachexia of the chronic diffuse tuberculosis of 
 infants must be distinguished from that of rickets, of chronic gastro-intestinal 
 catarrh, and of syphilis. In rickets the changes in the bones and cartilages, 
 in athrepsia the marked gastro-intestinal disturbance, and the, as a rule, more 
 enfeebled and senile look of the child, serve as distinguishing features. The 
 absence of enlargement of the spleen and liver or of the lymph-glands is an 
 important negative sign. A greater difficulty exists in distinguishing some of 
 the cases of profound syphilitic cachexia, as here the superficial glands may be 
 enlarged and the spleen and liver hypertrophied ; but, on the other hand, the 
 history, the facies, the skin-rashes, rhagades, and, above all, the prompt 
 improvement under antisyphilitic treatment, are important points of differen- 
 tiation. 
 
 m. Localized Tuberculosis. 
 
 (1) Tuberculosis of the Lymph-glands. 
 
 (a) Tuberculous Polyadenitis. — The lymphatic system may be the chief 
 seat of the disease, and the glands, internal and external, or the lymph-sacs 
 (serous surfaces), may present advanced tuberculosis without much involvement 
 of the viscera or other parts. This is more often the case than we have here- 
 tofore supposed. In some instances of general tuberculous infection in young 
 children there may be what Legroux calls micro-polyadenopathy, which in 
 doubtful cases may give an important diagnostic hint. More recently Lesage 
 and Pascal have described cases in children in which there was progressive 
 involvement of the lymphatic glands, usually at first those of the groin, then 
 those of the axilla, and lastly the cervical and internal groups. They regard 
 the affection in some of the cases as due to cutaneous tuberculosis; in others 
 they believe the disease to be congenital. The symptoms of this form of gen- 
 eralized enlargement of the superficial lymph-glands are progressive cachexia 
 without much fever and without signs of disease of the lungs or of the abdom- 
 inal organs, and frequently a ravenous appetite. 
 
 The cases must be carefully distinguished from the general slight enlarge- 
 ment of the lymph-glands in syphilis, and from the rare cases of Hodgkin's 
 disease in children, in which, however, the enlargement is much greater and 
 the involvement of one group is generally much more marked. It must not 
 be supposed, however, that every case of general moderate enlargement of the 
 superficial lymph-glands- in children is due either to tuberculosis, syphilis, or 
 Hodgkin's disease. Following the infectious fevers, and associated with chronic 
 catarrh of the upper air-passages, I have seen on more than one occasion 
 enlargement of the glands of the neck, of the groin, and of the axillae — 
 a condition of the superficial lymph-apparatus comparable to the swelling 
 of the Peyer's follicles and of the mesenteric glands found so frequently in 
 children dead of one of the infectious diseases, or, in fact, of any prolonged 
 illness. 
 
 (b) Cervical Adenitis. — The drainage-areas of the lymphatic glands of 
 the neck embrace the superficial and deep structures of the head and neck 
 
284 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The most important groups are the superficial cervical, beneath the platysma, 
 which drains the side of the head and neck and face and external ear, and the 
 deep cervical along the carotid sheath, which drains the mouth, the tonsils, 
 palate, pharynx, and larynx. In addition there are the submaxillary and 
 suprahyoid groups draining the lower gums, the front of the mouth and tongue, 
 and the chin and lower lips. 
 
 Tuberculous adenitis of the glands of the neck, so extremely common, which 
 fortunately often remains a local and curable affection, was regarded as one 
 of the most tvpical and characteristic manifestations of scrofula. Cornet's obser- 
 vations upon the presence of tubercle bacilli in the dust of cities and of rooms 
 show how widely spread the virus is, and how liable we are in crowded cities 
 to inhale, and even to swallow, bacilli with the dust. Whether the bacilli 
 are capable of passing through the healthy mucous membrane is perhaps doubt- 
 ful, though there are experiments which would seem to prove the liability of 
 infection through the healthy mucous membrane of the intestines. More prob- 
 ably the slight catarrhal troubles about the naso-pharynx, so frequent in chil- 
 dren, open, as one may say, the portals and allow the bacilli to reach the lymph- 
 glands. Preliminary irritation and enlargement of the glands in eczema of the 
 scalp and in sore throat in children may weaken the powers of resistance. 
 Here, no doubt, if the tissue-soil be unfavorable, they may exert no influence 
 whatever, but with that vulnerability of tissue, regarded by former writers as 
 the characteristic feature of scrofula, the bacilli find a suitable nidus, and a 
 local tuberculosis is the result — a process characterized usually by extreme 
 chronicity. 
 
 The glands may enlarge rapidly at first and become soft and painful ; more 
 commonly, they swell slowly, and can be felt as firm rounded masses freely 
 movable beneath the skin. They may gradually subside and undergo spon- 
 taneous healing. In other instances the glands increase, areas of softening are 
 found, the process involves the skin overlying the gland, which becomes red, 
 and finally ulcerates, discharging a cheesy matter and a thin watery sero-pus. 
 The sore thus left is very indolent, does not tend to heal; the skin about it is 
 livid and undermined. Many of the glands may suppurate in this way, and 
 when healing ultimately takes place the sides of the neck are disfigured by 
 irregular, unsightly scars. In the neck of young or old these are usually a 
 certain sign of healed tuberculosis. 
 
 It is to be borne in mind that involvement of the cervical glands may be 
 due to extension of tuberculous processes from the axillary glands or even from 
 carious cervical vertebrae. When the glands are large and growing actively 
 there is fever ; death very rarely follows, and even aggravated cases in children 
 may recover. In some instances the general nutrition is very slightly disturbed. 
 Tuberculous adenitis of the cervical or axillary groups may precede the devel- 
 opment of tuberculosis of the pleura or of the lung. 
 
 (c) Tracheo-bronchial glands. — Within the thorax the groups of lymph- 
 glands are of great importance. The sternal are placed along the course of the 
 internal mammary vessels; the intercostal along the heads of the ribs, and 
 sometimes extending outward; the anterior mediastinal group between the 
 lower part of the sternum and the pericardium ; the cardiac group in the inter- 
 pleural space about the arch of the aorta ; and, lastly, the tracheal glands on 
 either side of the windpipe, and the bronchial proper, continuous with them, 
 which surround the main bronchi and pass deeply in the hilus of the lung. 
 There are also glands in the posterior mediastinum along the thoracic aorta 
 and oesophagus. Tuberculosis of the tracheo-bronchial glands is extremely 
 
TUBERCULOSIS. 285 
 
 coimnon. Observations of Loornis (Jr.) show even that in apparently normal 
 glands bacilli may be present and the gland-tissue infective. Certainly in a 
 verv large proportion of all cases of tuberculosis in children it would appear 
 that the first infection was in these structures, while common experience shows, 
 contrary to the so-called law formulated by Parrot, that the glands may be 
 involved without any local lesion in the lungs. Of 125 cases examined by 
 Northrup, the bronchial glands were tuberculous in every case ; 42 had cheesy 
 masses in the bronchial lymph-nodes only, with recent tubercles in the lungs 
 and elsewhere ; in 13, it was limited to the bronchial glands alone. The glands 
 may present gray miliary tubercles, large, unpigmented, cheesy areas, foci 
 of softening with suppuration, or old calcified masses. In the long-standing 
 cases there is much sclerosis and pigmentation. The different groups may be 
 very differently involved; thus the tracheal may be much affected without 
 great involvement of the bronchial nodes proper. More commonly all the 
 glands are involved, and very often those deep in the hilus of the lung form 
 large caseous masses uniformly surrounding the main bronchus and its divisions, 
 and penetrating deeply between the lobes of the lung. When the glands sup- 
 purate the abscesses may perforate in different directions. The effects of these 
 enlarged glands are very varied, and for full details the reader is referred to the 
 elaborate section in the Traite of Barthez and Sanne (tome 3). It is suf- 
 ficient here to say that there are instances on record of compression of the 
 superior cava, of the pulmonary artery, and of the azygos vein. The trachea 
 and bronchi, though often flattened, are rarely seriously compressed. The 
 pneumogastric nerve may be involved, particularly the recurrent laryngeal 
 branch. More important, really, are the perforations of the enlarged and 
 softened glands into the bronchi or trachea, or a sort of secondary cyst may be 
 formed between the lung and the softened bronchial gland. Perforations of the 
 vessels are much less common, but the pulmonary artery has been opened. Per- 
 foration of the oesophagus has been described in several cases. One of the 
 most serious effects is infection of the lung or pleura by the caseous glands 
 situated deep along the bronchi. The infection may, as is often clearly seen, 
 be by direct contact, and it may be difficult to determine in some sections where 
 the caseous bronchial gland terminates and the pulmonary tissue begins. In 
 other instances it takes place along the root of the lung, and is subpleural. 
 Among rarer sequences may be mentioned diverticula of the oesophagus follow- 
 ing adhesion of an enlarged gland and its subsequent retraction, and, in the 
 case of the anterior mediastinal and aortic groups, the frequent association of 
 tuberculous adenopathy and pericarditis, either by contact or by rupture of a 
 softened gland into the pericardium. 
 
 Symptoms. — In the great majority of instances there are no indications 
 whatever, and even in enormous enlargement pressure-signs may not have been 
 present. Authors differ extremely in their views on this point. Many hold, 
 and I think correctly, that the manifestations, as a rule, are very slight. Com- 
 pression of the veins leading to dropsy, dilatations of the veins causing cyano- 
 sis, and haemorrhages are referred to by Barthez and Sanne\ Alterations in 
 the character of the heart-sounds and attacks of paroxysmal dyspnoea are des- 
 cribed by the same writers. The latter come on suddenly, often at regular 
 hours, frequently in the afternoon, and there is extreme oppression with rapid 
 breathing, cyanosis, and cold sweats, almost like an attack of severe croup. 
 These paroxysms may succeed each other, and they have been ascribed not so 
 much to pressure at the bifurcation of the trachea as to compression of the vagi, 
 causing in this way laryngeal spasm. More definite, undoubtedly, is the com- 
 pression of one or other bronchus, causing feeble breathing on the side most 
 
286 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 affected, with sibilant and fine rales. Usually, however, when the glands are 
 very much enlarged the lung is also involved, and it may be difficult to say how 
 far the alterations are due to the changes in it. Still less reliable is the infor- 
 mation obtained on percussion, for the dulness in the upper part of the sternum 
 and in the interscapular spaces is, when present, by no means a positive sign. 
 The thymus may cause sternal flatness on percussion; and behind, unless the 
 glands are enormously enlarged and the child very thin, it is difficult to deter- 
 mine any special modification of the resonance in the interscapular space 
 between the first and third dorsal vertebrae. 
 
 (d) Mesenteric Glands (Tabes Mesenterica). — The glands involved 
 are those of the mesentery and the gastro-hepatic omentum and the chain 
 of retroperitoneal glands along the aorta ; more rarely those of the pelvis. 
 Tuberculous disease of these glands is extremely common ; thus of 127 cases 
 of fatal tuberculosis in children, noted by Woodhead, these structures were in- 
 volved in 100, while Ashby states that of 103 consecutive post-mortems on 
 children dying of tuberculosis, in 62 there was tuberculous ulceration of the 
 intestines ; in 71, cheesy mesenteric glands ; in 55, both ulcers and cheesy 
 glands ; in 7, tuberculous ulcers without involvement of the glands ; and in 
 16, cheesy glands without ulcers. Of 144 children in which the mesenteric 
 glands were tuberculous, only 44 showed neither ulcerations nor tubercles in 
 the intestines (Barthez and Sanne). 
 
 In a great many instances the condition is found accidentally in children 
 who have died of other diseases. Unquestionably, as is indicated by these 
 figures, the infection in many of these cases is primary in the glands. Lesion 
 of the intestines is not necessary. Some experiments have shown that the 
 bacilli may gain entrance through a healthy mucosa. A special interest relates 
 to the possibility of infection by the bacilli in milk, more particularly as it is 
 well known that in animals experimentally fed with infected milk primary 
 tuberculosis of the intestines, with extensive disease of the mesenteric glands, 
 has been produced. The question will be referred to again on the subject of 
 primary tuberculosis of the intestines. The cases fall into four groups : 
 
 (1) Very slight tuberculous affection of a few glands (which may be the 
 only ones), met with accidentally in children who have died of various dis- 
 orders. 
 
 (2) In the chronic generalized tuberculosis, in both the acute and chronic 
 pulmonary tuberculosis, and in the more chronic forms of tuberculosis of 
 any of the organs in children, the mesenteric glands may be found enlarged 
 and caseous. There are instances, too, in which the affection of the mesen- 
 teric and retroperitoneal glands with those of the thorax constitutes the chief 
 lesion. 
 
 In both these groups the disease of the glands does not necessarily cause 
 any symptoms pointing to abdominal disorder. 
 
 (3) In a third group there are signs of chronic intestinal catarrh or ulcer- 
 ation and very marked disturbance in the general nutrition. These cases 
 are seen chiefly in children between the ages of eighteen months and five 
 years. The abdomen is distended, tympanitic, usually a little painful on deep 
 pressure, but no nodules are felt. The diarrhoea is the most troublesome symp- 
 tom ; the stools are frequent, brownish or yellow-brown in color, containing 
 mucus, not often blood. The diarrhoea is variable, and may sometimes persist 
 for several weeks. There is usually slight fever, but the general wasting and 
 debility are the most characteristic features. The name tabes mesenterica is 
 often applied to this condition. The course is chronic and may extend over a 
 
TUBERCULOSIS. 287 
 
 year or two, leading to the most extreme emaciation. It is sometimes very 
 difficult to determine whether actual tuberculous disease of the bowel is present 
 or not, as a chronic intestinal catarrh may lead to just such a condition of 
 extreme debility and wasting. In the diagnosis of these cases much stress can 
 be laid upon the presence or absence of tubercles in other parts. 
 
 (4) And, lastly, there are cases in which with ulceration of the intestines 
 the mesenteric glands are greatly enlarged, and in addition the peritoneum is 
 involved. Here the diarrhoea, the slight fever, the malnutrition, and progres- 
 sive wasting are as in the previous group ; additional symptoms are associated 
 with disease of the peritoneum, in which nodular masses may be felt, and there 
 may be considerable ascites. These cases will be referred to more particularly 
 under Peritoneal Tuberculosis. 
 
 (2) Tuberculosis of the Intestines and of the Abdominal Organs. 
 
 (a) Tuberculosis of the bowels. — The small intestine is most frequently 
 involved ; thus, of 141 children presenting tuberculous ulcerations in the 
 gastro-intestinal canal (Barthez and Sanne), in 134 the small intestine was 
 involved; in 60, the large intestine; in 71, the small intestine alone. It is 
 remarkable, considering the comparative rarity in the adult of tuberculous dis- 
 ease of the stomach, that in this series it should have been met with in 21 
 cases. That tuberculosis may originate in the alimentary canal is shown 
 experimentally by the feeding of guinea-pigs with cultures of the bacillus and 
 the feeding of calves and pigs with the milk of tuberculous animals. There are 
 now many series of cases demonstrating the facility with which animals may be 
 infected through this latter source. That the intestinal lesion may be primary 
 in children is acknowledged. The comparatively large number of children with 
 caseous foci in the mesenteric glands is very suggestive. On the other hand, 
 instances of primary intestinal tuberculosis are not very common. 
 
 In a great majority of the cases the tuberculous lesions are part of a 
 general infection, and are undoubtedly secondary. The ulcers are situated 
 chiefly in the ileum, involving the solitary and agminated follicles of Peyer. The 
 tubercles may be seen as small granulations in the submucosa ; sometimes the 
 whole ileum may present a remarkable appearance from the grayish-yellow 
 nodular tubercles, the size of split peas, occupying the submucosa and the 
 mucous membranes. The caseation and necrosis lead to ulceration, which may 
 be very extensive, involving at first Peyer's patches, but ultimately extending 
 beyond their limits. The tuberculous ulcer has the following characters : It 
 is "transverse to the long axis, rarely ovoid, often irregular in outline; the 
 edges and base are infiltrated, often caseous ; the submucosa and muscularis 
 are also involved in the tuberculous process ; and, lastly, colonies of young 
 tubercles or well-marked lymphangitis may be seen on the serosa." 
 
 Primary tuberculosis of the bowel is, as stated, rare; but in children with 
 extensive ulceration in the ileum and very slight lesions of other parts the dis- 
 ease may be regarded as primary ; thus in a child aged nine who was admitted 
 to my wards with dropsy and emaciation after an illness of six months' duration, 
 there were only a few small foci in the lungs, while the intestines showed most 
 extensive disease. About 50 cm. below the duodenum there was a large 
 circling ulcer, the edges of which were undermined, the bases irregular and 
 worm-eaten, and containing necrotic, grayish material. The peritoneum over 
 it was thick and opaque. Throughout the whole of the ileum there was a series 
 of these girdling ulcers at varying intervals. The caecum presented a very 
 
288 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 large, deep ulcer, while the mesenteric attachment about the ileum formed a 
 large tumor-mass from the extent of the involvement of the glands. The 
 peritoneum presented scattered tubercles and the mesenteric glands were enor- 
 mously enlarged. 
 
 In a few instances tuberculous disease of the bowels extends from a chronic 
 tuberculous peritonitis in which the coils of the intestine become matted toge- 
 ther, caseous and suppurating foci develop between the folds, and perforation 
 may occur in several places. 
 
 Symptoms. — The symptoms of intestinal tuberculosis are very varied. The 
 most common indication is a persistent diarrhoea. It is not always, however, 
 proportionate to the extent of the ulceration, and large ulcers in the ileum may 
 exist with constipation. When the ulceration is extensive in the large intestine 
 the diarrhoea is usually profuse and obstinate. The mode of onset is variable. 
 In a few instances of general tuberculosis there is diarrhoea from the start. In 
 a large number of cases the existence of intestinal complication is not suspected 
 until the signs of disease in other organs are well marked ; and in perhaps a 
 majority of the secondary cases the diarrhoea is rather an event of the latter 
 part of the illness. Of other symptoms, haemorrhage may occur, or peritonitis 
 from extension — a condition not very uncommon, and often associated with 
 disease of the mesenteric glands. The abdomen in these cases is usually 
 enlarged and painful, and the nodular masses may be felt. In a few instances 
 there are gastric symptoms, which do not necessarily indicate ulceration in the 
 stomach, but there may be loss of appetite and occasional vomiting, and there 
 are instances on record of profuse haematemesis or melaena from erosion of 
 an artery. 
 
 The outlook is unfavorable, and death may be caused by the severity of 
 the intestinal symptoms, or more rarely by the accidents, such as perforation or 
 haemorrhage. 
 
 Recognition is rarely difficult, except in the primary cases, which are 
 regarded at first as simple entero-colitis. Usually, however, when well es- 
 tablished, the diagnosis is easy, particularly when other organs become in- 
 volved. In suspected cases the stools should be carefully examined for tubercle 
 bacilli. 
 
 (b) Tuberculosis of Liver. — In all cases of acute miliary tuberculosis 
 granulations are found in this organ ; sometimes they are extremely minute 
 and are only detected microscopically. The liver is usually somewhat enlarged, 
 pale, and fatty. In more chronic cases, particularly the diffuse generalized 
 tuberculosis of young children, the tubercles may attain considerable size and 
 develop about the finer bile-ducts. They undergo rapid softening, and give a 
 very remarkable appearance to the liver, which is in extreme cases almost 
 honeycombed with tuberculous abscesses, varying in size from a pea to a marble ; 
 the pus is usually bile-stained. 
 
 Occasionally large, coarse, caseous masses are found forming irregular 
 tumors, most frequently in association with perihepatitis or tuberculous peri- 
 tonitis. The so-called tuberculous cirrhosis of the liver does not, I believe, 
 occur in children, though there may be in chronic cases of tuberculosis a 
 marked increase in the connective tissue of the organ. 
 
 (c) Tuberculous Peritonitis. — Tuberculosis is one of the most common 
 causes of peritonitis in children. It is more common about the eighth and tenth 
 years, and attacks boys more frequently than girls ; thus of 86 cases analyzed 
 by Barthez and Sanne', there were from 
 
TUBERCULOSIS. 289 
 
 1 to 2} yrs 11 cases. 
 
 3 to 5| " 26 " 
 
 6 to 10} " 40 " 
 
 11 to 15 " 9 
 
 a 
 
 The ratio of frequency in children may be gathered from the large statis- 
 tics of Aldibert, who found in 326 cases of tuberculous peritonitis, 52 in chil- 
 dren. As in the adult, the disease may be primary, but in a majority of the 
 cases it is secondary to tuberculosis of the intestines, mesenteric glands, or 
 of the genitalia. 
 
 Morbid Anatomy. — Tubercles in the peritoneum are not infrequently met 
 with in the bodies of children dead of tuberculosis. Ashby noted them 38 
 times in 105 post-mortems on tuberculous children. They occur either as (1) 
 the gray granulations with or without exudation, serous or sero-fibrinous. 
 Sometimes the entire peritoneum is found studded with (2) firm, hard, fibrin- 
 ous tubercles surrounded by a pigmented and firm connective tissue. In both 
 of these varieties the process may be latent, and the condition is met with acci- 
 dentally post-mortem. More frequently (3) when symptoms have been present, 
 the tubercles are in the form of caseous nodules, yellow-gray in color, often 
 forming flattened tuberculous plaques. The exudate is purulent or sero- 
 purulent, the coils of intestines are much matted together, and between 
 them there may be large caseous masses. It may be impossible to separate the 
 coils, and in advanced cases extensive ulceration occurs, with multiple perfora- 
 tion of the intestine. There are three anatomical points of special interest in 
 these cases : First, the effusion may be sacculated and form a definite tumor ; 
 sometimes the process is confined to the cavity of the lesser peritoneum ; in 
 other cases it is in the pelvis, less frequently in the middle portion. The cysts 
 may be multi- or mono-locular. 
 
 Second, there are cases in which occlusion of the intestine has resulted, 
 sometimes from compression of the coils by the large caseous masses ; more 
 frequently by the bands of connective tissue in the healing of the process. 
 Aldibert has found five instances of this sort in children. 
 
 Lastly — and much more frequently in children than in adults — there is peri- 
 umbilical suppuration. The intensity of the inflammation is in the central 
 portion of the abdominal cavity, adhesions take place, and a definite cyst is 
 formed, usually purulent, which projects at the umbilicus, and often opens 
 spontaneously, leaving a fistula, sometimes stercoral, which persists for months 
 but may ultimately heal. 
 
 Symptoms. — The symptoms of tuberculous peritonitis are extremely 
 varied, and it is very difficult to give a clear and definite picture of the disease. 
 For convenience three clinical types may be considered : 
 
 (1) The Ascitic Form. — The symptoms may come on acutely with a diffuse 
 eruption of miliary tubercles. So abrupt is the onset that cases have been 
 mistaken for acute enteritis, or even for acute obstruction or hernia. More 
 frequently the onset is subacute, and ascites gradually develops. Fever of some 
 degree, indigestion, and diarrhoea are present, and there may be abdominal 
 pain ; but in many instances the process is latent, and the enlarging abdomen 
 is the symptom for which the physician is consulted. The effusion, indeed, may 
 proceed to considerable degree without fever, and with no symptoms other than 
 those of gradually-failing health and progressive emaciation. Intestinal dis- 
 order occurs in some instances, diarrhoea, colicky pains, or often attacks of 
 diarrhoea alternating with constipation. The local symptoms are by no means 
 characteristic. The abdomen is distended, the skin thin, the superficial veins 
 
 19 
 
290 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 enlarged. Percussion gives dulness in the flanks, which is movable, resonance 
 in the umbilical region, and there is a well-marked fluctuation wave. Palpa- 
 tion may be entirely negative ; no nodular masses are felt. The liver and spleen 
 are not often enlarged. It may be extremely difficult, or quite impossible, 
 unless there are tuberculous lesions in other regions, to speak definitely of 
 the nature of the gradually-developing ascites. The clinical picture is very 
 similar, indeed, to that of the cases of ascites from cirrhosis, and an identical 
 condition is met with in the rare cases of simple chronic peritonitis in children. 
 The ascites may demand tapping, but the fluid reaccumulates rapidly. The 
 exudate may be encysted, forming a prominent tumor in the epigastric or 
 umbilical regions (in which case the effusion is probably within the lesser peri- 
 toneum), or it may be situated in the pelvis or in the flank, and simulate very 
 closely cystic ovarian disease. This form is not very uncommon in children, 
 and very good results have followed operation ; of nine instances in the litera- 
 ture, all recovered. This ascitic form, developing slowly, and ultimately 
 presenting the picture of a chronic ascites or an encapsulated exudate, is by 
 far the most favorable variety, and cases may recover spontaneously or after 
 operation. 
 
 (2) The ulcerative form is much more serious. The peritoneum here con- 
 tains larger caseous masses which break down, and there is a diffuse purulent 
 peritonitis. The coils of intestines are matted together, nodular tuberculous 
 masses develop on the parietal and visceral layers, the glands are greatly en- 
 larged, and in protracted cases extensive ulcerations occur. The onset in this 
 form is usually gradual, but the abdominal symptoms are pronounced. The 
 child complains of colicky pains, diarrhoea, and chronic indigestion. The 
 abdomen is enlarged and painful. The condition on examination may be entirely 
 different from that of the ascitic form. The outline is often symmetrical, not 
 flattened in the flanks ; nodular projections may sometimes be seen beneath the 
 skin. Unless there is a very extensive purulent effusion there is no movable 
 dulness. There is a flat tympany or there are alternating areas of resonance 
 and dulness. On palpation there is a boggy, doughy feel, and nodular masses 
 may be felt in different regions. The liver and spleen may both be enlarged. 
 In this suppurative form the effusion may be general, or it may be encysted 
 either in the upper abdominal region or in the pelvis. One form of this encysted 
 suppurative variety requires special consideration — namely : 
 
 Periumbilical Tuberculous Abscess. — This is seen most frequently in chil- 
 dren, and is in reality a localized suppurative peritonitis, which points at the 
 navel and frequently opens and discharges. The condition is almost constantly 
 tuberculous in the child. There may be a fistula discharging pus for weeks or 
 months, and recovery may ultimately take place. In other instances the fistula 
 communicates with the bowel. In the case of a colored child, aged five, 
 operated upon by my colleague, Dr. Halsted, there was distention of the abdo- 
 men, marked protrusion of the umbilicus, and here a spontaneous opening dis- 
 charging yellowish material for months. Then the opening healed and the 
 condition of the child improved. At the time of the operation there was a 
 large, prominent, cone-shaped, umbilical tumor. The child died some time after 
 the operation ; creamy pus was found between the intestinal coils, and there 
 were many tuberculous ulcers in the intestines. There was an extensive 
 caseous salpingitis. 
 
 There are instances also of perihepatic tuberculous abscesses. 
 
 (3) Chronic Adhesive or Dry Tuberculous Peritonitis. — In a very consider- 
 able number of all cases of tuberculous peritonitis there is little or no serous 
 or purulent exudate, but the tubercles are surrounded with a fibrinous lymph 
 
TUBERCULOSIS. 291 
 
 and they tend rapidly to cicatrize. The growing tubercles may not have caused 
 anv symptoms, and the condition is found accidentally post-mortem, and in 
 adults has often been met with in exploratory laparotomies for various condi- 
 tions. In long-standing cases the tubercles are hard, firm, often surrounded 
 by deeply pigmented fibroid adhesions. In some of these instances the tuber- 
 culosis of the peritoneum is localized; thus it has been found in a hernial sac 
 alone, or in the region of the caecum and appendix, or on the epiploon. There 
 are instances in which this membrane has been gradually curled and rolled 
 until it forms a ridge-like tumor lying across the upper portion of the abdomen. 
 This chronic adhesive form is not so frequent in children as in adults. The 
 symptoms are very indefinite. The abdomen is usually distended and tym- 
 panitic, everywhere resonant, sometimes distinctly painful on pressure. In 
 protracted cases the omentum may be felt as a firm ridge in the upper portion 
 of the abdomen. The general symptoms are very variable. There may be 
 wasting and cachexia, sometimes with marked fever, though these chronic 
 adhesive forms are not infrequently afebrile throughout, or the temperature, 
 indeed, may be subnormal. With the exception of the colicky pains there 
 may be no symptoms directly from the peritoneum, but the cases are very often 
 complicated with tubercles in other parts, and the mesenteric glands or the 
 lungs may be extensively diseased. These are cases in which spontaneous 
 recovery is not infrequent. 
 
 Diagnosis. — A gradually developing ascites in a young child with moderate 
 fever is in itself very suggestive of peritoneal tuberculosis. Doubtless very 
 many of the cases of simple ascites with recovery belong to this disease. 
 
 The condition is to be distinguished from ascites due to disease of the liver 
 and from chronic simple peritonitis. Cirrhosis of the liver, syphilitic or sim- 
 ple, is a rare disease in children. The local symptoms may give us no clue, 
 but after withdrawal of the fluid the liver in a cirrhotic case may be felt to be 
 unusually hard, and perhaps small, and possibly, when due to syphilis, irregu- 
 lar. The general symptoms are more important. In cirrhosis there is more 
 frequently a slight jaundice. The fever and gastro-intestinal symptoms are 
 not so marked. An encysted exudate is always in favor of tuberculosis. A 
 simple chronic peritonitis, though rare, occurs in children, and, even after the 
 exploratory laparotomy, the diagnosis may not be clear, inasmuch as there may 
 be small nodular fibroid bodies scattered over the membranes. It is very 
 important in these cases to have a careful microscopical examination made, in 
 order to determine the presence of bacilli, or, if the nodules are very firm and 
 fibroid, the experimental test should be made. It is quite possible that some 
 instances of reported recovery in peritoneal tuberculosis after laparotomy may 
 have been instances of this chronic simple peritonitis with fibroid nodules. 
 The ulcerative form with suppuration and the development of nodular masses 
 in the peritoneum with fever and a marked cachexia, rarely offers the slightest 
 difficulty in diagnosis. It is to be remembered, of course, that the suppurative 
 forms also may be encysted, and the periumbilical abscess with umbilical 
 fistula, simple or stercoral, is almost constantly tuberculous. 
 
 Prognosis. — The prognosis is often good, particularly in the ascitic and 
 chronic adhesive varieties. Many instances, no doubt, in which the ascites 
 has gradually disappeared have been tuberculous, and even in the ulcerative 
 variety, when the abscess has discharged at the navel, recovery has followed. 
 The operation of incision and drainage has certainly favored recovery in a con- 
 siderable number of cases. 
 
 Treatment. — The general treatment of tuberculosis will be discussed at 
 the end of the section ; here reference will be made more particularly to incis- 
 
292 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ion and drainage in tuberculous peritonitis. The results which have been 
 obtained are exceedingly satisfactory, even if we suppose, as is probable, 
 that many cases relapse and are not fully healed at the time of reporting. 
 The figures given in the monograph of Aldibert are extremely interesting : in 
 the ascitic form, of 32 instances in which laparotomy was performed, there 
 were 3 deaths and 29 recoveries, 4 of which had persisted for more than one 
 year. This demonstrates the impunity with which the abdominal cavity may 
 be opened, and the large percentage, at any rate, of those which are benefited 
 immediately by the operation. In the chronic adhesive form an operation is really 
 not indicated, as in the majority of the instances the tuberculosis is in pro- 
 cess of healing, but there are cases in which pain, associated with the adhesions, 
 has been relieved by an exploratory incision. In the ulcerative variety, when 
 generalized, the results have not been so satisfactory, but many instances with 
 an encysted purulent fluid have been opened and drained successfully. The 
 drainage favors the process of cicatrization in the tubercle, lessens the tendency 
 to effusion, and exerts a favorable influence on the whole process. Of the 52 
 cases in children in which laparotomy was performed, there were 45 recoveries 
 and 7 deaths. Of these 45, 9 had persisted for more than a year, and 2 for 
 more than two years (Aldibert). 
 
 (3) Tuberculosis op the Lungs. 
 
 In speaking of acute miliary tuberculosis and of chronic diffuse tuberculosis 
 we have considered affections in which the lungs are almost constantly involved 
 — in the one case the seat of miliary granules ; in the other of larger, coarse, 
 grayish-yellow tubercles. We shall speak in this section more particularly of 
 those forms in which the lungs are so involved, that the clinical features are 
 those of an acute or of a chronic pulmonary disease. Two groups of cases may 
 be recognized : the acute tuberculous broncho-pneumonia, and the chronic 
 ulcerative form, the first corresponding to the acute galloping phthisis, and 
 the other to the chronic phthisis, or, as we call it now, chronic pulmonary 
 tuberculosis. 
 
 (a) Acute Tuberculous Broncho-pneumonia. — In infants and children 
 we very rarely see pulmonary tuberculosis set in with the clinical picture of 
 an acute lobar pneumonia. Personally, I never remember to have met with an 
 instance, such as is not very rare in adults, in which the tuberculosis came on 
 abruptly, and at first ran the course of an ordinary lobar pneumonia, with pain 
 in the side, high fever, and rapid consolidation of an entire lobe. Such cases 
 are, however, on record, and it is only the absence of the crisis, the persistence 
 of the local signs, the gradual softening, and the development of hectic and 
 progressive debility which lead to a revision of the diagnosis. It is to be 
 remembered that while clinically the physical signs may be those of a lobar 
 affection, anatomically it is clearly seen that many groups of lobules are 
 involved, separated by strands of air-containing or collapsed lung-tissue. These 
 pseudo-lobar cases are almost impossible to differentiate during life. 
 
 Tuberculous broncho-pneumonia is common in children from the sixth 
 month to the fifth year. A large proportion of the cases occur after the sec- 
 ond year. 
 
 The disease is most common in children in institutions, in those debilitated 
 by previous illnesses, and more particularly in convalescents from one of the 
 infectious diseases — measles, whooping-cough, scarlet fever, or diphtheria. It 
 is most frequent perhaps after measles and whooping-cough. Its sequence in 
 the latter disease has been common knowledge in the profession since the days 
 
TUBERCULOSIS. 293 
 
 of Willis, whose axiom, " Tussis convulsiva vestibulum tabis," has been quoted 
 through two centuries. Children the subject of chronic naso-pharyngeal 
 catarrh and tonsillitis, and mouth-breathers seem more prone to the affection. 
 But it is to be remembered that it may develop in perfectly healthy, well- 
 nourished children. 
 
 And lastly, like miliary tuberculosis, it may be a terminal process in cases 
 in which local tuberculous disease exists in other parts — the skin, bones, lymph- 
 glands, or the urogenital tract. 
 
 Morbid Anatomy. — The condition varies considerably with the inten- 
 sity and duration of the process. The lungs may be voluminous and crepitant, 
 with firm and nodular masses scattered throughout the lobes. On section these 
 are seen to be peribronchial nodules ranging in size from a pea to a walnut. 
 Some of the more recent are reddish in color ; the older are grayish-yellow, 
 with, perhaps, central softening. Many of these peribronchial nodules are 
 seen to be composed of aggregations of tubercles undergoing caseation. In 
 the very acute cases the process is more extensive in the upper lobes or central 
 portion of the lungs, certain parts of which may be almost solid and scarcely 
 contain any air. The consolidation may indeed look uniform, but on section 
 it is noted that the process is not actually diffuse, as in a lobar pneumonia, but 
 the general consolidation has arisen from the involvement of a very large num- 
 ber of the lobules, groups of which are separated by strands of reddish col- 
 lapsed tissue. The consolidated areas have undergone caseation, and may in 
 places have softened, forming cavities. The older the process the more exten- 
 sive usually are the areas of caseation. Though primarily tuberculous, many 
 of these cases show a mixed infection, and there may be areas of simple 
 broncho-pneumonia due to streptococci, staphylococci, or pneumococci. The 
 pleura may show many nodules or a fresh, fibrinous exudate, sometimes a sero- 
 fibrinous or even purulent exudate. The bronchial and tracheal glands are 
 enlarged, tumefied, and studded with tubercles or uniformly caseous, not infre- 
 quently having softened to form definite abscess. The glands at the hilus 
 may be greatly enlarged and extend deeply between the lobes, and in some in- 
 stances there would appear even to be an invasion of the lung-tissue from these 
 deeply-placed large caseous glands. The other organs may present a few 
 scattered tubercles or there may be a generalized miliary tuberculosis. 
 
 As in other forms of broncho-pneumonia, the essential lesion is a bron- 
 chitis and peribronchitis excited by the tubercle bacilli, with inflammation 
 of the contiguous air-cells, which become filled with epithelial products, the 
 so-called catarrhal alveolitis. The accompanying phenomena of atelectasis and 
 emphysema occur just as in simple broncho-pneumonia, and the distinguishing 
 features are the caseation and necrosis with the presence of the bacilli. 
 
 Much discussion has taken place upon the relation of broncho-pneumonia 
 to tuberculosis, and some French observers have maintained that in many 
 instances the form following measles and diphtheria, and which anatomically 
 looks simple in character, is in reality tuberculous and due to the bacilli. It 
 may be difficult sometimes to determine whether a given patch of broncho- 
 pneumonia is tuberculous or not, but as a rule, macroscopically, there will be 
 seen small tubercles or areas of caseation, while in stained sections the bacilli 
 are readily demonstrable. The simple broncho-pneumonia in some cases pre- 
 cedes the tuberculous, particularly after measles, scarlet fever, diphtheria, and 
 whooping-cough. In institutions it is by no means uncommon to meet with cases 
 in which broncho-pneumonia has gradually subsided, and then symptoms have 
 developed pointing to fresh invasion, and ultimately death follows with the 
 lesions of an acute, recent, tuberculous broncho-pneumonia. Sometimes the 
 
294 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 infection is less intense, and a subacute or chronic pulmonary tuberculosis is 
 established. In cases of tuberculosis consecutive to broncho-pneumonia we 
 find the lesions of two sorts : simple, inflammatory, non-tuberculous, such as 
 peribronchial suppuration, dilatation of the bronchi, lesions of the alveolar epi- 
 thelium, and peribronchial and peri-alveolar sclerosis ; then, in addition, there 
 are the true tuberculous processes, peribronchial nodules, tuberculous infiltra- 
 tion, and caseous areas (Mosny). 
 
 In other instances the tuberculosis precedes the broncho - pneumonia. 
 This is met with particularly in children the subject of latent tuberculosis, in 
 whom, following one of the infectious diseases, a simple broncho-pneumonia 
 develops. According to Mosny, the lesions may be seen as an alveolitis 
 surrounding the tuberculous peribronchial nodules, or foci of simple and tuber- 
 culous broncho-pneumonia occur scattered throughout the apices of the lung. 
 It is a broncho-pneumonia dependent upon pneumococci or streptococci invading 
 a lung already the seat of local tuberculosis. 
 
 Symptoms. — Clinically, tuberculous broncho-pneumonia scarcely differs in 
 any feature from the simple form. The onset may be acute in a previously healthy 
 child, but more frequently the disease sets in during convalescence from one of the 
 infectious diseases. In the tuberculous form the fever is sometimes not so high 
 and not so persistent, showing more variations throughout the day. Cough and 
 dyspnoea are prominent symptoms. The physical signs are those of broncho- 
 pneumonia. The localization of the lesion is more commonly at the apices of 
 the lung, where there may be signs of consolidation with fine crepitant and sub- 
 crepitant rales. There are no physical signs of any moment in differentiating 
 a simple from a tuberculous broncho-pneumonia, and indeed even the local- 
 ization of the disease at the apex, upon which so much stress is laid, is not of 
 very much value, since we frequently find in young children a tuberculous 
 process beginning at the base or in the central portions of the lung. In the 
 course of the disease, however, indications of great value develop ; thus toward 
 the end of the second week there are more marked oscillations in temperature, 
 often with profuse sweats. The child emaciates rapidly, and there may some- 
 times develop signs indicating softening. In the acute cases the duration is 
 from three to five weeks. Throughout the course of the disease there may be 
 no single indication of much value in definitely determining the nature, and we 
 often have to depend more on the general features of the case. Careful inqui- 
 ries should be made as to heredity ; also the personal history immediately 
 preceding the onset. Sometimes important information may be gathered by a 
 systematic examination of the child. There may be a tuberculous adenitis, 
 local bone disease, or a tuberculous testis. Simple broncho-pneumonia tends 
 as a rule to recovery ; in exceptional cases, however, it becomes subacute, and 
 ultimately chronic. In the more subacute and chronic cases tuberculous 
 broncho-pneumonia may present large areas of caseation, which give the 
 physical signs of consolidation, perhaps of an entire lobe. In such instances 
 softening and the signs of cavity not infrequently develop, and give very 
 definite indications of the nature of the process. As the little patients rarely 
 expectorate, examination for bacilli can seldom be made. Sometimes, if 
 vomiting occurs, portions of mucus may be picked out, and important evi- 
 dence in this way obtained. 
 
 (b) Chronic Pulmonary Tuberculosis. — In infants and very young 
 children we find the lungs either involved in a generalized tuberculosis or the 
 seat of an acute tuberculous broncho-pneumonia. After the sixth or eighth 
 
TUBERCULOSIS. 295 
 
 year cases are not very uncommon in which the picture resembles that of 
 chronic tuberculosis pulmonum of the adult. 
 
 Morbid Anatomy. — The lesions are similar to those met with in the tuber- 
 culosis of adults — miliary tubercles, peribronchial nodules, caseous blocks, 
 areas of softening and of fibroid induration, and cavities of various sizes. We 
 do not see so frequently the invasion of the lung from the apex downward. 
 The chief seat of disease may be in the central portion of the lung, or even at 
 the base. As already mentioned in speaking of tuberculosis of the lymph- 
 glands, the groups along the trachea and about the bronchi may be greatly 
 enlarged and caseous, forming on section a very striking feature in the chronic 
 pulmonary tuberculosis of children. Indeed, in some instances the process 
 seems to spread directly from the deeply-placed glands in the hilus of the lung, 
 which may be enormously enlarged, uniformly caseous, and the organ may be 
 directly invaded from them. Large areas of caseous pneumonia are not uncom- 
 mon, and often present foci of softening. Small cavities are by no means infre- 
 quent in chronic pulmonary tuberculosis of children, but very large excavations 
 are rare ; thus in the 265 cases noted by Barthez and Sanne" there were 77 
 cases with excavation, chiefly, too, in the upper lobes. In the analysis by 
 Leroux of the cases of the late Professor Parrot, in 219 children under two 
 years of age there were 57 instances in which cavities existed. In 5 of these 
 the children were under three months. In long-standing cases hard, firm, 
 fibrous tubercles are found, and sometimes cretaceous nodules. The primary 
 lesion in a great majority of instances is a tuberculous broncho-pneumonia, 
 taking its origin in the smaller bronchioles, leading to peribronchial nodules 
 and subsequent peribronchial alveolitis. 
 
 Symptoms. — The general symptomatology of chronic pulmonary tuber- 
 culosis in the child is similar in essential details to that of the adult, but pre- 
 sents, however, as might be expected, certain peculiarities. The onset is gener- 
 ally more abrupt, and the first symptoms may be those of a broncho-pneumonia 
 at the apex. The child may have been in failing health or come of a markedly 
 tuberculous stock, or there may have been local glandular or bone disease. 
 Occasionally failing health, with repeated attacks of chills and fever, may arouse 
 the suspicion of malaria, but this mode of onset is not so frequent as in adults. 
 Some cases follow a protracted naso-pharyngeal catarrh with recurring bron- 
 chitis. Progressive failure in health and strength, cough and fever, are the 
 first symptoms to attract attention. There is loss of appetite, but rarely the 
 extreme anorexia which we find in some cases of pulmonary tuberculosis in 
 older subjects. Cough is rarely absent among the initial symptoms, and, with 
 variations, persists. It is short and dry at first, subsequently looser. It may 
 be distributed equally throughout the day or is most troublesome at night, and 
 paroxysms of coughing may return at fixed hours, so that the case may be mis- 
 taken at first for whooping-cough ; but there is never the noisy crowing inspira- 
 tion. Expectoration is absent in very young children. Children above the 
 age of ten can often be taught to expectorate. The sputum is mucoid at first. 
 with grayish-yellow streaks ; sometimes it is more sero-mucoid, and in the later 
 stages more definitely purulent. Haemoptysis may be said to be infrequent in 
 children under ten. Certainly it is very rare at the onset. It is usually small 
 in amount. The terminal haemoptysis, common in the adult, but rare in chil- 
 dren, results from the rupture of an aneurism in a small cavity or erosion of a 
 branch of the pulmonary artery. The fever of onset and during the early 
 periods is remittent, the daily excursions slight — a range between 102° and 
 104° is common. Subsequently, when the disease is more extensive and soft- 
 ening has taken place with the formation of cavities, the temperature is more 
 
296 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 hectic in character, and the morning observation may be normal or subnormal, 
 while in the evening the thermometer may register 103.5° or 104°, or even 
 higher. Chills are not very common. Drenching sweats are frequent, par- 
 ticularly toward the close. 'Dyspnoea may be present at the onset and during 
 the early stages, and may be due in part to the fever, sometimes to the presence 
 of a diffuse bronchitis. Marked increase in the respirations, with cyanosis, 
 indicates very rapid progress in the disease. In protracted cases, just as in the 
 adult, there may be very extensive destruction of the lung without the slightest 
 dyspnoea. The child may complain of pains in the chest, usually associated 
 with pleurisy. In a majority of instances the disease is painless throughout 
 its course. Qvisling states that an early sign is tenderness on percussion of 
 the affected side, or on pressure in the intercostal spaces, particularly in the 
 first space at the apex. 
 
 Progressive weakness and wasting are very pronounced symptoms, and 
 there is usually progressive pallor. Frequently the abdominal viscera become 
 involved, and there is diarrhoea due to tuberculous ulceration, and the liver 
 and spleen may become enlarged. The urine does not often show changes, but 
 as the disease progresses albumin is common and a secondary nephritis may 
 develop. A child may come under observation with general anasarca, due 
 partly to the anaemia, partly to the renal condition, and the pulmonary tubercu- 
 losis may be entirely overlooked. 
 
 Physical Signs. — Inspection frequently shows in advanced cases an 
 extremely thin chest, with marked intercostal spaces. Deformities due to 
 mouth-breathing or to rickets are not uncommon. On the affected side the 
 respiratory movement may be decidedly less marked, or the clavicle may stand 
 out prominently ; or there may be subclavicular depression at the affected apex — 
 a sign usually of a chronic process. In very long-standing cases with much 
 fibroid change there may be flattening of the affected side, with depression 
 of the shoulder. 
 
 By palpation one appreciates any differences in expansion on the two sides, 
 and the differences in the tactile fremitus, and it may be of value in eliciting 
 painful points. 
 
 Percussion. — In the early condition, when the tubercles are scattered or the 
 areas of broncho-pneumonia are limited, there may be no change in the per- 
 cussion note. Indeed, the emphysema about the affected areas may cause slight 
 hyper-resonance over the part affected. Extensive involvement at one apex 
 usually gives loss of resonance beneath the clavicle, which may amount to dul- 
 ness and is accompanied with marked increase in the resistance. Absolute 
 flatness is rarely met with. Skoda's resonance, the flat tympany, is not fre- 
 quent. The cracked-pot sound has very little value in children, as it may 
 sometimes be elicited in a thin-walled healthy subject. 
 
 Auscultation may give only the signs of bronchial catarrh, piping rales 
 and moist sounds, but when there is definite dulness there is usually change 
 in the character of the respiratory sounds, which have lost their vesicular cha- 
 racter and are harsh, broncho-vesicular, or definitely bronchial. Sometimes 
 with defective resonance there is enfeeblement of the respiratory murmur, 
 with prolongation of expiration. The auscultatory phenomena are often very 
 deceptive. Diffuse bronchitis may lead us to suppose that there is much greater 
 involvement of the lung than in reality exists. In very young infants signs of 
 cavity are rarely present, but in older children in advanced cases, with hectic 
 and emaciation, the metallic splashing or amphoric quality of the rales, with 
 the loud cavernous breath-sounds, leaves no doubt as to the existence of a 
 vomica. In children, more frequently than in adults, we are deceived by the 
 
TUBERCULOSIS, 297 
 
 so-called pseudo-cavernous signs. Over an area of slightly defective resonance 
 or of positive dulness inspiration and expiration are cavernous, the rales large 
 and resonant, and the whispered voice may be conveyed intensely to the ear. 
 In acute cases with high fever one is not so apt to be deceived ; these signs are 
 also met with in broncho-pneumonia and in pleurisies. 
 
 Course. — The course of chronic pulmonary tuberculosis is more rapid in 
 children than in adults, and a majority of cases die in from six to twelve months. 
 The disease is marked, now by intervals of improvement, in which the fever 
 lessens and the severity of the symptoms subsides, now by aggravation of the 
 local and constitutional condition, sometimes with attacks in which the fever and 
 dyspnoea increase, and the child may become quite cyanotic. Some of these 
 intercurrent attacks simulate closely acute tuberculosis, but often pass away at 
 the end of a week or ten days. In the chronic cases they probably indicate 
 the invasion of other portions of the lung. 
 
 Occasionally, in a case of chronic pulmonary tuberculosis extensive fibroid 
 substitution takes place, with gradual retraction of the affected side, depression 
 of the shoulder, and all the signs of so-called fibroid phthisis. Usually in such 
 instances there is dulness at the base and side with modified resonance, and 
 cavernous signs at the apex. When involving the left lung, the heart is drawn 
 over, and there may be a very extensive cardiac pulsation from the second to 
 the fifth interspaces. A child may gradually regain a fair measure of health 
 and for years live a tolerably comfortable life, troubled only by one or two 
 spells of coughing through the day. There may be dyspnoea on exertion, and 
 gradually the terminal phalanges become clubbed. Haemoptysis is rare, but 
 occasionally terminates the case. 
 
 Diagnosis. — Progressive emaciation with hectic and cough in a child should 
 always arouse the suspicion of chronic pulmonary tuberculosis. In the early 
 stages the condition is usually that of tuberculous broncho-pneumonia. Care- 
 ful and repeated physical examination may be necessary to establish the diag- 
 nosis, and one should take into consideration carefully the condition of the 
 other organs. The position of the physical signs at the apex or central portions 
 of the lung, the increased fremitus, the moist sounds, are all suggestive, and 
 frequently one may trace the progressive character of the lesion. The disease 
 most frequently confounded is empyema, but here the movable dulness, the 
 bulging of the intercostal spaces, and the absence of fremitus are valuable 
 points. 
 
 Auscultation is an extremely fallacious guide, and in several instances the 
 persistence of a loud, almost cavernous, respiratory murmur at the base has led 
 the practitioner astray. When in doubt the exploratory needle should be freely 
 used for the purpose of diagnosis. The differentiation of chronic simple broncho- 
 pneumonia sometimes gives a great deal of trouble, and the time element alone 
 may determine whether we have to do with a tuberculous process or not. These 
 are the very instances in which any fragments of sputum should be carefully 
 sought for and examined. In a paroxysm of coughing the child may bring 
 up a mouthful of food, and with it the expectoration, which should be carefully 
 picked out and examined for tubercle bacilli. 
 
 Prognosis. — The prognosis in a large majority of the cases is bad. particu- 
 larly when hectic is established and there is disorganization of one lung. On 
 the other hand, when cases are seen early and placed under suitable conditions 
 recovery may take place. The large number of individuals whose lungs and 
 bronchial glands present traces of old tuberculous processes shows how con- 
 siderable a proportion of all those who are infected must survive. We do not 
 see many cases of chronic pulmonary tuberculosis in children between the ages 
 
298 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of six and fifteen, for the reason, no doubt, that the tuberculous broncho- 
 pneumonia is so often an acute process, carrying off the victim before it has 
 assumed the characters of a chronic affection. 
 
 (4) Tuberculosis of the Pleura. 
 
 This is usually secondary to existing disease in the lung or in the bronchial 
 glands. A certain number of acute serofibrinous pleurisies in children may 
 be, as in the adult, due to tuberculosis ; but the cases, as a rule, run a favor- 
 able course, and unless the child has definite manifestations of tuberculosis in 
 other parts the assumption in any given case is of course purely gratuitous. 
 Purulent pleurisies in children are most commonly associated with lobar or 
 broncho-pneumonia, but in a certain proportion of the cases the process is tuber- 
 culous. The disease is usually latent, and failing health, pallor, and shortness 
 of breath are the symptoms for which relief is sought. The general symptom- 
 atology and diagnosis of tuberculous pleurisy are practically those of the simple 
 forms which are elsewhere considered. 
 
 (5) Tuberculous Pericarditis. 
 
 This is by no means rare in children, and cases have been reported in 
 infants under a year. In 65 cases collected from the literature by Brackman, 
 19 were in children. The disease is associated in almost all instances with 
 tuberculosis of the mediastinal or bronchial glands. An enlarged and softened 
 gland may perforate the pericardium and produce an acute sero-fibrinous or 
 suppurative inflammation ; and no doubt a considerable number of all the cases 
 of so-called idiopathic suppurative pericarditis have been due to this cause. 
 The tuberculous process may slowly invade the pericardium from the medias- 
 tinal glands, and produce a chronic adhesive pericarditis, leading to great 
 thickening of the membranes and gradual hypertrophy of the heart. The 
 patient may die with all the symptoms of cardiac dropsy. 
 
 (6) Uro-genital Tuberculosis. 
 
 (a) Tuberculosis of the Kidneys.— As part of a general diffuse tuber- 
 culosis these organs are very frequently affected — more commonly, indeed, than 
 in adults. Usually there are scattered gray tubercles or coarse yellow nodules 
 in the cortical substance. Sometimes, however, the lesion is primary, and one 
 or other kidney is extensively diseased. The affection in these cases appears 
 to begin in the papillae and calices, gradually invades the substance, and may 
 ultimately destroy the entire organ, converting it into a series of excavations 
 containing a cheesy material. When confined to one kidney, this (known as 
 the scrofulous kidney) is sometimes met with in children, the other kidney being 
 healthy and greatly enlarged. When there is extensive tuberculous pyelo- 
 nephritis there is often pain over the kidney ; the urine contains pus, very 
 rarely blood. Irregular fever and chills are common. Frequent micturition 
 may lead to the diagnosis of cystitis, with which, of course, it is frequently 
 associated; but it is to be borne in mind that in connection with either calcu- 
 lous or tuberculous pyelitis frequent micturition may be a marked symptom. 
 Sometimes the tuberculous organ is large enough in a child to be palpable. 
 Tuberculosis rarely produces so extensive pyonephrosis as that due to stone. 
 
 The diagnosis can rarely be made from calculous pyelo-nephritis except by 
 the detection of bacilli in the urine. 
 
TUBERCULOSIS. 299 
 
 Tuberculosis of the ureters and bladder, very rare as a primary affection, 
 is nearly always secondary to disease of the pelvis of the kidney, sometimes to 
 disease of the prostate. 
 
 (b) Tuberculosis of the Testis. — Disseminated miliary tubercles may be 
 present in the testicles, but primary tuberculosis of these organs is not at all 
 rare in children. Dreschfeld has reported an instance of congenital tubercu- 
 losis of the testis. Many cases have been reported of late years. Of 20 cases 
 by Jullien, 6 were under one year, and 6 between one and two years. Both 
 organs may be affected. The disease most commonly develops in the tunica 
 albuginea or in the epididymis, and may lead to the formation of hard circum- 
 scribed tumors. In other instances the process may be more diffuse. When 
 the nodular masses are large the testis may have a dumb-bell or double outline 
 from enlargement of the epididymis. It is a serious affection in children, 
 usually associated with tuberculous disease in other parts. Its existence should 
 always be borne in mind, as in obscure abdominal or thoracic affections the 
 presence of nodular masses in the testicles is of great help in diagnosis. The 
 lesion may gradually heal. The cheesy masses may break down and suppurate, 
 and, forming adhesions to the skin, the pus discharges, and the organ may 
 become much enlarged — the condition formerly known as strumous orchitis. 
 
 (c) Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus. — 
 These parts are rarely affected primarily in children. It is not very uncom- 
 mon in generalized tuberculosis to find, even in infants, a double salpingitis. 
 
 IV. Prophylaxis. 
 
 While the possibility of inherited transmission from an infected mother 
 cannot be denied, we have to face the fact that in a large proportion of all cases 
 of tuberculosis the infection is at the gateways of the body — namely, in the 
 bronchial and mesenteric lymph-glands — and we have here a clue to the two 
 chief sources of danger. 
 
 To ensure freedom from contamination through the air the greatest care 
 should be taken to prevent tuberculous patients spitting about in a careless 
 manner. Every part of the expectoration should be carefully collected and 
 boiled, and the patient's handkerchiefs should be thrown into boiling water. 
 The liability of children to infection from this source is very much greater than 
 that of adults, possibly on account of the intimate relations which the child 
 has to the members of the family, more particularly the mother should she 
 happen to be diseased. The habit of young infants, as they creep about, of 
 putting everything in their mouths enhances greatly the liability to con- 
 tamination. 
 
 The second danger to be avoided in children is the use of milk from tuber- 
 culous animals. Experiments have shown the readiness with which young 
 pigs and calves become infected when fed on the milk of tuberculous cows. 
 We have, unfortunately, no reason to believe that children are less susceptible 
 than calves. Fortunately, the health authorities have at last awakened to the 
 importance of careful inspection of dairy herds. The safeguard lies in the use 
 of boiled milk, unless the source is known to be free from all possibility of 
 contamination. The infection through meat is probably a very slight danger 
 in a community. 
 
 Individual prophylaxis is of almost equal importance. A child born of 
 delicate parents or in a family in which tuberculosis has prevailed should be 
 reared with the greatest care. Very special pains should be taken to guard it 
 against catarrhal affections of all sorts, particularly of the nose and throat, and 
 
300 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 on the first indication of mouth-breathing a thorough examination of the naso- 
 pharynx should be made and any adenoid vegetations removed ; and if the 
 tonsils are at all enlarged, it is better to have them cut out. The child should 
 live in the open air as much as possible, and the nursery should be thoroughly 
 ventilated, more particularly at night. The meals should be at regular hours, 
 the food plain and nutritious. Every encouragement should be given to take 
 fats, and milk and cream should be used freely. It is a good practice for 
 the mother to sponge the throat and neck of the child night and morning 
 with cold water. 
 
 The trifling ailments should be carefully watched. The convalescence from 
 measles, scarlet fever, diphtheria, and whooping-cough should be specially 
 guarded. As the child grows older a systematically regulated exercise or course 
 of pulmonary gymnastics may be taken. 
 
 V. Treatment. 
 
 Fortunately, a very large proportion of all cases of tuberculosis recover. 
 Many instances of adenitis and disease of the bones heal spontaneously. 
 Even in pulmonary tuberculosis it is remarkable how often we find post 
 mortem evidences of healed lesions, the percentage in some series being as 
 high as 38. In fact, one may say that in a very large number of all cases 
 in which the bacilli find a lodgment in the glands and in the solid organs, 
 the conditions not being favorable, the growth remains local and tends to heal 
 spontaneously. The essential point in the treatment of tuberculosis is the main- 
 tenance of nutrition at the highest possible grade. To aid in this three meas- 
 ures are to be practised : 
 
 First : A life in the fresh air and sunshineo The importance of environ- 
 ment is well shown in Trudeau's experiments with inoculated rabbits. Those 
 confined in a damp, dark place succumbed rapidly ; those allowed to run 
 wild recovered or showed very slight lesions. By far the most important 
 single element in the treatment of tuberculosis of all forms is the constant inhal- 
 ation of fresh air. The good effects obtained at Gobersdorf, Falkenstein, Saranac 
 Lake, Davos, and Colorado are due primarily to the fact that the patients live 
 a life in the open air and sunshine. Even in cities much can be done by insist- 
 ing upon open windows night and day, except, of course, in the very inclement 
 seasons. It is an easy matter to protect the patient from draughts, and neither 
 fever, cough, nor night-sweats contraindicate in any way fresh air. This is in 
 reality the very essence of the climatic treatment of tuberculosis ; that other 
 considerations, such as moisture, barometric pressure, temperature, etc., are 
 secondary is well shown by the fact that cases of various types of tuberculosis 
 recover completely at places so diametrically opposite as Colorado Springs and 
 Torquay. The regions of high altitudes with low barometric pressure are cer- 
 tainly more stimulating, and, according to Jaccoud, are better for cases of early 
 pulmonary tuberculosis. Cases of bone and gland tuberculosis do remarkably 
 well at the Adirondacks and in Colorado. The level regions with low barometric 
 pressure, such as Riviera, Florida, and Southern California, are reputed to be 
 more sedative in their action and better for tuberculosis in the more advanced 
 grades and with high fever. 
 
 The second important measure is feeding, and the outlook in any case, par- 
 ticularly of pulmonary tuberculosis, depends very much upon the stability of the 
 digestive powers. In no way does the open-air treatment do more good than 
 in improving the appetite and digestion. A highly nitrogenized diet, consist- 
 ing of broths, eggs, milk, and meat, should be taken. In children the milk 
 
TUBERCULOSIS. 301 
 
 diet is particularly to be commended while fever persists. Raw meats scraped, 
 various meat extracts, and peptones may be used when the digestion is feeble. 
 In tuberculous children it is sometimes extremely difficult to manage the diet, 
 and many patients have an aversion to the very articles of food which seem 
 best adapted. Gavage can rarely be resorted to with any advantage in them. 
 
 Third, the use of such remedies as cod-liver oil, hypophosphites, and 
 arsenic, which improve the general nutrition. Other measures are frictions, 
 rubbing, and bathing, all of which stimulate and improve the general metab- 
 olism. 
 
 Treatment directed to the Tuberculous Processes. — The specific treatment 
 by the tuberculin of Koch, which consists of a glycerine extract of the cultures 
 of tubercle bacilli, has been practically abandoned, though the good results 
 obtained in the hands of Trudeau and others with Hunter's modification 
 raise the hope that something yet may be accomplished by its use. Anti- 
 bacillary medication is as yet unknown, and the introduction of various anti- 
 septic agents by inhalation, subcutaneously, or directly into the local lesion has 
 not been followed by very brilliant results. The direct action of iodoform 
 on local tuberculosis is of great interest, and the remarkable effects in joint 
 tuberculosis should encourage a more widespread use in other forms of the 
 disease. Creasote is a remedy which is believed to have a beneficial action on 
 the tuberculous processes. It probably has no definite antibacillary action, 
 though it is stated to influence powerfully the secondary and associated infec- 
 tions so common in tuberculosis. It seems rather to act as a general nutritive 
 stimulant, improving the appetite, diminishing the fever, and promoting tissue- 
 metabolism and, according to some, sclerotic processes. It is probably at 
 present more widely used than any other single remedy. It has been a favo- 
 rite with some practitioners for many years, and its reintroduction has been 
 due to the powerful advocacy of Sommerbrodt, Bouchard, and others. It 
 should be given in large and increasing doses, beginning in young children 
 with a minim three times a day, and increasing to five or even ten minims. It 
 may be given in perles, or in pills or in mixture ; in the latter a convenient 
 way is with tincture of gentian, alcohol, and sherry. As a rule, it is well borne 
 by the mouth. It may also be given in the form of inhalations, the so-called 
 vapor creasoti consisting of creasote, 80 minims, light carbonate of magnesium, 
 30 grains, water to one ounce ; a teaspoonful in a pint of water at 140°. Inha- 
 lations with this are strongly recommended. Intrapulmonary or intratracheal 
 injections of creasote in oil have been practised. . The active principle of it, 
 guaiacol, has been much used, both by the mouth and hypodermatically. Given 
 in solution, it may be made up with tincture of gentian, rectified spirits, and 
 sherry. Hypodermatically, it is used with sterilized olive oil, 5 per cent, 
 solution ; 1 or 2 per cent, iodoform may be employed with it, and 1 cc. of the 
 mixture injected, gradually increasing to 3 cc. or even 4 cc. One rarely 
 sees bad effects from creasote : the beneficial results are most marked in indi- 
 viduals who can take large quantities and who can enjoy the associated 
 action of fresh air and a good diet. Creasote without these accessories is not 
 of very great service, as witnessed in ordinary hospital practice. Patients are 
 remarkably tolerant of it, and one rarely sees any ill effects. Other balsamic 
 substances, such as eucalyptol, terebene, terebinthine, thymol, and menthol, 
 have been recommended. 
 
 Symptomatic Treatment. — In this we shall refer more particularly to pul- 
 monary tuberculosis. 
 
 The fever of tuberculosis is serious and obstinate. It will be found in the 
 early stages that the combination of rest with fresh air is the most beneficial. 
 
302 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 The child may be wrapped up and taken into the fresh air for the greater part 
 of the day. We have no thoroughly satisfactory medicinal means for reducing 
 the temperature. Antipyrine, antifebrin, and acetanilide, if used at all, must 
 be given with great care. Quinine and salicylic acid are still used by many 
 practitioners. When the temperature is persistently high in the early stages 
 of tuberculous broncho-pneumonia, cold in various forms will probably be the 
 most efficient measure, and by careful sponging the temperature may be reduced 
 several decrees. The most satisfactory antipyretic is found in the fresh air, 
 more particularly the change to a resort such as the Adirondacks or Colorado. 
 
 In the chronic pulmonary tuberculosis of children, when the fever is of a 
 hectic type, sweating is a very troublesome and disagreeable symptom, for which 
 atropine, aromatic sulphuric acid, and tincture of nux vomica may be used. In 
 young children great care should be taken to prevent the chilling of the body 
 after a profuse night-sweat. For the cough, if troublesome at night, paregoric 
 or small doses of Dover's powder may be used. Codeine or, in extreme cases, 
 small doses of morphine may be given. Where there is marked tenderness on 
 the chest or pleuritic complications the cough is sometimes relieved by mild 
 counter-irritation or the application of a warm poultice. Inhalation of terebene 
 and oil of eucalyptus may sometimes diminish the profuse expectoration. 
 
 Haemoptysis in the pulmonary tuberculosis of young children is usually a 
 terminal and fatal symptom, quickly beyond treatment. 
 
 The diarrhoea may demand very careful regulation of the diet, and if pro- 
 fuse the acetate of lead, alone or with opium, may be used. Preparations of 
 tannin and gallic acid are also beneficial. In all tuberculous processes there is 
 a more or less marked tendency to anaemia, and many patients improve quickly 
 under the administration of iron. Careful attention should be paid to the 
 gastric symptoms. If the digestion is poor, dilute hydrochloric acid may be 
 used, and if heartburn and pain be present some time after eating, the carbo- 
 nate of sodium or the alkaline mineral waters. 
 
MALARIAL FEVER. 
 
 By W. S. THAYER, M. D., 
 
 Baltimore. 
 
 Synonyms. — Intermittent fever; Swamp or Marsh fever; Paludism or 
 Paludal fever ; Fever and ague ; Chills and fever. 
 
 The term "malaria," which has been applied in a general way to a variety 
 of febrile and non-febrile processes, must now be limited to a certain definite 
 class of febrile affections which we know to have a specific infectious origin. 
 The specific micro-organisms which are the cause of these processes belong to 
 the class of protozoa and inhabit the blood of the infected individual. 
 
 Etiology and Pathology . — The geographical distribution of the malarial 
 fevers is a point of considerable interest, particularly inasmuch as it is not 
 entirely constant. In Europe, France, Germany, and England are compara- 
 tively free from malarial fever, while in Southern Russia and Italy the disease 
 is very frequent. In many parts of Africa and India some of the severest 
 forms of malaria are seen. In this country there are various localities in which 
 malaria is endemic, particularly in certain regions in the Southern States, in 
 Louisiana, Mississippi, Arkansas, and Texas. In the low, marshy lands along 
 the coast throughout the Southern and Central States there are many places 
 in which malarial fevers are common. In parts of New England malaria also 
 occurs, particularly in the Connecticut Valley, while of late a considerable 
 number of cases has been seen along the course of the Charles River in 
 Massachusetts. In New York City the disease is rare, though certain low- 
 lying districts in the neighborhood give rise to a number of cases. In Phila- 
 delphia the disease is perhaps more frequently seen, but most of the cases in 
 that city come from outlying districts. In parts of Baltimore also malarial 
 fever occurs, though a great majority of the cases come from the districts bor- 
 dering on Chesapeake Bay. In the Western States malaria is less common, but 
 in certain parts about the Great Lakes it is more or less prevalent. 
 
 A very interesting point in connection with the geographical distribution 
 of malarial fever is the manner in which the disease wanders from one region 
 to another, diminishing greatly in intensity or almost dying out in a district 
 where it has formerly been endemic, and developing perhaps in a region where 
 it has been for many years an unknown disease. An instance of this is the 
 appearance during the last five or six years of malarial fever along the basin 
 of the Charles River in Massachusetts, where it had been for many years 
 unknown. Again, in districts in which malarial fever has for years been 
 endemic there seem to be cycles in which the intensity of the process increases 
 and diminishes. 
 
 Malarial fever is particularly prevalent in low, swampy, and badly-drained 
 districts, and especially in areas which are rich in vegetable matter and have 
 
 303 
 
304 AMEBIC AN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 been allowed to fall out of cultivation. It is much more prevalent in tropical 
 or semitropical regions, and is more severe in climates where the moisture is 
 considerable. It has been thought that winds have possibly some connection 
 with the carrying of the contagion ; for instance, in some malarial districts the 
 residents on one side of a stream may be relatively free from the disease, while 
 those upon the other side, toward which the prevailing winds blow, may suffer 
 considerably. The danger of contracting malarial fever is apparently greater 
 among those living in the lower stories of a house than in the upper. 
 
 In temperate climates the frequency of the malarial fevers varies greatly 
 with the seasons. The majority of cases occurs in the late summer and fall, 
 though a certain number develops in the spring and early summer, while in 
 the winter it is very rare. In tropical climates, where the disease occurs all 
 the year round, the greater number of cases is seen in the fall and spring 
 months. 
 
 The Specific Micro-organism. — All our accurate knowledge of the causal 
 element of malarial fever dates from the discoveries of Laveran in 1880. 
 While studying malarial fever in Algiers, Laveran discovered certain pig- 
 mented bodies in the blood of affected individuals. These bodies had long 
 been observed by others, and by some accurately described, and even pictured, 
 but, while the older observers considered them to be altered blood-corpuscles, 
 Laveran recognized them as parasites, and asserted that they were the definite 
 exciting agent of malarial fever. These discoveries have been confirmed by 
 numerous other observers in Italy, the United States, Russia, Germany, and 
 India. In this country Councilman, Abbott, Osier, James, and Dock have 
 made valuable observations. Laveran and his school have published careful 
 and accurate descriptions of the different forms of the parasite, which may be 
 seen in the blood, but they assert that they are unable to associate any definite 
 types of organism with distinct types of fever. From the observations which 
 have been made, however, by the numerous Italian observers, led by Golgi, 
 there can be to-day little doubt that certain definite types of the organism are 
 associated with certain definite types of fever. 
 
 In this country, as in Italy, there are several main types of fever : 
 
 (1) The milder forms of intermittent fever, which form the great majority 
 of the cases in the spring and early summer, but which occur at all malarial 
 seasons: (a) tertian and double tertian (quotidian) fever; (b) quartan fever, 
 with its combinations. 
 
 (2) The more severe, often more or less irregular, fevers which occur here, 
 as in Italy, more commonly in the later summer and fall — the gestivo-autumnal 
 fevers of the Italians, the tropical malaria of the Germans. This type of 
 fever includes the so-called remittent malarial fevers as well as most of the 
 cases of pernicious malaria and of the malarial cachexia. Some of the Italian 
 observers have attempted to divide these fevers, again, into (e) quotidian fever, 
 and (d) malignant tertian fever. In this country, however, we see probably 
 only the quotidian type. With each of these types of fever is associated a dis- 
 tinct type of the specific micro-organism. 
 
 (a) The Parasite of Tertian Fever. — Golgi was the first observer who 
 accurately described and differentiated the organisms of the tertian and of the 
 quartan forms of malarial fever, and his admirable observations have remained 
 practically unassailed. If we examine the blood from a case of tertian fever 
 just after the paroxysm, we find in certain of the red blood-corpuscles small 
 round, colorless bodies (Fig. 1, 1 ' 2 > 3 ) which appear to have a slight depres- 
 sion in the centre, and when stained in dried specimens show a paler central 
 area with a darker periphery. These bodies, examined in the fresh specimen, 
 
MALARIAL FEVER. 
 
 305 
 
 show active amoeboid movements. A few hours later the organism will be 
 found to have increased somewhat in size, and to contain a few fine brownish 
 pigment-granules which dance actively under the eye (Fig. 1, 4 ), the motion 
 probably being due to undulatory movements in the protoplasm. On the 
 day between the paroxysms the bodies will be found to have about half 
 filled the red corpuscle (Fig. 1, 5 ). They are still actively amoeboid, and 
 the number of pigment-granules has considerably increased. The red cor- 
 puscle at this stage will be seen to be a trifle larger than its unaffected 
 neighbors, and to be considerably decolorized. On the day of the paroxysm 
 
 Fig. 1. 
 
 4 
 
 
 
 10 
 
 o%% 
 
 11 
 
 
 
 12 
 
 6 
 
 r 
 
 The Parasite of Tertian Intermittent Fever (drawings made from the blood of patients in the Johns Hop- 
 kins Hospital, with the camera lucida. Winckel, 1-14 oil immers. lens, 4 eye-piece) : 1, 2, 3, hyaline 
 intracellular amcehoid bodies, seen during the febrile stage of the paroxysm ; 4, 5, half-grown bodies 
 seen on the day between paroxysms; 6, the same, further advanced; 7, full-grown body seen during 
 the paroxysm ; 8, segmenting body seen during the paroxysm ; traces of the red corpuscle still seen 
 about the organism ; 9, 10, segmenting border further advanced ; 11, 12, extracellular pigmented bodies, 
 regenerative forms ; 13, flagellate body (somewhat diagrammatic, not drawn with the camera lucida). 
 
 the organism has entirely filled and almost destroyed the red blood-corpuscle, 
 which is represented only by a faint pale rim about the full-grown parasite, 
 if indeed it has not entirely disappeared (Fig. 1, 7 ). The pigment-granules 
 may show at this stage a very active motion, but the amoeboid movements 
 of the organism as a whole are but little marked. At the time of the 
 paroxysm an interesting change takes place ; the pigment gathers together 
 in a more or less solid clump, usually in the centre of the organism, while the 
 rest of the protoplasm looks somewhat granular and shows a suggestion of 
 
 20 
 
306 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 lines radiating outward from the centre (Fig. 1, 8 ). This appearance gradu- 
 ally changes, the lines becoming more distinct (Fig. 1, 9 ), until finally we see 
 the central clump of pigment surrounded by from fifteen to twenty small ovoid 
 or round glistening segments, each one having a central more refractive spot, 
 and resembling strongly the hyaline bodies which we see immediately following 
 the chill (Fig. 1, 10 ). This segmentation of the organism is always coincident 
 with the paroxysm, and the presence in the blood of a segmenting body is a 
 sure indication that the paroxysm is present, or is about to occur. Immedi- 
 ately followiug the paroxysm fresh hyaline bodies appear in the red corpuscles. 
 Though the invasion of the corpuscles by these fresh segments has never been 
 actually observed, the evidence that this occurs is so strong that we can safely 
 accept it as a fact. Besides these forms w r e see not infrequently small or large 
 extra-cellular pigmented bodies ; that is, organisms resembling exactly those 
 within the red blood-corpuscles, excepting that they are free in the blood-cur- 
 rent (Fig. 1, llf 12 ). These may be seen at times to break up into several 
 smaller bodies, while at other times they may show a long, tail-like, non-motile 
 process, containing sometimes a few pigment-granules. They are probably 
 organisms which have escaped from the red corpuscles, or full-grown bodies 
 which have broken up ; they are considered to be degenerative forms. At 
 times also we find the so-called flagellate bodies. Their development from the 
 pigmented organism may indeed be observed, the pigment of the full-grown 
 body becoming very actively motile, then collecting in the centre of the 
 organism, while several long, thread-like flagella burst out of the body and 
 move actively about among the surrounding corpuscles (Fig. 1, 1 3 ). Some- 
 times we may see one of these flagella which has broken away from the organ- 
 ism and is moving rapidly through the field. This is also thought by the 
 Italians to be a degenerative process. The characteristics of this form of 
 organism, which is observed in tertian fever alone, are so marked that with a 
 little study of the parasite one can make a definite diagnosis of the type of 
 fever from an examination of the blood alone. 
 
 (b) The Parasite of Quartan Fever. — Quartan fever is not at all common 
 in this country, but in the few cases which the writer has observed the 
 organisms differ distinctly from the tertian parasite, and show accurately the 
 characteristics described by Golgi. Here the first stage of the organism is 
 similar to that observed in tertian fever, excepting that the amoeboid move- 
 
 Fig. 2. 
 
 ^ r > 
 
 "*»«_'« 
 
 "A STk ©P G 
 
 ©1° 
 
 The Parasite of Quartan fever (drawings mainly after Marchiafava, Bignami, and Mannaberg) : 1, 
 hyaline amoeboid intracellular body ; 2, 3, 4, further stases in the growth of the bodv ; 5, full-grown 
 form ; 6, 7, segmenting bodies. 
 
 ments are not so active. As the body develops the rods and clumps of pig- 
 ment are larger and darker than those in tertian fever, while the amoeboid 
 
MALARIAL FEVER. 307 
 
 movement of the organism is relatively slight. The full-grown forms are 
 materially smaller than in tertian fever, while the red blood-corpuscle, instead 
 of being expanded and decolorized, appears at times shrunken about the body, 
 and of a somewhat deeper old-brass color (Messingfarbe). In segmentation the 
 organism divides into from six to ten different parts instead of twenty or thirty, 
 as in the tertian form (Fig. 2, 1_7 ). 
 
 (c) The Organisms of the JEstivo-autumnal Fevers. — The organisms asso- 
 ciated with the gestivo-auturunal fevers have been carefully studied, but much 
 remains to be done, particularly in this country. There is some difference 
 of opinion as to whether there are not two types of organism associated with 
 these fevers. Some Italian observers divide them into the quotidian and the 
 malignant tertian organisms. The differences made out by the Italians are, 
 however, very slight, and have not been observed in this country. In the 
 first place, we see just after the paroxysm small hyaline bodies which may 
 or may not be actively amoeboid ; these can sometimes be distinguished 
 from those appearing in the initial stage of either tertian or quartan fever, 
 in that they are generally somewhat smaller and have oftentimes a charac- 
 teristic ring-like appearance (Fig. 3, 1_4 ). In the early stages — during the 
 first week, for instance — of an attack of this form of fever we may see only 
 the hyaline, unpigmented forms, but commonly, if we observe carefully, we 
 may see, some time after the exacerbation of temperature, shortly before the 
 beginning of another, bodies which are a trifle larger than these smallest hyaline 
 forms, and which contain one or two very minute pigment-granules lying near 
 the periphery (Fig. 3, 3 - 4 ). Just before or during the paroxysm we may see 
 
 Fig. 3. 
 
 12 
 
 ® 
 
 Parasites seen in ^Estivo-autumnal Fever— tropical malaria. (Drawn with the camera lucida from the blood 
 of patients in the Johns Hopkins Hospital ; Winckel, 1-14 oil immersion lens, 4 eye-piece. ) : 1. 2, 3, hya- 
 line, ring-like amoeboid bodies seen in the blood toward the end of the paroxysm ; 4, the same further 
 developed; 5, 6, disc- and ring-shaped bodies with one or two small pigment-granules, seen shortly 
 before a paroxysm ; 7, full-grown body with central pigment-granules, seen during paroxysm : 8. full- 
 grown body with central active pigment-corpuscle crumpled and shrunken: 9-12, crescentic and 
 ovoid bodies with coarse central pigment. 9 and 11 show remains of the corpuscle (from a ease oi 
 chronic malaria with normal temperature). 
 
 bodies with a small central clump of motile or non-motile pigment-granules 
 lying usually in cells which are more or less shrunken and crumpled, and of a 
 deeper color than the normal corpuscles (Messingfarbe). These bodies are 
 
308 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 generally not half as large as the red corpuscle (Fig. 3, 8> 9 J. After the first 
 week or ten days of the disease, or after treatment has been begun, we see, 
 however, certain very characteristic and easily recognizable forms which are 
 only seen with this type of fever. These are, first, round or ovoid bodies 
 about the size of a red blood-corpuscle, a little smaller or a little larger, with 
 clear, rather highly refractive, waxy-looking protoplasm, and coarse dark pig- 
 ment-granules, which are usually collected in a ring or a mass in the centre of 
 the organism (Fig. 3, 9> 10, 12 ). The granules are usually very slightly motile. 
 At one side of the body we often see a small bib-like attachment which may 
 show a slightly yellowish color. On examination this proves to be the remains 
 of the red blood-corpuscle in which the organism has developed. In association 
 with these are seen crescentic bodies (Fig. 3, 1X ), the protoplasm of which shows 
 the same characteristics as that in the forms above described, while the pigment 
 is collected in the middle in a similar ring or bunch, and is but slightly motile. 
 On the concave side of these crescents one may also often see a bib-like attach- 
 ment, just as in the ovoid forms. At times during the examination of the fresh 
 specimen we may see the change from an ovoid body into a crescent take place. 
 The development of these forms from the hyaline bodies can be followed out 
 on careful observation. They are thought by some to be a resting stage of 
 the organism. Segmenting bodies are almost never seen in the circulating 
 blood of this form of malarial fever, though the presence of the round intra- 
 cellular bodies with central pigment is a sure sign that segmentation is going 
 on elsewhere. It has been found by the Italians that after the accumu- 
 lation of a few pigment-granules the organisms seek the internal organs, 
 where segmentation takes place. The bodies are still small and contained 
 within the red corpuscle. The pigment gathers in the centre, as in the other 
 types of segmentation, while the segments are very small and rarely more than 
 twelve in number. During the paroxysm we may see large numbers of leuco- 
 cytes containing pigment granules and clumps which are probably the remains 
 of segmenting organisms. Flagellate bodies may be observed here as in the 
 tertian and quartan fevers, but only when ovoid and crescentic pigmented bodies 
 are present. They may be seen to develop from the round bodies with central 
 pigment. 
 
 Careful studies concerning the morphological characteristics of the malarial 
 parasite have shown that it belongs to the class of Protozoa, and is possessed 
 of a nucleus containing one or more nucleoli. At the time of sporullation this 
 nucleus divides — according to some directly, according to others by karyokinesis. 
 
 Pathological Anatomy. — In the acutely fatal cases of malarial fever 
 (pernicious malaria) certain fairly characteristic changes are found in the 
 various organs. 
 
 The brain may show few changes. At times, however, there may be a 
 slight subpial oedema, with hyperemia of the cerebral substance and per- 
 haps punctate haemorrhages. Melanosis may be entirely absent. Micro- 
 scopically, however, the changes are most characteristic. The cerebral capil- 
 laries are crowded with malarial parasites, which may be in all stages of 
 development, though generally one of these phases is most marked. At times 
 the organisms may not be so numerous, but free clumps of pigment may be 
 found, and large endothelial cells and leucocytes containing pigment-clumps 
 and red corpuscles. There is usually a marked granular and fatty degen- 
 eration of the endothelium of the vessels, a change upon which the punc- 
 tate haemorrhages may depend. These lesions are particularly marked in the 
 comatose forms of pernicious malaria. In other forms the cerebral lesions 
 may be much less marked. 
 
MALARIAL FEVER. 309 
 
 The spleen is always enlarged : the capsule is tense ; the parenchyma is 
 cyanotic, of a slaty -gray color, and almost diffluent. In some cases of acute 
 malaria death may occur from rupture of a greatly enlarged spleen. The pulp 
 contains enormous numbers of red blood-corpuscles, many of which contain 
 parasites. It also contains numerous large white elements rich in protoplasm, 
 containing usually a single bladder-like nucleus, and at times coarse granula- 
 tions. These elements are usually laden with pigment, which at times has the 
 same arrangement as it does in the body of the parasite itself. Sometimes 
 these cells may contain the entire red corpuscle with the organism. There 
 may be free pigment in the intercellular spaces of the pulp. The small 
 mononuclear elements and the lymphocytes of the follicles never contain pig- 
 ment. The capillaries are usually filled with the plasmodia, while the splenic 
 veins show relatively few, though they always contain large cells enclosing pig- 
 ment or the remains of red blood-corpuscles. 
 
 The liver has usually a slaty-gray color. There is always cloudy swelling, 
 while microscopically small areas of necrosis have been described by Guar- 
 nieri. The capillaries are filled with leucocytes which contain numerous pig- 
 mented bodies. Relatively few plasmodia are found in the blood-corpuscles in 
 the vessels. Numerous liver-cells are found containing clumps of hsematin 
 and altered red corpuscles — a condition similar to that which has been found 
 in pernicious anaemia, which, as Bignami suggests, may explain the polycholia 
 which is commonly found in subjects who have died of pernicious malaria. On 
 this probably depends the icteroid hue in severe malaria. 
 
 The lungs show in their capillaries numerous cells containing pigment-clumps 
 and well-preserved parasites, though it is unusual to find pigment in the endo- 
 thelial cells, in the capillaries, and smaller veins. In the areas of broncho- 
 pneumonia which may occur, polynuclear leucocytes are chiefly found, while the 
 large pigmented cells take no part apparently in the active inflammatory process. 
 
 The vessels of the kidneys contain relatively few organisms. The glomeruli 
 may be considerably pigmented. There may be marked degeneration of the 
 epithelium of the capsules, and at times changes in the parenchyma, especially 
 areas of necrosis of the epithelium of the convoluted tubules. The other viscera 
 show no especially characteristic changes excepting at times the melanosis. 
 
 In the more chronic forms of malaria and in malarial cachexia the 
 anaemia is usually particularly marked. The spleen is always enlarged and 
 very firm. There is a marked thickening of the capsule, which is often adher- 
 ent to the neighboring tissue. On section the spleen is generally of a dark 
 brownish-gray color, the fibrous tissue throughout the organ being greatly 
 thickened. The liver is considerably enlarged, and usually has a grayish- 
 brown or slaty color. Microscopically, Kupfer's cells and the perivascular 
 tissue may contain much pigment. At times there is a considerable iD crease 
 in the connective tissue. The kidneys show no particular characteristic changes, 
 though there may be considerable pigmentation ; the pigment is most marked 
 about the blood-vessels and the Malpighian bodies, and sometimes in the 
 region of the convoluted tubules. There are no characteristic changes in the 
 other organs, excepting the slaty-grayish pigmentation. 
 
 Symptoms. — As may be gleaned from what has already been said con- 
 cerning the specific organisms, malarial fever occurs in several main types : 
 (1) The milder intermittent fevers, which form the majority of all cases in the 
 more temperate climates, and occur in the warmer climates more commonly in 
 the spring and early summer : (a) Tertian intermittent fever and its combi- 
 nations ; (6) Quartan intermittent fever and its combinations. (~) The more 
 irregular, sestivo-autumnal fevers, which usually show quotidian paroxysms. 
 
310 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
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 Tertian Fever. 
 
 headache, and is usually very fretful. There 
 
 renewed attacks of vomiting or diarrhoea. 
 
 Tertian Intermittent 
 Fever. — This is by far the 
 commonest form of malarial 
 fever in this country, and with 
 the quartan fever forms the 
 mildest type of the disease. It 
 is the type of the intermittent 
 fever of the spring and early 
 summer, though it may be seen 
 at any time of year. It shows 
 often no particular tendency to 
 increase in severity, while in 
 many instances, under proper 
 care and change of climate, 
 spontaneous recovery may oc- 
 cur. It depends, as we have 
 seen, upon the invasion of the 
 blood by an organism which 
 passes through its cycle of ex- 
 istence in forty-eight hours. 
 The febrile paroxysms occur 
 when these parasites have 
 reached their full development 
 and begin segmentation. These 
 periods occur with considerable 
 regularity at intervals of forty- 
 eight hours one from another. 
 In older children the parox- 
 ysms may usually be divided 
 into three stages : first, the 
 chill ; secondly, the fever ; and 
 thirdly, the sweating. The 
 child, who may have been feel- 
 ing fairly well beforehand, be- 
 comes suddenly uneasy, may 
 begin to yawn, or may have an 
 attack of vomiting or diarrhoea, 
 which is followed or accom- 
 panied by a well-marked rigor, 
 associated with cyanosis and 
 coldness of the extremities. 
 The temperature rises to a con- 
 siderable height, possibly to 
 108° F. This stage lasts for 
 a varying time, from ten min- 
 utes to an hour. As the chill 
 ceases the patient passes into a 
 stage in which there is marked 
 flushing of the skin,with great 
 heat and dryness. The child 
 complains bitterly of thirst and 
 may be, as in the first stage, 
 
 This stage, after lasting for a vari- 
 
HAL A RIAL FEVER. 
 
 311 
 
 able length of time, from half an hour to three or four hours, is followed by 
 profuse sweating, the temperature falling within an hour or two to a normal or 
 even a subnormal point. With the sweating the child may seem exhausted and 
 weak, but shortly afterward appears again perfectly well. 
 
 Such an attack as this differs but little from the intermittent fever of 
 adults, and indeed above the age of six the differences are very slight. Under 
 this age, however, there are marked differences in the paroxysm. Very com- 
 monly in young children both the first and the third stages, those of the chill 
 and sweating, are absent. The first stage is then generally represented by a 
 slight restlessness, the face looks pinched, the eyes sunken, the finger-tips and 
 toes may become cyanotic and cold, while the child may yawn or stretch itself. 
 Oftentimes there is nausea or vomiting, and possibly diarrhoea. This may be 
 the only manifestation of the first stage, though it may be followed by slight or 
 severe nervous symptoms. These begin usually with a slight spasmodic 
 twitching of the eyelids or of the extremities, and may go on to general convul- 
 sions. The chill in the adult is very often represented in the young child by 
 the convulsion — a fact which is as true in all other acute febrile processes as in 
 malarial fever. This stage lasts usually for a short time, not more than an 
 hour or so. The temperature rises rapidly, possibly to 108° F. ; then comes 
 the period of fever, during which the child is much flushed, is restless, 
 thirsty and fretful, while, as has been already said, various gastro-intestinal 
 disturbances may occur. The fever remains at its height for an hour or two ; 
 afterward there is a gradual fall of temperature, unaccompanied by sweating. 
 In many instances, besides the slight coldness of the hands and blueness 
 
 Fig. 5. 
 
 Double Tertian (quotidian fever). 
 
 of the finger-tips, and a somewhat pinched expression of the face in the 
 first stage, the first and the third stages of the attack may be entirely 
 lacking. 
 
 Pure tertian fever is rare in children, as the process is almost always a 
 double infection ; that is, the blood contains two sets of organisms, which 
 attain maturity on alternate days, and give rise to quotidian paroxysms. If, 
 
312 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 as is unusual, the case is one of pure tertian fever, the child may seem per- 
 fectly well on the day between the attacks. 
 
 Physical examination during the very first attack may reveal little or 
 nothing, but usually by that time, and always after one or two paroxysms, an 
 enlarged spleen may be made out. If a child has had more than two supposed 
 malarial paroxysms and the spleen is not distinctly enlarged, we have almost 
 sufficient evidence to put aside the diagnosis of malarial fever. Herpes 
 labialis is a very common accompaniment. Anaemia is usually noticeable if 
 the process has lasted for any length of time. The discovery of the specific 
 organism in the blood is the one diagnostic point. The paroxysm in tertian 
 malarial fever may last altogether from twelve to fifteen hours, though com- 
 monly it is much shorter, the first stage lasting from ten minutes to an hour, 
 the second stage from an hour to three or four hours, and the third stage a 
 varying length of time. As the length of time which the tertian organism 
 requires to attain its full growth is almost exactly forty-eight hours, the 
 attacks dependent upon one group of parasites occur almost regularly forty- 
 eight hours apart, though in some instances we may find a tendency to antici- 
 pation or to retardation in the attacks. This point can only be determined by 
 observation, so that one cannot definitely prophesy the hour at which an 
 attack will occur until he has seen several paroxysms. It is easy to see that 
 in the quotidian cases, which depend upon the presence of a double infection, 
 the chills on the alternate days may occur at different hours, one group of 
 organisms segmenting perhaps at ten o'clock, and the other at two. Usually, 
 however, these differences are slight. Not infrequently we find the history 
 of tertian attacks at first, and later on daily attacks of fever. The common- 
 est time for the paroxysm in tertian fever is in the early part of the day, 
 between eight in the morning and two in the afternoon, though they may 
 occur at all hours either of the day or night. Irregularities in the course of 
 the fever, no matter what the type may be, are much commoner in children 
 than in adults. 
 
 Quaktan Fever. — This form of fever is rarely observed in this country. 
 Out of about 500 cases of malaria treated at the Johns Hopkins Hospital in 
 four years, it only occurred twice. Here the length of time required for 
 the development of the organism is seventy-two hours, and the paroxysms 
 occur every fourth day. The nature of the paroxysm does not differ from 
 that observed in tertian fever. As one may easily see, complex attacks of 
 fever may arise from a double or triple infection with quartan organisms. Thus 
 we may have a daily paroxysm due to a quartan infection, or, on the other 
 hand, paroxysms on two days in succession, with one day intermission, a triple 
 or a double infection. The diagnosis of quartan fever may be made by a 
 skilled observer from one examination of the blood by the discovery of the 
 characteristic quartan organism. 
 
 The JEstivo-autumnal Fevers. "Tropical Malaria." "Febris 
 Irregularis." — The malaria occurring in the late summer and fall is often of 
 a much more severe type than that occurring in the spring, and, as has been 
 shown by the Italian observers, most of these cases are due to a different 
 type of the specific organism. It is in the later summer and fall that we see 
 most of the cases of apparently irregular fever, and the so-called remittent 
 malarial fever. The typical malarial cachexia, while it may follow any form 
 of intermittent fever, usually results from this type of malaria. Most of the 
 pernicious forms also come under this heading. 
 
 The So-called Irregular Remittent Fevers. — The recent Italian 
 observers, asserting that there is in reality no actual irregularity, divide these 
 
MALARIAL FEVER. 
 
 313 
 
 fevers into the quotidian, in which a daily paroxysm occurs, and the tertian, in 
 which the paroxysm occurs on every other day ; but in both instances there is 
 a greater tendency to irregularity in the time required for the development of 
 each brood of organisms. On the one hand, there is often a very marked 
 tendency for the paroxysms to anticipate one another, or there may be a 
 retardation, while again the attacks do not present themselves in so clean-cut 
 and regular a form as in the spring fevers. They may be much lengthened 
 out. so that one attack may follow another without the temperature ever 
 actually reaching a normal point. Most of the cases of this type of fever seen 
 
 Fig. 6. 
 
 109 
 108 
 107 
 
 ao6 
 
 105 
 T04 
 103 
 102 
 101 
 JOO 
 
 Temp 
 ZVUe 
 
 I 
 
 e 
 
 ?i 
 
 s 
 
 o 
 
 m 
 
 £:::: 
 
 :** 
 
 4* 
 
 b± 
 
 iEstivo-autumnal fever. (Quotidian. 
 
 in this country show a distinct daily paroxysm ; it is doubtful whether we see in 
 America the " malignant tertian fever " of the Italians. The attacks may differ 
 little from those in the ordinary tertian form, excepting that they are often more 
 severe and of a somewhat longer duration, so that the afebrile periods are shorter 
 or even absent. On the other hand, the onset may be very gradual, with daily 
 exacerbations of temperature, accompanied by restlessness, flushing, often 
 vomiting or diarrhoea, and headache, but without chills or perhaps even sweating. 
 The attacks may be prolonged and run into one another, so that a remittent 
 temperature results. There is often delirium or drowsiness and somnolence ; 
 the spleen is always enlarged. In this condition the diagnosis from typhoid fever 
 or meningitis may be impossible without an examination of the blood. Such 
 cases as this, however, do not generally go on to recovery without treatment, but 
 tend to become pernicious, the paroxysms increasing in severity till death. 
 
 Malarial Cachexia. — The fever in some instances may never rise as high 
 as it does in the paroxysms of tertian fever, nor may the immediate symptoms 
 of the paroxysm be as striking, and the attention of the physician is often 
 called to the patient for the first time when the stage of malarial cachexia has 
 been reached. The child may then show a pitiful appearance. It is pale, of 
 a sallow, parchment-like color, and often much emaciated. The skin is dry. 
 the face has a drawn, pinched look, the eyes are sunken; there may be marked 
 symptoms on the part of the digestive tract, frequent attacks of vomiting and 
 
314 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 diarrhoea. The fever may stand in the background. Indeed, in some of these 
 cases there may be for weeks relatively little fever. The spleen is always 
 enlarged. Malarial cachexia does not exist in children without an enlarged 
 spleen. In all instances, no matter whether our attention is called to the child 
 on account of the fever or of the gastro-intestinal derangement, an examination 
 of the blood will show the organisms, usually those characteristic of the sestivo- 
 autumnal or tropical malarial fever, the small hyaline bodies, and the pig- 
 mented crescents and ovoid forms. Malarial cachexia may follow all forms of 
 the disease, and not infrequently is seen in improperly treated cases of tertian 
 fever or in those who have been subject to repeated attacks, but it is much more 
 commonly seen in this type of fever. 
 
 Pernicious Malarial Fever. — It is in the aestivo-autumnal fevers that 
 we see more commonly the pernicious forms of malaria, though these are rare 
 in temperate climates. In these cases a previously healthy child may begin to 
 show a slight restlessness, with a pinched expression of the face and some blue- 
 ness of the extremities. An attack of vomiting or diarrhoea may occur, which 
 may be followed suddenly by severe convulsions and a very rapid rise in tem- 
 perature, which may be as high as 108°. The convulsions may continue or 
 the child may pass into a dull, comatose condition, the pupils being fixed and 
 possibly irregular ; in this condition it may remain until death ensues. In 
 some instances the whole attack may be represented by a condition of coma 
 with collapse, possibly with little or no rise in temperature. These severe 
 attacks are rare in this country, and it is not at all improbable that in regions 
 in which severe malarial fever prevails many non-malarial attacks are ascribed 
 to this disease. The definite diagnosis can only be made by the discovery of 
 the parasite in the blood. Some of the most severe of these attacks are prob- 
 ably due to the infection with several groups of the organisms at once, so that 
 segmentation is going on continuously. 
 
 Affections of Other Viscera sometimes Associated with Mala- 
 rial Fever. — Respiratory Apparatus. — In all forms of malarial fever bron- 
 chitis is a common complication, as it is, indeed, with any acute febrile affec- 
 tion. This is particularly true in children. The appearance of a profuse 
 coryza in the absence of the sweating stage has been noted. 
 
 Alimentary Tract. — In almost all cases of malarial fever in children symp- 
 toms are present on the part of the stomach and intestines. Vomiting in the 
 first and second stages of the paroxysm is extremely common, while diarrhoeas 
 are also very frequently seen in all forms of malaria, particularly in the more 
 remittent forms and in the chronic cachexia, where it is probably generally due 
 to a secondary infection to which the debilitated child is more readily subject. 
 Little is to be noticed on the part of the circulation. 
 
 Kidneys. — Slight albuminuria may often be observed, and in rare instances 
 hematuria occurs. Malarial hematuria is generally considered a grave symptom. 
 It is probably, however, a rare condition, except in districts where the severest 
 forms of the disease are common. Many of the so-called malarial hsematurias 
 are due to other causes. 
 
 The literature of malarial fever contains numerous references to "malarial 
 pneumonia," "malarial bronchitis," "malarial neuralgia," "malarial diar- 
 rhoeas," and the like, most of which, in the light of our present knowledge, 
 have probably little or no connection with malarial fever. It is easy to 
 understand that the child debilitated by a severe malarial fever may more 
 readily fall a victim to a variety of other diseases. In this way probably the 
 gastro-intestinal and bronchial disturbances so commonly observed are to be 
 explained. That there is any such thing, for instance, as a specific malarial 
 
MALARIAL FEVER. 315 
 
 pneumonia is wholly out of the question. The chills which may occur sometimes 
 with some regularity in the course of many of the specific fevers are commonly 
 attributed to a malarious influence. These inferences are for the most part 
 unjustifiable. In rare instances a patient who is subject to an acute or chronic 
 malaria may develop typhoid fever at the same time, or the converse may occur, 
 but these instances are few and far between, and the great maj ority of instances 
 of chills occurring in typhoid fever have no connection whatever with malaria. 
 Pneumonia may develop during the course of a malarial attack, but it is due 
 in these cases to its specific cause. The examination of the blood is our one 
 safe clue to the explanation of such complications. 
 
 Diagnosis. — The Milder Tertian and Quotidian (double tertian) Fevers. — 
 The diagnosis of malarial fever in children may be made, in the first place, from 
 the character and periodicity of the attacks ; secondly, from the enlargement of 
 the spleen, which is always present after the first or second attacks ; and thirdly, 
 by the presence of the malarial organism in the blood. In some instances there 
 may be relatively few parasites, but the careful examination of several fresh 
 specimens of the blood will always reveal the organism if present. Even in 
 the absence of definite data with regard to the attacks, the diagnosis may be 
 made by the type of organism found. The commonest type, as has been said, 
 is the double tertian, quotidian fever. 
 
 The commonest condition with which malarial fever is confounded is 
 tuberculosis in its various forms ; the hectic evening temperature is often 
 ascribed to malaria. Most pediatrists may, I fancy, remember more than one 
 instance where after a diagnosis of malarial fever evidences of pulmonary, 
 abdominal, or even glandular tuberculosis have developed. The absence of 
 definite signs of tuberculosis, the splenic enlargement, and the anaemia, which 
 may be marked, speak in favor of the malarial nature of the affection, while 
 the absence of malarial organisms in several specimens of fresh blood, even in 
 the presence of marked febrile paroxysms, is a sure sign of the absence of 
 malarial fever. 
 
 The same rules of diagnosis apply to quartan fever. The characteristic 
 organism of that type will be found on examining the blood. 
 
 JEstivo-autumnal Fevers. — It is the more irregular and remittent fevers 
 and the malarial cachexiae which give the most trouble to the diagnostician. 
 The regularly intermittent fever may not here give us our clue to the 
 diagnosis. On the other hand, the presence of a considerable anaemia in 
 association with a markedly enlarged spleen, which is always present in this 
 form of fever, will lead us to suspect the proper diagnosis, which will be con- 
 firmed by the discovery of the small ring-like hyaline intracellular organisms, 
 and, if the case has lasted a week or more, the ovoid and crescentic pigmented 
 bodies in the blood. This form of fever may often be confounded with tuber- 
 culosis. It may also simulate very closely, from the physical examination 
 alone, leukaemia or the anaemia infantilis pseudo-leukaemica of Von Jaksch. 
 In some instances where the paroxysms tend to run into one another and pro- 
 duce a more or less remittent fever, the differentiation of the process from fever 
 may be impossible from the physical examination alone. The frequent herpes. 
 the large size and prominence of the spleen, as well as the rapidly developing 
 anaemia, may be suggestive, but here, as elsewhere, the examination of the 
 blood alone gives us our certain diagnosis. In the absence of an examination 
 of the blood, the chronic cachexiae may be considered to be the result of the 
 concomitant gastro-intestinal derangements or of the bronchitis, while in many 
 instances the atrophy, the dyspepsia, and the diarrhoea may be found to depend 
 upon the presence of the malarial organisms in the blood. In the cases of 
 
316 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 severe pernicious malarial fever the examination of the blood is also our only 
 safe clue to a diagnosis. 
 
 Methods of Examination of the Blood. — The examination is best 
 made with fresh specimens. The lobe of the ear is punctured with a sharp, 
 spear-pointed lancet ; a very small cut is all that is necessary. This may be 
 done behind the back without the child seeing the instrument, so that it may 
 not be alarmed, while if the instrument is sharp the process is almost painless. 
 In some instances it may be done while the child is asleep, without even 
 awakening it. After wiping away the first drop or two of blood, a perfectly 
 clean cover-glass is brought into contact with the tip of a small drop of blood, 
 and allowed to fall immediately upon a freshly-cleaned slide. If the slide and 
 cover-glass have been washed in alcohol just before using and are perfectly 
 clean, the drop of blood will spread out regularly under the glass, and the 
 corpuscles may be seen lying side by side free from crenation or any other 
 artificial changes. Pressure on the cover-glass may spoil the specimen. It is 
 best to hold the cover-glass in a forceps in order to avoid any injury to the cor- 
 puscles from the moisture of the hand. The specimen is then examined at best 
 with a ^ oil-emersion lens, and a 2, 3, or 4 eye-piece. A 4 eye-piece with an 
 8 objective, or a Zeiss E or F, will answer the purpose well, though an oil- 
 emersion lens is clearer and better. In this manner all forms of the organism 
 may be seen while yet alive. When it is impossible to examine the fresh spec- 
 imen, dried and stained specimens may be used. A small drop of blood is 
 taken upon one cover-glass, which is then allowed to fall upon the second glass. 
 The drop immediately spreads out, and the two glasses are separated by being 
 gently drawn apart. These specimens are allowed to dry in the air. They 
 may be kept for almost any length of time before examining. There are 
 numerous different methods for preparing and staining the specimen. As 
 satisfactory a method as any is to place the glass in a solution of absolute 
 alcohol and ether, equal quantities, for a half to one hour, or the spec- 
 imens may be heated for from one to two hours at 100°-120° C. The 
 specimen may then be stained in a concentrated aqueous solution of methylene 
 blue for about a minute, washed in water, dried between filter-paper, mounted 
 in balsam or oil, and examined. The red corpuscles remain unstained. Only 
 the nuclei of the leucocytes, the malarial organisms, and occasional blood- 
 platelets take up the blue coloring. In case a double stain is desired, one 
 may make use of two solutions : Solution 1. Eosin 1 part ; 70 per cent, 
 alcohol 100 parts ; Solution 2. Saturated aqueous solution of methylene blue. 
 After preparing the specimen in absolute alcohol and ether as before, place 
 it in Solution 1 for from fifteen seconds to half a minute, wash in water, 
 dry between filter-paper ; place it then in Solution 2, which has been 
 diluted one-half with water, letting it stain for from one half to one minute ; 
 wash in water, and dry. By this method the red corpuscles and the eosinophilic 
 granules in the leucocytes are stained red by the eosin, while the nuclei of the 
 leucocytes and the malarial parasites are stained blue. 
 
 Good results may be obtained by Romanowsky's method : saturated aqueous 
 solution of methylene blue, 1 part, 1 per cent, aqueous solution of eosin 2 parts. 
 Do not shake or filter the mixture. Place the specimen (heated as above) in 
 this mixture for two to three hours, and then in water for one to two hours, and 
 dry. The parasites are Stained blue. In this manner any practitioner who pos- 
 sesses a microscope may, without much labor, make the diagnosis of malarial 
 fever. The examination of the fresh specimens will probably be found to be 
 more satisfactory, and the observer who studies only stained specimens must 
 beware of certain mistakes which one who is not familiar with the examination of 
 
MALARIAL FEVER. 317 
 
 the blood may readily make, such as the confusion of the blood-plates, the 
 hreraatoblasts of Hayero, with the malarial parasite — a mistake which certain 
 good observers have recently made. 
 
 Course and Prognosis. — Excepting in the acute pernicious cases the prog- 
 nosis in malarial fever is good, provided the case is recognized and properly 
 treated. 
 
 If untreated the fever may take one of three courses : 
 
 (1) Mild cases may go on to spontaneous recovery ; 
 
 (2) The paroxysms may gradually diminish in intensity, the fever becoming 
 less marked, while grave anaemia develops, and the patient passes into the con- 
 dition of chronic cachexia ; 
 
 (3) The paroxysms may increase in severity, assuming finally a pernicious 
 type. 
 
 Treatment. — Prophylaxis. — In a malarial district certain prophylactic 
 measures should be taken with children as well as with adults. The child 
 should be kept in the house after sundown and should be carefully kept away 
 from those regions in which experience has shown that malaria is present. 
 Sleeping on the ground floor of houses in malarious districts should be 
 avoided. 
 
 Medicinally, we possess in quinine one of the few specific drugs which are 
 at the command of the physician. In almost all cases of malarial fever we may 
 expect with confidence a complete recovery after the use of quinine. There is 
 only one form of malarial fever, and that rarely seen in this country, the acute 
 pernicious malaria, in which we cannot entirely rely upon this drug. In the 
 milder forms of the disease, the tertian and quartan fevers and their combina- 
 tions, small doses of quinine are rapidly efficacious. One or two grains of 
 quinine (.065-. 13), three times a day in children under six years of age, will 
 be followed by the rapid disappearance of all symptoms. The best time to 
 administer a single larger dose of quinine is immediately after a paroxysm. 
 In the more chronic and irregular forms, which are so apt to occur in the later 
 summer or fall, the forms in which the smaller organisms are found, much 
 longer treatment and larger doses of quinine may be required. Ordinarily, 
 however, doses larger than two or three grains (0.13-0.2) three times a day are 
 not required under five or six years of age. Relatively large doses of quinine 
 may, however, be well borne, and in cases of pernicious malaria must be admin- 
 istered. Ferreiera states that he has given doses as large as 15 grains in infants 
 under one year of age without noticing ill effects ! 
 
 In pernicious cases the quinine must generally be administered hypoder- 
 matically. A good preparation is the muriate of quinine and urea. In ordinary 
 cases it is probably better to give smaller doses several times a day than it is 
 to give one large dose with the idea of " breaking up" the fever. In some 
 children it is very difficult to administer quinine by the mouth, on account of 
 the difficulty in disguising the taste, and because in some cases it is constantly 
 vomited. In some cases in infants the drug is with difficulty retained. Here 
 small doses should be given and often repeated. In these instances it may be 
 administered by the rectum ; the dose under these circumstances should be 
 about double that by the mouth. The administration of quinine through 
 the skin by means of ointments is probably of little value. In cases of the 
 more chronic aestivo-autumnal forms of malaria, associated with crescent organ- 
 isms in the blood, the treatment by quinine may have to be continued for a 
 considerable length of time. The crescents may be found in the blood for 
 months. The fever, however, if the case is truly one of malaria, will surely 
 yield to the treatment after a few days. Much has been written about those 
 
318 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 forms of malaria both in children and adults which do not yield to quinine. 
 These cases are probably not true malarial fever, as examination of the blood 
 will show. Few cases of fever in this country do not yield within a few days 
 to treatment by quinine. By this it is not said that relapses may not occur ; 
 they are frequent in cases where the treatment has been continued too short a 
 time. In some of the acute forms of fever, and more particularly in the more 
 chronic forms and in the malarial cachexia, the anaemia and various gastro- 
 intestinal disturbances may also demand our attention. In most instances, 
 with proper attention to the diet, the gastro-intestinal symptoms will disappear 
 after the disappearance of the fever. The anaemia, however, may require 
 extended treatment with various preparations of iron, and even in the severe 
 cases with arsenic, which is particularly well borne by children. The adminis- 
 tration of arsenic, which is common in chronic malaria, has its chief value 
 in its effect on the anaemia. Various other drugs have been tried in malarial 
 fever, some of which have some influence on the attacks. The most important 
 of these are preparations of eucalyptus and, of late, methylene blue. None, 
 however, approach quinine in efficacy. 
 
 One attack of malarial fever does not, unfortunately, render the patient 
 immune. On the other hand, he seems, if anything, to be more readily subject 
 to fresh attacks, and in some instances these attacks may be so frequent and 
 prolonged that a removal of the child to a proper climate is necessary. 
 
PART IV. 
 GENERAL DISEASES NOT INFECTIOUS. 
 
 RACHITIS. 
 
 By J. LEWIS SMITH, M. D., 
 
 New York. 
 
 Rachitis is a constitutional disease, but its most conspicuous anatomical 
 characters pertain to the osseous system. The gross nutritive changes which it 
 produces in the bones and cartilages, causing deformities, are well known to 
 physicians and the laity. In addition to these anatomical changes in the 
 skeleton, typical cases exhibit a lack of tonicity with stretching of the liga- 
 ments, causing the knock-knee and flat-foot; weakness of the muscles, resem- 
 bling paralysis and sometimes mistaken for it in severe cases ; reflex irritability, 
 rendering rachitic patients liable to laryngismus and tetany ; undue perspi- 
 ration ; anaemia and proneness to catarrhal inflammation ; and certain anatomi- 
 cal changes in the spleen and liver in aggravated forms of the disease. These 
 many and divers anatomical and functional characters indicate the constitutional 
 or general nature of rachitis. Therefore theories which restrict rachitis to 
 the osseous system are inadequate and erroneous. 
 
 Rachitis is probably an ancient disease. It is said that an old statue of 
 iEsop, who was thrown from a precipice by the indignant Delphians 564 years 
 before Christ, exhibited rachitic deformities ; and Hippocrates, born 460 years 
 before Christ, is believed to have alluded to it in his treatise on the Articu- 
 lations. 
 
 Occasionally expressions in the works of Celsus and Galen in the second 
 century of the Christian era have led writers on rickets to believe that they 
 also had observed the deformities produced by this disease. But rickets was 
 first investigated in a scientific manner by Whistler, Grlisson, and their contem- 
 poraries in the middle of the seventeenth century. During the last few years 
 many excellent monographs have been written on this malady, and its causa- 
 tion, pathology, and treatment are better understood than formerly. 
 
 Frequency. — Rachitis is a widespread disease, but it is comparatively 
 infrequent in rural localities, where families enjoy the hygienic requirements 
 of pure air, sunlight, and a plentiful diet of good quality. It is most common 
 in crowded and badly-fed families in city tenement-houses, where antihygienic 
 conditions prevail. 
 
 Mild cases of rickets, not manifested by any prominent signs or symptoms, 
 are often overlooked, so that the physician is not summoned, or, if he be sum- 
 moned and have not given particular attention to this disease, he, in not a few 
 instances, does not detect its presence. In the absence of deformity, which 
 occurs later, the fretfulness, tenderness of surface, and perspirations are likely 
 
 319 
 
320 AMERICAN TEXT-BOOK OF DISEASES OF CHIIDBEN. 
 
 to be attributed to other causes than the correct one. Hence, according to my 
 observations, rachitis is more common in its milder forms in the asylums and 
 dispensaries and in the tenement-houses of New York, and probably in other 
 American cities, than is commonly believed by the laity, and even by physi- 
 cians who have given little attention to the disease. A few years since in one 
 of the New York asylums my attention was directed to a rachitic child in whom 
 the anatomical characters of rachitis had become so pronounced that they 
 attracted the attention of the nurses. Prompted by the occurrence of this case, 
 which had developed during my attendance in the asylum, I made an exami- 
 nation of all the infants, and found, what I had previously not suspected, that 
 about one in nine presented unmistakable signs of rachitis, though in a mild 
 form and for the most part in its commencement. The late Dr. John S. Parry 
 of Philadelphia stated that at least 28 per cent, of the children between the 
 ages of one month and five years who came under his observation in the Phila- 
 delphia Hospital, during the three years preceding the publication of his paper 
 in 1872, were rachitic. According to Dr. Gee, whose observations were, how- 
 ever, made as far back as 1867 and 1868, of the patients under the age of two 
 years in the London Hospital for Sick Children, 30.3 per cent, were rachitic; 
 and Bitter von Rittershain, whose observations were also made several years 
 ago, stated that of 1623 out-door patients under the age of five years brought 
 to the Clinique at Prague, 504, or 31.1 per cent., manifested this disease. 
 Recently Prof. Henoch of the University of Berlin has stated that he had seen 
 many thousand cases of rachitis, and he adds that its spread in the large 
 cities of Northern and Middle Europe is enormous. He states that his obser- 
 vations in regard to the frequency of rachitis in dispensary practice correspond 
 with those of Bitter, as many as 31 per cent, being rachitic. In Manchester 
 also, with its large number of operatives, Ritchie's statistics show that of 728 
 out-door patients 219 were rachitic. The curator of the New York Found- 
 ling Asylum for the last ten years informs me that he believes, without the 
 accuracy of statistics, that as many as 20 per cent of the cadavers examined 
 by him in the dead-house have presented the anatomical characters of rachitis, 
 usually in a mild form. 
 
 The recent large emigration from Europe of destitute families, living from 
 choice or necessity in filth and degradation, who for the most part remain in 
 the cities, occupy small, dark, and dirty apartments, and whose food is of the 
 poorest quality and often insufficient, greatly increases the number of rachitic 
 children in New York and probably in other American cities. In the out- 
 door department of Bellevue, to which many thousand immigrants from the 
 lowest class of European society carry their sick children for treatment, 
 rachitis is not infrequent ; and the fact has been observed in this institution 
 that a larger proportion of severe cases attended by marked deformities occur 
 in the Italian families than in those from other parts of Europe. In families 
 of American parentage it is generally admitted that rachitis is more prevalent 
 in the negro than in the white race. 
 
 Although this disease occurs most frequently in the families of the destitute 
 and poorly feci, nevertheless children of well-to-do families occasionally suffer 
 from it, even in an aggravated form, in consequence, I think, usually of igno- 
 rance on the part of parents in regard to the dietetic requirements of young 
 children. Merei, in his treatise on the Disorders of Infantile Development 
 (London, 1850), states that in Manchester, where his observations were made, 
 one child in every five in comfortable circumstances presented rachitic symp- 
 toms. In the United States, rachitis is rare in well-to-do families, who provide 
 sufficient and suitable diet for their children and have a proper regard for sani- 
 
RACHITIS. 
 
 321 
 
 tary requirements. When it does occur in such, it is due usually. I think, 
 to improper feeding. But this cause will be discussed in another place. 
 
 Diagnosis. — In preparing statistics relating to rachitis it is obviously 
 important that the diagnosis of mild and incipient cases should be clear and 
 unmistakable. What symptoms and anatomical characters indicate rachitis ? 
 The fact that an infant has reached its ninth month without a tooth is regarded 
 by Sir William Jenner as a reliable sign of rachitis. In order to determine to 
 what extent dentition is retarded by rachitis — and retarded dentition may be 
 considered a sign of rachitis — Dr. H. R. Purdy, physician to the Out-door 
 Department of Bellevue Hospital, made the following observations : 
 
 Table I. — Showing at ivhat Age WO Infants exhibiting no 
 cut the First Tooth — cases consecutive. 
 
 3 cut first tooth at 2 months. 
 14 " " " " 3 " 
 
 2g " « « " 4 a 
 
 20 " " " " 5 " 
 24 " " " " 6 " 
 
 37 " " " " 7 " 
 
 28 cut first tooth at 8 months. 
 20 " " " " 9 " 
 24 " « » « 20 " 
 15 " " " " 11 < 
 g « « « a 22 " 
 2 » « « « 23 " 
 
 Of these, 132 were wet-nursed, 68 bottle-fed. 
 
 Table II. — Shaving at what Age 50 Infants exhibiting one or more Rachitic 
 Symptoms cut the First Tooth — cases consecutive (18 wet-nursed, 32 
 bottle-fed). 
 
 2 cut first tooth at 4 months. 
 
 2 « u u « 5 « 
 
 3 u u a u g 
 
 9 it a a a n it 
 
 5 cut first tooth at 8 months. 
 
 6 " " " " 9 " 
 
 7 it (i u a 22 " 
 
 5 " " " " 12 u 
 
 6 cut first tooth at 13 months. 
 3 " " " " 14 
 2 a tt u u 26 « 
 2 tt u a u jg « 
 
 Table III. — Thirty Infants without Teeth, but with pronounced Rachitic 
 Symptoms. (In all these cases the rachitic rosary, enlarged subcutaneous 
 veins, profuse perspirations, abdominal distention, and enlarged joints were 
 present. Bottle-fed, 21 ; wet-nursed, 9. Age at which they cut the first 
 tooth.) 
 
 6 at 7 months. 
 
 1 at 10 months. 
 
 2 at 13 months. 
 
 10 " 8 " 
 
 4 " 11 
 
 2 " 14 
 
 1 " 9 " 
 
 3 " 12 
 
 1 " 15 
 
 It is evident from these interesting statistics that dentition delayed until 
 the ninth, or even the tenth or eleventh month, is not a certain sign of rachitis, 
 but slow teething is common in the rachitic, and therefore it aids in the diag- 
 nosis. It is one of the diagnostic signs. 
 
 In order to determine whether rachitis incipient or of a mild form be present, 
 all the signs which characterize it should be considered — the fretfulness, free 
 perspiration upon the head, neck, face, and chest, the tenderness of surface, 
 anaemia and general deterioration of health, delayed dentition, swelling of the 
 joints, craniotabes, bending of the long bones, rachitic rosary, misshapen head, 
 prominent frontal and parietal bones, deformity of the thorax with depression 
 of the ribs, projecting or misshapen sternum and prominent abdomen, with 
 Harrison's groove. All these signs and symptoms must be considered before 
 making a diagnosis in incipient or mild rachitis. In order to determine 
 the diagnostic value of enlargement of the costo-chondral articulations, "the 
 rachitic rosary," in three of the New York institutions I have examined these 
 joints in children supposed to be healthy or suffering from other ailments than 
 
 21 
 
322 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 rachitis. In many young children believed to be healthy these joints are not 
 appreciable on palpation. In others a slight prominence can be felt in one or 
 more joints. In order that the beading of these articulations be sufficient to 
 indicate rachitis, it should, I think, be plainly detected by the fingers in most 
 of these articulations. Less than this I would not regard as sufficient evidence 
 of this disease. 
 
 Age of Occurrence. — Rachitis is, with few exceptions, a disease of infancy. 
 A large majority of the cases occur before the age of three years. Now and 
 then it occurs in the foetus, producing deformities such as are present in typical 
 cases. In the Kinderspital Museum at Prague is a specimen of foetal rachitis 
 described by Kitter. Hink and Winkler also relate foetal cases, and Virchow 
 alludes to a specimen in the Wurzburg Museum which exhibits such deformities 
 as characterize rachitis. Bednar even regards foetal rachitis as not uncommon 
 (Hillier, Parry). In the Wood Museum of Bellevue Hospital is a skeleton which 
 is probably similar to those in the Prague and Wurzburg museums. It shows 
 in a striking manner the deformities of congenital rachitis. The case occurred 
 in my practice, and the dissection was made by Prof. Francis Delafield. The 
 infant, born at term, died a few hours after birth from atelectasis, apparently pro- 
 duced by the lateral depression of the ribs and contracted state of the thorax. 
 The parents were hard-working English people, whose mode of life and sur- 
 roundings were such as are known to conduce to rachitis. They were free 
 from syphilitic taint. The accompanying wood-cut represents this skeleton. 
 
 The following remarkable case of supposed foetal rachitis was related to me 
 by Dr. Heitzmann, whose interesting experiments will presently be detailed : 
 A woman who had frequently inhaled the vapor of lactic 
 Fig. 1. acid each day for many months, as she was employed to feed 
 
 animals with this agent, gave birth to an infant at term which 
 died immediately after it was born. It exhibited the signs 
 of congenital rachitis in a high degree. The skull-bones 
 were completely absent ; in the cartilages of the bones of 
 the extremities and in those of the ribs there were scanty 
 depositions of lime salts and numerous infarctions. The death 
 of the child was evidently due to the absence of the skull- 
 bones, inasmuch as the pressure upon the head occurring 
 during birth had caused cerebral haemorrhage. The organs 
 of the chest and abdomen were fully developed and normal. 
 In the New York Journal of Obstetrics for Nov., 1870, 
 Dr. A. Jacobi also published the description of a case of 
 congenital rachitic craniotabes. 
 
 Enlargement of the costo-chondral articulations, known 
 as the rachitic rosary, has been observed, though rarely, in 
 infants only a few weeks old. Dr. Parry saw it as early as 
 the sixth week after birth, and Dr. Lee at the third or fourth 
 week. The significance of this enlargement as a sign of 
 rachitis we have treated of elsewhere. We have stated that 
 congenital Rachitis, with few exceptions rachitis begins before the close of the 
 third year. Though first detected and diagnosticated at a 
 later date, it will ordinarily be ascertained, on inquiry, that its symptoms had 
 an earlier beginning. Still, according to certain observers, it may have a con- 
 siderably later commencement. Glisson, Portal, and Tripier state that they 
 have seen it commence in children who were well on toward the age of puberty. 
 Sir William Jenner says that he has seen children of seven and eight years 
 who were only beginning to suffer from rachitis. 
 
RACHITIS. 323 
 
 The following are the aggregate statistics of Bruennische, Von Rittershain, 
 and Eitsche relating to the age at which rachitis occurs : 
 
 No. of Cases. 
 
 During the first half year 99 
 
 " " second half of first vear 259 
 
 " " " vear 342 
 
 " " " third year 134 
 
 " " « fourth year 31 
 
 " " " fifth year 17 
 
 Between the fifth and ninth years 21 
 
 903 
 
 Etiology. — Inheritance. — Some patients with rachitis appear to have 
 inherited a predisposition to it. Feeble digestion and defective assimilation 
 in the infant — which are, as we Ayill see, important factors in producing the 
 rachitic state — are often traceable to disease or cachexia of one or both parents. 
 Among the parental causes may be mentioned poverty, hardships, and defect- 
 ive nutrition of either parent ; age of father and exhausting discharges of the 
 mother, such as purulent, hemorrhoidal, or uterine fluxes. The offspring of a 
 tubercular, syphilitic, or otherwise enfeebled parent is more likely to become 
 rachitic than is one of healthy and robust ancestry. We will especially empha- 
 size the syphilitic dyscrasia in either parent as a potent cause, but M. T. Parrot, 
 in his thesis published in 1872, evidently went too far in attempting to show 
 that congenital syphilis is the common cause of rachitis. Most rachitic cases 
 are entirely free from the syphilitic taint, and a large proportion of the chil- 
 dren who have inherited the syphilitic dyscrasia do not exhibit any signs of 
 rachitis. 
 
 Antihygienic Conditions. — In the damp, dark, filthy, and overcrowded 
 tenement-houses of the city, rickets occurs most frequently and in its severest 
 forms. There can be no doubt that general mal-hygiene is a potent factor in 
 causing this disease, and that it sometimes produces it in those who have inher- 
 ited good constitutions. On the other hand, many children with healthy parent- 
 age and vigorous at birth, reduced by poverty to a life of squalor and privation, 
 do not become rachitic. 
 
 Food. — Of the antihygienic conditions which give rise to rachitis, the most 
 common and potent appears to be the use of food not sufficiently nutritious, or, 
 if nutritious, not suited to the age and digestive powers of the child. The use 
 of thin and poor breast-milk and artificial food of poor quality or not suitable 
 for the stage of growth and development is a common cause of rachitis. Those 
 children who have been prematurely weaned, and who have been given a food 
 which is not a proper substitute for the natural aliment, and those too long wet- 
 nursed by scantily-fed and poorly-nourished mothers, and not allowed the addi- 
 tional aliment which they require, are especially liable to this disease. Those 
 children whose digestive power is feeble, from whatever cause, are more likely 
 to become rachitic than those who in a state of robust health have a hearty 
 digestion. Hence we meet with rickets as a sequel of various protracted and 
 exhausting maladies during infancy. 
 
 I might relate cases of rachitis occurring during the use of certain of the 
 popular proprietary or commercial foods. I have examined the analyses of 
 these foods made by Prof. Leeds in order to determine what ingredient is lack- 
 ing, and they are found to contain a considerably smaller percentage of fat than 
 occurs in human milk. Too little fat in the food may, as Cheadle observes, 
 be one of the chief dietetic causes of rachitis. Infants suckled by healthy 
 mothers or wet-nurses who have an abundance of milk, of good quality, do not 
 become rachitic as long as their nutriment is derived from this source. But 
 
324 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 those prematurely weaned and given a diet deficient in nutritive properties, and 
 those who are allowed the promiscuous food of the table or have largely a fari- 
 naceous diet during the first and second years, when the food should be chiefly 
 milk, are especially liable to become rachitic. 
 
 It is an interesting fact, and one that throws light on the dietetic cause of 
 rachitis, that it does not occur in Japan. Physicians who have had abundant 
 opportunities to observe the diseases of the Japanese state that they have never 
 seen or heard of a case among them. M. Remy, in his Notes Medicales sur 
 le Japon, says that the Japanese women have a remarkable abundance of milk, 
 and that they suckle their young until the age of five or six years, but their 
 children are also given artificial food after the first year. Reniy's explanation 
 of the immunity of the Japanese from rachitis is as follows : " The Japanese 
 have always eaten plentifully of fats and oil of fishes, the blubber of the 
 
 whale, the eel and loach especially The universal use of the food 
 
 under notice from the time of ancient Buddhist flesh-prohibition, but espe- 
 cially the consumption of fish by the lactating women, together with the fish 
 given to the children as supplementary feeding, which at that time is allowed 
 them by Japanese tradition, are, in my opinion, main causes of the non-exist- 
 ence of rachitis in Japan." 
 
 Observations on the feeding of animals have also aided in the elucidation 
 of the causation of rachitis. Guerin gave certain puppies a diet of meat four 
 or five months, and they became markedly rachitic, while other puppies of the 
 same litter, suckled by their mother, remained well. At a meeting of the 
 section of Diseases of Children of the British Medical Association, held in 
 August, 1888, Dr. W. B. Cheadle read an instructive paper on rachitis, in 
 which he said that the results of feeding young animals in the Zoological Gar- 
 dens strongly support the view that a deficiency of animal fats and earthy salts 
 are the most efficient agents in producing rickets. He states that in the Zoo- 
 logical Gardens the young monkeys taken from their mothers and fed with a 
 vegetable diet, chiefly fruits, became rachitic. Such diet is destitute of animal 
 fat, and is deficient in proteids and earthy salts. Two young bears were fed 
 with rice biscuits, and occasionally with lean meat, which they licked, but rarely 
 ate. Fat, proteids, and lime salts were practically excluded from their food. 
 The bears died of extreme rickets while still young. Cheadle also states that 
 more than twenty litters of lions had died successively of rachitis, and the 
 next brood were fed with cod-liver - oil, pulverized bones, and milk. In three 
 months all signs of rickets had disappeared. The addition of fat and bone- 
 salts caused the change, and after eighteen months, when the last observa- 
 tions were made, the brood of young lions were strong and healthy. They had 
 received in every respect the same treatment as the litters that had perished, 
 except as regards the diet. The latter had been fed with the carcasses of old 
 horses, which are destitute of fat and whose bones resisted the lions' teeth. 
 
 The theory that lactic acid is the causal agent in rachitis has been strongly 
 advocated by Dr. C. Heitzmann, formerly of Vienna, but now of New York. 
 He administered lactic acid by mouth and subcutaneous injection to five dogs, 
 seven cats, two rabbits, and one squirrel. The lactic acid administered to the 
 dogs and cats, with "restricted administration of calcareous food," produced 
 the characteristic enlargement of the epiphyses, and finally the " curvatures 
 of the bones of the extremities." After four or five months of administration 
 of lactic acid the long bones were very flexible, and repeated inflammations 
 of the conjunctiva, bronchi, stomach, and intestines had occurred. 
 
 But in many cases of rachitis there is no evidence of an excess of lactic 
 acid, and an objection to the lactic-acid theory apparently valid is that lactic 
 
RACHITIS. 325 
 
 acid, produced by imperfect digestion, would unite with a base, either the 
 soda or potash in the blood, which is always alkaline, before it reached the 
 osseous system. The more the causation of rachitis is elucidated by observa- 
 tions on man and experiments on animals, the stronger is the evidence that 
 its chief cause is dietetic — that there is a failure to receive or to digest and 
 assimilate certain important substances in the food, particularly the fat, phos- 
 phate of lime, and proteids. The deprivation of these alimentary substances 
 produces the rachitic dyscrasia, which is manifested by malnutrition in many 
 tissues. Of course general antihygienic conditions, which lower the vitality, 
 may, as we have stated elsewhere, be a factor in causing rachitis. 
 
 Pathology. — Distinguished pathologists and clinical observers who have 
 investigated rachitis, and whose investigations have been chiefly, if not entirely, 
 restricted to the osseous system, have regarded this disease as an inflammation 
 affecting the bones and cartilages. Among those who have expressed this 
 opinion may be mentioned Yirchow and Niemeyer. Niemeyer says : " It seems 
 to me that the most probable hypothesis regarding the cause of rachitis is that 
 which refers it to inflammation of the epiphyseal cartilages and periosteum." 
 The increased vascularity of the periosteum, the proliferation of periosteum 
 and cartilage, the tenderness and pain on motion, and the elevation of tem- 
 perature in acute forms of the disease, indicate inflammation rather than any 
 other recognized pathological state. If the rachitic disease of the osseous 
 system be regarded as an inflammation, it obviously presents a subacute or 
 chronic character, like cirrhosis and certain forms of chronic nephritis, in 
 which proliferation of connective tissue and sclerosis occur. The eburnation, 
 instead of normal ossification, which terminates the rachitic process, might be 
 considered an osteosclerosis. Moreover, the thickening, hyperemia, and infil- 
 tration of the periosteum, exudation and formation of new vessels in the peri- 
 osteum and underlying cartilaginous and osseous tissues, are conformable with 
 the theory of the inflammatory nature of rachitis. On the other hand, some 
 of the structural changes in the soft tissues in rachitis which are described in 
 this paper are not such as ordinarily result from inflammatory processes. Bill- 
 roth, seeing the difficulties in the way of the inflammatory theory, wrote of 
 rachitis that it " cannot be exactly classed among the chronic inflammations, 
 although nearest related to this process." It seems most in consonance with 
 the facts to regard rachitis as a constitutional or general disease, a dyscrasia 
 affecting the nutrition of various tissues of the body, and producing disease in 
 the osseous system which is either inflammatory or closely allied to inflammation. 
 
 Changes in the Soft Tissues. — We have stated that although the con- 
 spicuous lesions of rachitis pertain to the skeleton, the soft tissues are also 
 more or less implicated, as might be expected, since the disease is systemic in 
 its nature. The skin in mild cases is but little involved, but as a rule the per- 
 spiration of the rachitic is excessive from the head, face, neck, and chest. 
 This may occur before changes are observed in the skeleton. Pyrexia is in 
 some patients absent or slight, but catarrhs of the mucous surfaces are common, 
 and these are likely to give rise to some elevation of temperature. The fever 
 that frequently accompanies severe cases may sometimes result from the disease 
 of the skeleton. In protracted and severe cases the patients become mark- 
 edly anaemic, but in recent and mild cases the pallor may be so slight as not to 
 attract attention. Emaciation is not pronounced, as a rule, in the rachitic. 
 but in certain patients the muscles throughout the system become shrunken 
 and flabby, partly perhaps in consequence of the gastro-mtestinal disorder, 
 indigestion, and malnutrition, partly perhaps from want of use, for the rachitic 
 are likely to be passive. 
 
326 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Mucous Membranes. — Rachitis, as we have stated above, increases the 
 liability to catarrh of the mucous surfaces. Writers on this disease have 
 remarked the frequent occurrence of bronchitis, broncho-pneumonia, entero- 
 colitis, and conjunctivitis. 
 
 Ligaments. — The ligaments become relaxed and flabby, giving unusual 
 mobility to the joints and unsteadiness to the movements. The fibrous bands 
 which unite the vertebrae, as well as the ligaments of the extremities, participate 
 in the relaxation. Talipes valgus and knock-knee are especially likely to occur 
 in rickets as a result of the relaxation of ligaments, even when the bones are 
 but slightly involved. Kyphosis, lordosis, and scoliosis — backward, forward, 
 and lateral curvatures of the spine — also result from relaxation of the liga- 
 ments, aided by the softening and change in shape of vertebrae and of the 
 intervertebral cartilages. 
 
 The Spleen and Liver. — The spleen is sometimes enlarged, as ascer- 
 tained by palpation and percussion. Hitter von Rittershain found this organ 
 decidedly enlarged in 10 out of 35 cases which he examined after death. The 
 enlargement is the result of cellular proliferation, common in diseases which 
 are attended by a dyscrasia. In a recent very anaemic and fatal case of rachitis 
 in the New York Foundling Asylum the spleen extended below the level of 
 the umbilicus. But in many cases of rachitis, even when profound, splenic 
 enlargement is slight or is not appreciable. 
 
 The liver in many patients undergoes no perceptible change, except that it 
 is carried downward by the lateral depression of the ribs. It is occasionally 
 enlarged from fatty infiltration, but no special significance attaches to this, for 
 fatty liver is common in various forms of disease attended by innutrition and 
 wasting. It is common in tuberculosis and in protracted intestinal catarrh, and 
 its pathological significance appears to be the same in these various diseases. 
 There can be no doubt that Sir William Jenner errs when he states that albu- 
 minoid infiltration of the liver is common in rachitis. Parry, Gee, Dickinson, 
 and Senator agree that it is rare, and that when it does occur it is a coincidence. 
 
 In the discussion of rickets at the meeting of the British Medical Asso- 
 ciation in August, 1888, Dr. Ranke of Munich said that, according to the 
 records of 34 post-mortem examinations of rachitic cases in Yirchow's Patho- 
 logical Institute between 1872 and 1880, 13 exhibited changes in the liver, 
 mostly parenchymatous fatty infiltration with increase of volume. In the 34 
 cases the spleen was recorded enlarged in 9 and small in 2. In the remaining 
 23 cases the size and appearance of the spleen were probably normal, or some 
 mention would have been made of it. Dr. Ranke also consulted the records 
 of the Munich Pathological Institute under Professor Bollinger, and in 9 of 
 25 post-mortem examinations of rachitic cases more or less enlargement of the 
 liver was recorded. We may therefore infer from these carefully conducted 
 examinations that enlargement and structural changes of the liver and spleen 
 only occasionally occur in rachitis — that in the majority of cases this disease 
 runs its course without any notable alteration in these organs. My own 
 observations lead me to believe that hypertrophy of the spleen, and probably 
 also of the liver, occurs chiefly in decidedly anaemic subjects. 
 
 The Abdomen is Protuberant from various causes. The lateral depres- 
 sion of the thoracic walls causes the liver and spleen to descend a little lower 
 in the abdominal cavity than natural, producing at the base of the chest 
 anteriorly Harrison's groove, which is transverse and corresponds with the 
 insertion of the diaphragm. The enlargement of the liver and spleen, the 
 feeble tonicity of the intestinal muscular fibres, and consequent distention 
 of the intestines with gas, and the rachitic shortening of the spinal column, 
 
RACHITIS. 327 
 
 which causes approximation of the ribs and pelvis, necessarily produce abdom- 
 inal protuberance. 
 
 The Kidneys and Urine. — Observations thus far have not detected any 
 structural change or disease of the kidneys attributable to rachitis, except that 
 this organ is enlarged in some cases. Moreover, the records of the urine are 
 so conflicting that more exact and more numerous examinations of this excre- 
 tion are required before any positive statement can be made in reference to its 
 composition. Dr. C. H. Flagge has seen two cases in which there were large 
 quantities of uric acid in the urine. Ephraim also mentions an increased elimi- 
 nation of uric acid up to 18 per cent. Ephraim likewise, as well as Marchand 
 and Lehmann, state that there is an increase of phosphate of lime and the 
 occurrence of lactic acid in the urine. 
 
 Brain and Spinal Cord. — It is not improbable that the symptoms of 
 rachitis which are referable to the nervous system, such as laryngismus strid- 
 ulus, tetany, convulsions, and weakness or paralysis of the extremities, may 
 be largely due to the pressure exerted in places upon the cerebro-spinal axis 
 by its bony covering. Hence we will postpone their consideration until we 
 have described the changes produced by rachitis in the osseous system. 
 
 Changes in the Osseous System. — A knowledge of the normal anat- 
 omy and normal development of the osseous system will enable us to better 
 understand the changes which occur in this system in disease, and especially, 
 which concerns us at present, in rachitis. Hence we will give a brief resume 
 of the anatomy of the skeleton in health before we consider the changes pro- 
 duced in it by rachitis. 
 
 Osseous System in Health. — In health and when fully developed, bone 
 consists of animal matter (chiefly gelatin) and earthy salts, in the proportion, 
 by weight, of about one part of the former to two of the latter. The following 
 is the analysis, which may be regarded as approximately correct, of healthy 
 human bone of the adult: 
 
 Animal matter 33.30 
 
 f Tribasic phosphate of calcium 51.04 
 
 | Carbonate of calcium 11.30 
 
 Earthy salts, -{ Fluoride of calcium 2.00 
 
 | Phosphate of magnesium 1.16 
 
 L Soda and chloride of sodium 1.20 
 
 100.00 
 
 In childhood the bones are softer, more elastic, and less likely to fracture than 
 in the adult. Of the earthy salts in bone, it is seen that the phosphate of cal- 
 cium is the most abundant, and it is the most important. Hence it is termed 
 "bone earth." The phosphate of calcium, combined with animal matter, pro- 
 duces a hard compound. The enamel of the tooth consists chiefly of phos- 
 phate of calcium (88J per cent.), while the softer egg-shell consists chiefly of 
 the carbonate of calcium. The strength of bone is remarkable, being, according 
 to Holden, when compared with wood, nearly three times that of the elm or ash, 
 and double that of the oak. It is elastic on account of the animal matter 
 which it contains. If a long bone be placed at right angles upon a hard sub- 
 stance, and the projecting end receive a blow from a hammer, the latter will 
 rebound. The Arab children are said to make bows of the camel's ribs. 
 
 If a longitudinal section be made through a long bone, we observe a hard 
 or compact outer part, and in the interior the medullary canal, containing mar- 
 row. In birds of flight the hollow of the bones contains air instead of mar- 
 row, and this air communicates with the lungs. 
 
328 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The hard or compact portion of bone, though solid like a stone, consists of 
 layers in close apposition, so that there is no interval between them. On 
 approaching the joints the internal layers of the compact structure separate 
 from each other, forming the cancellous tissue, so that the compact wall becomes 
 thinner. If the earthy salts be removed by an acid, the animal matter remain- 
 ing is found to consist of layers, which can be separated from each other. In 
 inflammation the afflux of blood and the exudation cause separation of the 
 layers and enlargement of the bone. 
 
 The cancellous tissue occupies the interior of the bone, and is most abun- 
 dant in its articular ends. The bony layers in the cancellous structure are 
 separated from each other, so as to form cavities, which are strengthened by 
 cross-plates like latticework. In the adult the marrow in the interior of the 
 shafts of the long bones is yellow, consisting of 96 per cent, of fat, but in the 
 articular ends of the long bones, in the ribs, cranial bones, and short bones, the 
 marrow has a reddish tinge, and it consists of about 75 per cent, of water and 
 about 25 per cent, of albumin, without fat or only a trace of it. This kind 
 of marrow occurs in all the bones of the foetus and the infant, and it contains 
 cells with many nuclei, designated " myeloid cells." Holden says that bones 
 are as minutely provided with blood r vessels and nerves as are the soft tissues. 
 Near the extremities of the long bones are numerous minute openings through 
 which blood is conveyed to and from the cancellous tissue. On the shafts of 
 the long bones are slight grooves parallel with the shafts, at the bottom of 
 which are minute holes, scarcely visible, through which blood is conveyed to and 
 from the compact tissue. The blood which supplies the osseous tissue is con- 
 veyed through these holes by minute arteries from the vessels of the periosteum, 
 and is returned by veins to the periosteum. Near the middle of the shaft of the 
 long bone is a distinct canal passing obliquely through the shaft. This canal 
 contains the nutrient artery of the medulla, dividing, after entering the medul- 
 lary cavity, into two branches, one passing upward and the other downward. 
 The blood-vessels supplying the different parts of the bone from these various 
 sources intercommunicate. Other bones than the long bones are supplied with 
 blood in a similar manner, and the nutrient vessels are accompanied by nerves, 
 as in other parts of the system. 
 
 The microscope is required in order to reveal the minute anatomy of bone. 
 It is found to consist of canals, termed the Haversian, and around each canal 
 the bone is arranged in concentric layers, like the concentric rings of a tree. 
 Between the rings are dark spots, designated lacunae, arranged concentrically, 
 now known to be minute reservoirs containing blood. Minute lines are seen 
 connecting the reservoirs with each other and with the adjacent Haversian 
 canal. The lines are minute blood-vessels, and through them the blood is con- 
 veyed to every part of the bone. They are designated canaliculi. They con- 
 nect externally with the vessels of the periosteum, and internally with the 
 vessels of the medullary membrane or endosteum. In the interspaces between 
 the lacunae and canaliculi, in the animal matter, an infinite number of osseous 
 granules is deposited, consisting mainly of phosphate and carbonate of lime. 
 
 Alterations in the Osseous System in Rachitis. — For convenience of descrip- 
 tion the course of rachitis as regards the osseous system is divided into 
 three periods : (1) That of proliferation and altered nutrition of cartilage and 
 periosteum; (2) That of curvature and deformity; (3) That of reconstruc- 
 tion. 
 
 1. Anatomical Characters in the Stage of Proliferation and Altered 
 Nutrition. — The long bones in normal growth increase in length by the 
 formation of bone in the cartilage between the diaphysis and epiphysis, and 
 
BACHITIS. 329 
 
 in thickness by the development of bone from the vascular and cellular under- 
 surface of the periosteum. As regards the flat and short bones, growth in 
 the thickness occurs from the periosteum, and growth in breadth occurs from 
 the development and ossification of the cartilaginous borders and edges, which 
 correspond with the epiphyseal cartilage of the long bones. 
 
 If we examine the epiphyseal cartilage of a long bone during normal ossifi- 
 cation, we observe, beginning at the distal end, a white zone, consisting of the 
 hyaline matrix, in which are the usual cartilage-cells. This constitutes most of 
 the cartilage. Underneath this, and nearer the bone, is the zone of prolifer- 
 ation, the cartilage in which is softer and more yielding than that of the distal 
 zone, in consequence of cell-formation and absorption of the matrix to make 
 way for cell-groups. Each cell in the proliferating zone has divided into 
 two cells, and each of these cells into two other cells ; and the division has been 
 repeated, so that eight cells instead of one are observed, surrounded by a com- 
 mon capsule. The capsule becomes distended by the cell-multiplication and 
 the swelling of each cell, the size of which is considerably greater than that of 
 the parent cell. Near the bone, along the extremity of the diaphysis, the cell- 
 groups, enclosed in their capsules, nearly touch each other, the matrix having 
 been for the most part absorbed. The end of the diaphysis is covered with a 
 layer of these cell-groups about to undergo ossification, with almost no inter- 
 vening matrix. The proliferating zone has very little depth. It appears to the 
 naked eye as a very thin, scarcely perceptible layer of a reddish-gray color 
 upon the end of the shaft. It is so thin that it but slightly increases the thick- 
 ness of the cartilage. 
 
 In rachitis the state is different. The zone of proliferation, instead of 
 being confined to a single or at most double layer of cell-groups, consists of 
 many layers, involving nearly the whole epiphyseal cartilage. The cells, still 
 enclosed in their capsules, undergo a more frequent division than in health, so 
 that, instead of groups of eight cells, as in the normal state, each group con- 
 sists of thirty or forty cells enclosed in the distended capsule. Therefore in 
 rachitis the proliferating cartilaginous zone is a broad cushion, very soft, of a 
 grayish translucent appearance, causing the characteristic swelling observed 
 around the joint. Over the distal end of the proliferating cartilage there may 
 still be a zone, though perhaps of little depth, of normal cartilage like that in 
 health. 
 
 While the changes described above occur in the cartilages, the ossifying 
 process is arrested or rendered abnormal. We indeed perceive an effort in the 
 direction of bone-formation. The Haversian canals, surrounded by capillary 
 loops, extend from the bone into the proliferating zone of cartilage. Their 
 extension is effected by absorption of the matrix and appropriation of cell- 
 groups which lie in their way. The cells in these groups, as they enter the 
 Haversian system, become much smaller by rapid segmentation, forming medul- 
 lary cells. We also find, as further evidence of the attempt at bone-formation, 
 granules and masses of lime scattered through the cartilage, and here and there 
 spiculae and nodules of true bone springing up from the bony substance of the 
 shaft. Some of the canals are prolonged far into the cartilage — nearly, indeed, 
 to its free surface — but most of them terminate in its lowest portions. 
 
 We have stated that the growth of bone in thickness occurs from the under 
 surface of the periosteum. In health a soft, vascular germinal tissue springs 
 from the periosteal surface, rapidly receives lime salts, and is transformed 
 into bone. This germinal tissue, consisting largely of capillaries rising from 
 the fibrous tissue of the periosteum, is a very thin substance, barely visible, 
 transient, and constantly changing from its conversion into bone. 
 
330 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 In rachitis this vascular subperiosteal tissue, not undergoing, or undergoing 
 slowly and imperfectly, the osseous transformation, and at the same time increas- 
 ing more rapidly than in health under the irritating influence of the rachitic 
 disease, becomes a thick layer. Its color and appearance are like spleen-pulp, 
 so that the older observers supposed that there was hemorrhagic extravasation 
 between the periosteum and the bone. There is, however, no extravasation of 
 blood, unless it accidentally occurs from the numerous delicate capillaries. 
 The resemblance to extra vasated blood or spleen-pulp is due to the abundant 
 growth of large and thin-walled capillaries from the under surface of the perios- 
 teum, as shown by the microscope. This vascular outgrowth is, for the most 
 part, quite uniform over the shafts of the long bones, while upon the cranial 
 bones its thickness is much greater in one locality than in another. The 
 attempt at ossification also appears in this tissue. Lime salts are scantily and 
 loosely deposited through it, forming osteophytes, vascular and fragile, rather 
 than true bone. The question naturally arises, How does rachitis affect bone 
 which is already formed when the rachitic state begins ? Virchow's answer is 
 the following: "Rachitis has by more accurate investigation been shown to 
 consist, not in a process of softening in the old bone, as it has previously been 
 considered to be, but in a non-consolidation of the fresh layers as they form : 
 the old layers being consumed by the normally progressive formation of medul- 
 lary cavities, and the new remaining soft, the bone becomes brittle." 
 
 We have seen that in healthy bone the earthy salts are in excess of organic 
 matter nearly in the proportion of two to one, but in rachitis the proportion is 
 reversed, the organic matter being much in excess. The following table gives 
 analyses of rachitic bones by Marchand, Davy, Boettger, and Friedleben : 
 
 
 Femur. 
 
 Radius. 
 
 Vertebra. 
 
 
 Inorganic. Organic. 
 
 Inorganic. Organic. 
 
 Inorganic. Organic. 
 
 Case I. . . 
 
 . . 20.60 74.40 
 
 21.24 78.76 
 
 18.68 81.32 
 
 Case II. . . 
 
 . . 37.80 62.20 
 
 20.00 80.00 
 
 32.29 67.71 
 
 Caselll. . 
 
 . . 20.89 79.11 
 
 
 
 Case IV. . 
 
 . . 52.85 47.15 
 
 
 
 As might be expected, the relative proportion of the inorganic matter (the 
 earthy salts) and the organic matter varies greatly in different cases. In severe 
 rachitis many bones are affected. It is stated that there is no bone in the 
 entire skeleton that may not suffer, but in mild cases only a few are involved, 
 at least to such an extent as to produce structural changes appreciable to touch 
 or sight. 
 
 Rachitic bone, when the disease is still in its active period, presents a bluish 
 or dusky-red appearance from its increased vascularity. After a variable time 
 — weeks or months according to the severity of the disease — deformities begin 
 to appear. 
 
 2. Anatomical Characters of the Stage of Deformity. — Characters 
 or the Rachitic Fcetus. — Spiegelberg's description of the rachitic foetus cor- 
 responds for the most part with what I observed in the one whose skeleton 
 is represented in a foregoing page: According to this writer, the body and 
 limbs are plump, the latter short and curved, the abdomen large and prominent, 
 and the head sometimes hydrocephalic. The skin is well developed and mov- 
 able, the adipose tissue sufficient, the liver large, the epiphyses swollen and 
 soft, the short and curved diaphyses sometimes broken ; the rotundity of the 
 thorax is preserved, and the sternum is not carried forward, since there has 
 been no respiration. The ribs in softness and liability to fracture correspond 
 with the long bones of the extremities. The sternum, most of all the bones, 
 
PLATE XI. 
 
 RACHITIS. 
 
RACHITIS. 331 
 
 shows the delay in ossification ; the clavicle is among those least affected. The 
 cranium may be represented by a membranous bag with plaques of bone, or 
 the cranial bones may be formed and in shape, but thickened and softened ; 
 the sacral promontory is pressed forward and downward; the ilia flattened 
 and widened ; the pubic arch increased. 
 
 Characters of the Rachitic Child. — In typical rachitis the bone sel- 
 dom retains its normal form or shape : its projecting points are rounded, and 
 as soon as it softens it begins to yield to pressure exerted upon it. Hence the 
 curvatures so common and characteristic. The portion of a long bone which 
 is formed after rachitis commences contains so little earthy matter that it bends 
 readily in its fresh state either by muscular action or by the weight of the 
 trunk " in the manner," says Vogel, " of a quill or willow stick." The interior 
 of the bone, which was formed before rachitis began, and which contains nearly 
 or quite the normal proportion of lime, is likely to break instead of bending, 
 but, as it is surrounded on all sides by the soft tissue, the fragments are not 
 displaced, and probably do not crepitate. So scanty is the calcareous deposi- 
 tion in typical cases that, says Trousseau, " the bones .... can be cut 
 with a knife with as much ease as a carrot or other soft root," and the dried 
 specimen weighs from one-sixth to one-eighth of the weight of normal bone. 
 One writer states that the dried rachitic bone is sometimes so porous from the 
 small amount of lime which it contains that it is possible to respire through it 
 as through a sponge. 
 
 In ordinary cases the bones which exhibit most strikingly the rachitic 
 change, and which, therefore, should be examined carefully in making the 
 diagnosis, are the cranial bones, the ribs, and the radius — the sternal ends of 
 the ribs and the lower end of the radius. It is seldom that these bones do not 
 give evidence of the disease if it be present, and in greater degree than other 
 bones. They are the first to be affected to an extent that is appreciable to the 
 observer. 
 
 Changes in the Cranial Bones. — In these bones interesting and important 
 alterations occur. Their edges, which correspond with the epiphyseal cartilages 
 of long bones, undergo proliferation, and become thickened like the latter. 
 This thickening and the delayed union of the sutures produce grooves which 
 can be traced by the fingers between the bones, and which are sometimes 
 appreciable to the sight. Rachitis causes enlargement of the cranium, but the 
 enlargement seems greater than it really is, on account of the retarded growth 
 of the facial bones. In a discussion on rachitis in the London Pathological 
 Society, reported in the London Lancet (1880, ii, 1017), it was stated that in 
 seventeen rachitic children with an average age of 4.72 years, the average cir- 
 cumference of the head was 21. 22. inches, while in the same number who were 
 non-rachitic, and whose average age was 6.05 years, the average circumference 
 was 19.95 inches. The retarded ossification is manifested not only in the open 
 sutures, but also in the large size and patency of the fontanelles, which are not 
 closed until long after the usual time. The anterior fontanelle in the healthy 
 infant is closed at about the fifteenth or sixteenth month, but in the rachitic it 
 remains membranous a longer time : in some cases it is still membranous as late 
 as the third or fourth year. Since examination of the anterior fontanelle aids in 
 determining whether or not rachitis be present, it should be borne in mind that 
 in the normal state this space increases in size till the seventh month, when it 
 is at its maximum, and that after the ninth month it becomes progressively 
 smaller. Ossification in severe rachitis is retarded for a longer period than is 
 stated above, for Gerhard relates a case in which the anterior fontanelle had not 
 entirely closed at the ninth year. 
 
332 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The shape of the rachitic head varies. In general, instead of its normal 
 rounded form it approaches a square shape. Another type is sometimes observed 
 in which there is no marked angularity, but in which the antero-posterior diam- 
 eter is enlarged. In the square head the forehead projects, and both the frontal 
 and parietal protuberances are unusually prominent. The sutures are depressed 
 to a certain extent, as has already been mentioned, and the anterior, lateral, 
 superior, and posterior surfaces are more flattened than in health. The undue 
 prominence of the frontal and parietal eminences is largely due to the exaggerated 
 proliferation of the periosteum and to the vascularity and infiltration under- 
 neath. Enlarged veins are seen ramifying in the scalp, which in marked rachi- 
 tis supports a scanty growth of hair. The free perspiration from the scalp, and 
 in some cases the activity of its sebaceous follicles, will be mentioned elsewhere. 
 
 Craniotabes. — Thinning of the cranial bones in places, so that the brain 
 lacked proper protection, had long been noticed in the examination of rachitic 
 heads, but the injury that resulted to the infant was overlooked until pointed 
 out by Elsasser. Craniotabes occurs for the most part in infants under the age 
 of one year, and a large proportion are under eight months. Its occurrence in 
 the foetus, as shown by a case published in the New York Obstetrical Journal 
 in 1870, and by Heitzmann's case, has already been alluded to. The factors 
 in producing this thinning are rachitic softening of the bones and pressure from 
 the brain within and from the pillow without. Consequently, the portions of 
 the cranium in which the thinning is most pronounced are the posterior and 
 lateral, the occipital bone and the posterior half of the parietal. If the 
 infant lie in its crib chiefly on one side, on this side the craniotabes occurs, 
 while those portions of the cranium which are not pressed upon exhibit no 
 thinning or a less degree of it. The soft spots in the cranium are yielding 
 when pressed upon, and in the cadaver they are seen to be translucent when 
 the bone is held to the light. There are in some instances simple depres- 
 sions like erosions in the bone, a continuous but thin bony layer remain- 
 ing. In other cases, such as have been particularly examined and studied by 
 physicians, the bony absorption has been complete over areas of greater or less 
 extent. On examining a child for craniotabes it should be borne in mind that 
 the margins of the cranial bones, even when there is no thinning, but thicken- 
 ing from the cartilaginous proliferation, are flexible in the rachitic. The pres- 
 sure must be made in a direction away from the sutures to ascertain whether 
 craniotabes has occurred. The pressure should at first be made lightly and 
 cautiously with the fingers, for if there be total absence, unless of very little 
 extent, deep and forcible pressure might injure the brain, since so soft and del- 
 icate an organ, covered only by scalp and dura mater, badly tolerates pressure. 
 If the first examination detect no soft place, the fingers may be pressed more 
 firmly against the scalp, when, if the bone be much thinned, so that there is 
 only a small layer of lime salts underneath, it will be found to yield. The sen- 
 sation communicated to the fingers when there is an open space in the cranium, 
 and the dura mater and scalp are in contact, has been likened to that expe- 
 rienced when pressing upon a fully-distended bladder. At a meeting of the 
 London Pathological Society, reported in the Lancet for November, 1880, Dr. 
 Lees presented statistics to show that craniotabes is one of the lesions of inher- 
 ited syphilis ; but whether it does sometimes result from inherited syphilis or 
 not, the evidence that there is a cranial softening which is strictly rachitic, and 
 which occurs in those who have not inherited syphilis, appears from reported 
 observations to be conclusive. 
 
 Changes in the Vertebroe, etc. — The short bones which participate in 
 the rachitic disease become softer and more yielding, and their cancelli are filled 
 
RACHITIS. 
 
 333 
 
 with a reddish pulpy substance. In many rachitic cases the vertebrae are but 
 slightly involved, so that no deformity of the spinal column results ; but occa- 
 sionally, "when many bones are affected, the vertebrae and intervertebral carti- 
 
 Fig. 2. 
 
 Head of a Rachitic Child in the New York Infant Asylum. This child also had laryngismus stridulus. 
 
 lages soften, and spinal curvatures result. The curvatures are due to the weight 
 of the shoulders and head on the spinal column. They are, with some devia- 
 tions, an exaggeration of those present in the normal 
 state. Rachitic curvatures of the spinal column are Fig. 3. 
 
 therefore mainly antero-posterior, often with more or 
 less lateral deflection. When there is much curvature 
 the vertebrae become wedge-shaped, narrowed upon the 
 concavity and thickened upon the convexity. The in- 
 tervertebral cartilages are also more or less changed 
 by the pressure, being thinned where the vertebrae 
 approximate to each other on the concave aspect of 
 the curvature, and of normal thickness or thicker 
 than normal upon the convexity. The accompany- 
 ing wood-cut exhibits the appearance and nature of 
 
 rachitic spinal curvature continuing into adult life. 
 Rachitis, having occurred at the usual age, resulted 
 in the permanent deformity here illustrated. 
 
 In extreme cases, fortunately rare, the functions 
 of important organs may be seriously impaired by 
 the curvature and consequent compression, as they are 
 in Pott's disease. Thus, according to Miller, the aorta 
 has been so doubled upon itself as to materially dim- 
 inish the flow of blood to the lower extremities, so that 
 their nutrition was sensibly impaired. The effect of so 
 great curvature upon the heart and lungs must obvi- 
 ously be detrimental. At first the spinal curvatures 
 disappear when the child reclines or is lifted by the 
 axillae so as to raise the head and shoulders from the spine ; but when the 
 deformity has continued so long that the vertebrae and cartilages have become 
 
 Rachitic Spinal Curvature in 
 an Adult (from a specimen 
 in the Wood Museum, Belle- 
 vue Hospital). 
 
Fig. 4. 
 
 334 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 wedge-shaped, it remains for life or can only be rectified slowly and with 
 difficulty by mechanical appliances. As seen in the wood-cut, the common 
 curvature in the dorsal region is backward (kyphosis), while to compensate 
 the patient instinctively carries the neck forward, with the head thrown back, 
 causing cervical lordosis, a similar anterior curvature being common in the 
 lumbar region. Lateral curvature (scoliosis) may or may not be present even 
 when there is considerable antero-posterior flexure. Scoliosis is sometimes 
 produced by the nurse in carrying the infant habitually over one arm. 
 
 Changes in the Maxilla?. — Fleischmann has investigated the changes 
 which rachitis produces in the maxillary bones. Stunted growth of the facial 
 bones, generally, has long been known, and has been remarked upon by various 
 writers ; but, according to Fleischmann, other interesting changes occur in the 
 jaw-bones which affect the direction and position of the teeth. According 
 to this observer, the arched shape of the lower jaw becomes polygonal, and the 
 direction of. its alveoli also changes, so that they incline inward. This devi- 
 ation in the arch and in the alveolar border of the lower jaw, which begins in 
 the region of the canine teeth, necessarily causes softening of the jaw. Com- 
 mencing soon after, a change is observed in the upper jaw-bone from the zygo- 
 matic arch forward, so as to cause length- 
 ening of this bone, changing the shape of 
 the arch and the position of the teeth. 
 The external incisors, instead of being 
 in front, have a lateral position, and 
 when the jaws are closed the superior 
 incisors and molars overlap the corre- 
 sponding teeth of the lower jaw in front 
 and upon the sides — a condition opposite 
 to that seen in the jaws of old people. 
 Fleischmann attributes these changes in 
 the lower jaw to the action of the mas- 
 seter and the mylo-hyoid muscles, and 
 perhaps the genio-glossus, and to pressure 
 of the lip, the deficiency of earthy salts 
 in the bone rendering it more easily 
 acted on by the muscles. The change 
 in the upper jaw-bone he attributes 
 largely to lateral pressure of the zygo- 
 matic arches. 
 
 Changes in the Ribs. — The ribs are 
 easily affected in rachitis. The swell- 
 ing of their anterior ends, where they 
 unite with the costal cartilages, pro- 
 ducing the "rachitic rosary," has been 
 already alluded to as one of the first 
 and most conspicuous signs of rachitis. The costochondral articulations are 
 enlarged in all directions, appearing as nodules under the skin. If at an 
 autopsy an opportunity of inspecting the pleural surface of the articulation 
 occur, the nodular prominence is seen to be even greater and more distinct 
 than under the skin (Fig. 4). 
 
 The deformity of the thorax, consequent upon softening of the ribs, is 
 interesting. Commencing with the spine, the ribs extend nearly directly out- 
 ward : at the union of the dorsal and lateral portions they make a short curve 
 forward and then turn inward, also with a short curve, toward the sternum 
 
 
 Rachitic Child with characteristic deformity of 
 head and ribs. (From a patient in the New 
 York Foundling Hospital). 
 
RACHITIS, 
 
 335 
 
 (Fig. 5). This abrupt bending of the ribs, which in their softened state has 
 been caused by atmospheric pressure during respiration, produces a depress- 
 ion in the thoracic wall at about the point where the ribs and their cartilages 
 unite. A groove extends on the antero-lateral aspect of the thorax from the 
 second or third rib downward and a little outward. In some cases the costo- 
 chondral articulations are in the line of greatest depression in the thoracic 
 walls ; in other cases they are a little inside or outside of the deepest part of 
 the groove. The transverse diameter, therefore, of the anterior half of the 
 thorax is less than that in the normal rotund form of health. This neces- 
 sarily diminishes the antero-lateral expansion of the lungs in inspiration and 
 causes unusual prominence of the sternum. Hence the expressions " pigeon- 
 breasted," "resemblance to the prow of a ship," etc. applied to this deformity. 
 The presence of the heart renders the depression or groove less on the left 
 side between the fourth and sixth ribs than on the opposite side, since this 
 organ affords partial support to the chest-wall. On the other hand, the depres- 
 sion on the right side below the sixth or seventh rib is, on account of the 
 support given by the liver, less than on the left side. But on the left side, 
 as well as on the right, the lower part of the thorax, that below the eighth 
 or ninth ribs, widens, being pressed outward and supported by the abdominal 
 viscera. This gives rise to an antero-lateral furrow or groove near the base 
 of the chest, sometimes designated Harrison's groove. 
 
 The ribs with their attached muscles are important agents in respiration, 
 but their soft and yielding nature in the rachitic retards, and to a great 
 
 Fig. 5. 
 
 Deformity of Chest in Kachitis. 
 
 extent prevents, the lateral expansion of the thorax which is necessary for 
 normal and full inspiration. The action of the respiratory muscles and the 
 pressure of the air from within descending along the air-passages is not suffi- 
 
336 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cient to fully overcome the external atmospheric pressure in the absence of the 
 proper resiliency of the ribs. Consequently with each inspiration we observe 
 more or less sinking of the thorax on each side, just as when a moderate 
 obstruction to the entrance of air exists in the larynx or trachea. As the 
 ribs become firmer from the deposit of lime salts, respiration is more regular 
 and normal. 
 
 Changes in Bones of Upper Extremities. — Although swelling of the 
 lower end of the radius is one of the earliest signs of rachitis, the bones of 
 the upper extremities are less frequently curved and distorted than those 
 of the lower extremities. The clavicle sometimes softens and bends, pro- 
 ducing two curvatures — one backward near the scapula, and another, of larger 
 radius, nearer the sternum, directed forward and a little upward. Careful 
 examination shows, in some rachitic patients, thickening of the margins of the 
 scapulae like that of the cranial bones. The humerus is occasionally bent, and 
 usually at the insertion of the deltoid in consequence of the powerful action of 
 this muscle in raising and supporting the arm. The radius and ulna are bent 
 outward and twisted. This deformity is attributed by Sir William Jenner to 
 the fact that rickety children support themselves while in the sitting posture 
 upon the palms of the hands pressed upon the floor or couch. Supporting the 
 weight of the body in this manner not only, in his opinion, causes bending of 
 the ulna and radius, but also aids in producing the deformities of the humerus 
 and clavicle. 
 
 Changes in the Bones of the Pelvis. — The deformities of the pelvic bones 
 resulting from rachitic softening are very important in the female infant, 
 since pelvic deformities during the procreative period are the common cause of 
 tedious or instrumental labor and stillbirth. These deformities, which elon- 
 gate some and contract other axes of the pelvis, necessarily occur when the 
 rachitic child is in the erect position, since the pelvic bones support the weight 
 of the trunk, head, and shoulders. A common deformity produced in this 
 manner is the carrying forward of the promontory of the sacrum, which sus- 
 tains the weight of the spine. There is, moreover, twofold pressure from below 
 — that caused by the heads of the thigh-bones in standing, and that exercised 
 by the tuberosities of the ischia in sitting. Both these forms of pressure have 
 a tendency to narrow the outlet of the pelvis. Hence the marriage of the 
 female who has been rachitic in infancy may involve serious consequences. 
 
 Fig. 6. 
 
 Fig. 7. 
 
 Fig. 8. 
 
 Rachitic Deformities of the Pelvis (from specimens in Wood's Museum). 
 
 Many of the tedious instrumental labors in the families of the city poor, 
 which severely tax the patience and endurance of young practitioners, are 
 attributable to rickets in early life. 
 
RACHITIS. 
 
 337 
 
 Changes in the Bones of the Lower Extremities. — The curvature of 
 the femur is usually forward or forward and outward. The neck of the femur 
 sometimes bends by the weight of the body or by use of the legs, so that the 
 
 Fig. 9. 
 
 Fig. 10. 
 
 Rachitic Deformities of the Femur (Wood's Museum). 
 
 Fig. 11. 
 
 Fig. 12. 
 
 angle which it forms with the shaft is changed. The accompanying wood-cuts 
 show the rachitic bend of this bone in an adult, years after rachitis had ceased 
 and when the bone had become consolidated by the new deposition of lime 
 salts. ~ (Figs. 9 and 10.) 
 
 The curvature of the tibia and fibula varies in different cases. In those 
 under the age of one year it is likely to be outward, so that the knees are sep- 
 arated from each other. In those old enough to stand, the weight of the body 
 usually determines a forward bending of these bones. In one case in my prac- 
 tice an anterior curvature, so abrupt that an angle of about 70° was formed, 
 existed about five inches above each ankle. This 
 patient, although old enough to walk, almost con- 
 stantly sat during the day with the feet extended 
 beyond the sofa, so that the edge of the latter corre- 
 sponded with the abrupt curvature or angle of the 
 legs. It seemed that the weight of the feet, unsup- 
 ported beyond the edge of the sofa, had caused these 
 curvatures, especially as the case was one of very 
 marked rachitic softening of the different bones. 
 
 Still, tibial and fibular bending at this point has 
 been noticed by different observers, who have attri- 
 buted it to the weight of the body in walking. Vari- 
 ous other curvatures besides those mentioned occur in 
 the bones of the lower extremities, the direction in 
 which the limbs bend being determined by the par- 
 ticular circumstances of the case. In mild cases of 
 rickets most of the deformities described above may 
 be lacking, but in typical cases certain of them stand 
 out prominently, so as to be readily detected by one 
 familiar with the disease. In all such cases the nature 
 of the malady is apparent, for the changes that occur 
 are not only conspicuous, but pathognomonic. 
 
 Rachitis produces another important effect on the 
 skeleton. Its growth is stunted, not only during the 
 rachitic period, but subsequently, so that those who 
 have been rachitic in childhood, unless very mildly, 
 have less than the average stature in adult life. The 
 stunted growth is apparent, though ample allowance 
 
 be made for curvatures. The arrest of development is greater in some bones 
 than in others. It is greatest in the bones of the face, pelvis, and lower extre- 
 mities. Stunted growth of the pelvic bones of the female infant, conjoined 
 
 22 
 
 Rachitic Deformities of the 
 Femur, Tibia, and Fibula 
 (Wood's Museum). 
 
338 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 with the deformities alluded to above, may seriously affect her subsequent life, 
 for the stunted development of the pelvic bones, like the deformities mentioned 
 above, constitutes a valid reason for avoiding marriage. As a rule, the older 
 the child is when rachitis begins, the less is the skeleton affected and the less, 
 consequently, is the deformity. 
 
 Effect of Rachitis on Dentition. — As might be expected from the nature 
 of rachitis, dentition suffers severely. The delay in dentition has been con- 
 sidered elsewhere in this paper. Teeth which appear during the rachitic 
 state are frail, deficient in enamel, and crumble readily. They decay and 
 break before the usual time. If certain teeth have appeared before rachitis 
 begins, several months elapse before others cut the gum. It is even said 
 that a child who has rachitis severely for a lengthened period may never have 
 a tooth, and may remain toothless for life ; but I have never observed such a 
 case. Ordinarily, when the rachitic state ceases and the health is fully restored 
 dentition goes on in the normal way. 
 
 3. Anatomical Characters of the Stage of Reconstruction. — This 
 stage will be better understood if we recollect what has occurred during the 
 first and second stages. The very vascular periosteum is drawn tightly over 
 the convexities, the pressure upon which diminishes the hyperemia and the 
 amount of exudation underneath. Over the concavities the periosteum is 
 loose : it is hyperaemic with abundant new capillaries, the interspace between 
 it and the bone being filled with the exuded soft material having a gelatiniform 
 appearance. The reparative process goes forward rapidly, the deposition of 
 lime salts being more abundant upon the concave surfaces, where there has 
 been free exudation with no compression of the capillaries, than elsewhere. 
 The lime salts are deposited from the blood. Consequently, from the increased 
 capillary circulation and hyperaemic state of the periosteum produced by rachi- 
 tis, the earthy material is rapidly deposited wherever there is an open space 
 under the periosteum and where the capillaries are in a state of enlargement. 
 Hence the reconstructed bone is thicker and firmer upon the concave aspect of 
 the long bones than elsewhere, and thinnest upon the convex aspect, where the 
 periosteum is more tense and its capillaries more or less compressed. 
 
 Normal ossification does not at first take place during the reparative stage. 
 The deposition of the earthy salts is designated by some writers as a petrifac- 
 tion rather than a true bone-formation. Trousseau likens it to the formation 
 of a callus upon a fracture. A deposition occurs of lime salts more compact 
 than ordinary bone. The term " eburnation " has been applied to this new 
 osseous formation, and I have designated it osteo-sclerosis. It resembles, as 
 regards its hardness and morphological appearance, the enamel of the tooth 
 rather than true bone, the Haversian canals and lacunae being small and im- 
 perfectly formed. Of course after complete recovery the subsequent formation 
 of bone is normal. Recovery from rickets is gradual. Little by little the car- 
 tilaginous and periosteal proliferations cease, the hyperaemia abates, and the 
 various parts of the osseous system and the soft tissues resume their normal 
 function and development. 
 
 General Symptoms of Rachitis. — Preceding and accompanying rachitis 
 symptoms may be present which are due to indigestion and intestinal catarrh, 
 such as flatulence, unhealthy stools, and poor and capricious appetite. When 
 rachitis begins the infant becomes fretful ; its sleep is frequently restless and dis- 
 turbed, and it awakens often. It repels attempts to amuse it, and is apparently 
 annoyed by them. Nurse and mother speak of it as a cross child. It perspires 
 freely from the head and neck both when awake and when asleep, while its 
 extremities and trunk are dry. Its pillow is wet with perspiration during sleep, 
 
RACHITIS. 339 
 
 and sweat-drops may be seen upon forehead and face. If the surface be dry, 
 a little excitement or elevation of temperature causes perspiration to appear. 
 The rachitic child does not well tolerate the bed-clothes, and it attempts to 
 throw them off from its limbs, even in cool weather lying exposed and causing 
 considerable annoyance to the nurse, who strives to prevent its taking cold. 
 Sometimes miliaria due to the moist state of the skin appears upon the face 
 and neck. "We have elsewhere stated that the subcutaneous veins that return 
 blood from the head are large and the jugular veins full. Another symptom 
 is soon observed, to wit : tenderness over a considerable part of the surface, 
 perhaps largely due to the morbid state of the periosteum over so many bones, 
 though it is also experienced when pressure is made upon soft parts, as the 
 abdomen. The tenderness is probably the cause in part of the fretful disposi- 
 tion. The little patient appears to dread to be touched ; its flesh is sore ; it 
 repels attempts to amuse it, and wishes to be quiet. Dangling it upon the 
 arms, swinging it, or even walking with it, which delights the healthy child 
 and elicits a smile or notes of glee, only adds to its discomfort. It is most at 
 ease when left alone upon a soft cot or pillow, or, if it have craniotabes, when 
 quietly held over the shoulder. Languor, disinclination to use the limbs or to 
 play, moderate thirst, with other symptoms referable to the digestive apparatus 
 which are present in many cases, and which have already been described, are 
 soon followed by changes in the skeleton that are perceptible to the sight and 
 on palpation. The pulse and temperature in a large proportion of the ordinary 
 chronic cases do not deviate from the healthy state, except that in some patients 
 there is a moderate rise in temperature and acceleration of the pulse in the lat- 
 ter part of the day, indicative of a slight fever. 
 
 A bruit de souffle of greater or less intensity, synchronous with the pulse, 
 has frequently been heard in rachitic cases by applying the ear over the ante- 
 rior fontanelle. Drs. Whitney and Fischer, New England physicians, first 
 called attention to this murmur, believing it to be a sign of chronic hydrocepha- 
 lus. MM. Rilliet and Barthez heard it in cases of rachitis, and therefore con- 
 cluded that the American physicians had confounded the two diseases. More 
 recent observations have established the fact that this bruit has little diagnostic 
 significance. It is heard whenever there is sufficient patency of the anterior 
 fontanelle both in health and disease. It is conducted from the base of the 
 brain through the brain-substance to the membranous covering of the fonta- 
 nelle. Dr. Wirthgen heard the bruit in 22 of 52 infants, of whom all except 
 4 were in good health. I have auscultated the anterior fontanelle in 29 infants 
 who were, with two exceptions, between the ages of three and thirty months. 
 All were well or affected merely with trivial ailments which did not disturb 
 the cerebral circulation. In most of them a murmur could be distinctly heard 
 synchronous with the respiratory act, and in 15 of the 29 cases no other sound 
 could be detected, while in the remaining 14 a bruit could be detected synchro- 
 nous with the pulse. 
 
 As might be expected, craniotabes gives rise to symptoms quite distinct 
 from those of the general rachitic disease. It usually occurs during the first 
 year of infancy, and most frequently prior to the tenth month. The brain at 
 this age is soft and yielding, since it contains a large percentage of water. 
 Unless handled with care at an autopsy, it is readily lacerated, and moderate 
 pressure upon it is seen to disturb and move it a considerable distance from the 
 point of contact. It will assist to a proper understanding of the symptoms 
 referable to the cerebro-spinal system to which the rachitic are liable, to recall 
 to mind the fact, well known to surgeons, that slight depression of even a small 
 portion of the skull is likely to produce grave consequences. It is not surpris- 
 
340 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ing, therefore, that craniotabes, when there is a space of considerable size in 
 the cranial arch destitute of bone, is attended by symptoms due to the mechan- 
 ical effect of external pressure whenever a substance less yielding than the 
 brain comes in contact with the unprotected part. 
 
 Every rachitic child is fretful, but one with craniotabes is especially so if 
 the open spaces, in which the lime salts are lacking or constitute a thin and 
 yielding layer, are of considerable size. If the child lie upon the pillow in the 
 position that is most natural for it, the unprotected portion of the brain may 
 be so pressed upon by the weight of the head that it is uncomfortable and rest- 
 less. It does not have quiet sleep because the cerebral circulation and functions 
 are disturbed because of the fact that the cranial arch no longer protects the 
 brain from undue pressure. Carefully placed in an apparently comfortable 
 position, it awakens often and frets until it is taken in the nurse's arms. Some- 
 times it instinctively seeks a position on the edge of the pillow, with its face 
 downward, and it becomes more quiet when resting over the nurse's shoulder 
 with no pressure or support upon the cranial arch. 
 
 But if fretfulness, disturbed sleep, and the necessity of closer attention on 
 the part of mother and nurse were the only ill effects of craniotabes, it would 
 possess much less pathological significance than pertains to it. Pressure upon 
 so delicate and important an organ as the brain involves risks and produces 
 serious symptoms in proportion to its degree. Even a slight injury of the 
 skull which causes depression, though it may be of trifling amount, will cause 
 serious forms of nervous disorder. Rachitic craniotabes sustains a causal rela- 
 tion in not a few instances to one of the most dangerous of the neuroses — to 
 wit, laryngismus stridulus, or spasm of the glottis. Pressure on the cardiac 
 and vaso-motor centres of the medulla in the rachitic infant, in whom reflex 
 excitability is exaggerated, causes contraction of the muscles that close the 
 glottis. It is certain that a large proportion of those who suffer from laryn- 
 gismus stridulus are rachitic, so that it is more common and severe where 
 rachitis is prevalent, as in England, than where it is rare, as in the rural 
 districts of America. It is not often the cause of death in America, and the 
 fatal cases that do occur are, I think, nearly always in the cities, whereas in 
 parts of Europe, where rachitis is much more common than with us, it is said 
 to cause not a few deaths. 
 
 Certain infants when in a state of excitement have what are termed "hold- 
 ing-breath spells." The face is flushed and breathing ceases for some seconds, 
 after which respiration returns and is normal. The attacks are unimportant, 
 but they appear to be the same in nature with the more severe and dangerous 
 seizures of laryngismus stridulus. They have no pathological significance, 
 excepting that they show the same neuropathic state as that in laryngismus, 
 and that they may be precursors of it. 
 
 Laryngismus stridulus, or glottic spasm, is usually preceded by more or 
 less impairment of the general health and often by fretfulness, which is charac- 
 teristic of the rachitic state ; but the attack occurs suddenly, without premonition, 
 and is of short duration. It begins with an arrest of respiration, a true apnoea, 
 as if from paralysis of the respiratory centre in the medulla ; the lips may be 
 livid, a pallor spreads over the face; sometimes more or less rigidity of the 
 limbs occurs, with carpo-pedal contractions. After a few seconds, a quarter 
 or half minute, a long and deep but difficult inspiration through the narrow 
 chink of the glottis follows, accompanied in many patients by a whistling or 
 crowing sound, and the attack ends with perhaps a momentary appearance of 
 bewilderment or dread on the child's face. Laryngismus stridulus, like eclamp- 
 sia, does not have a uniform causation. In certain cases it is a reflex phe- 
 
BACHITIS. 341 
 
 nomenon due to an irritant in some part of the system, as in the intestines, 
 but many observations establish the fact that rachitis is probably its most 
 common cause. A large proportion of the infants affected with it exhibit 
 unmistakable rachitic signs ; and it has been held that the exposed state of 
 the brain in craniotabes affords explanation of the symptom. But from obser- 
 vations which I have made and from those of other observers, like Senator, it 
 is certain that laryngismus stridulus is common in the rachitic who do not have 
 craniotabes, so that there must be a causal relation in rachitis to spasm of the 
 glottis independently of the cranial softening. 
 
 Distinguished British observers, as Gee and Jenner, have noticed the fact 
 that rachitic infants are especially liable to eclampsia. The immediate or 
 exciting cause seems to be in many cases the severe catarrh of the respiratory 
 and digestive systems to which rachitic infants are especially liable. Indiges- 
 tion, flatulence, and fermentative diarrhoea, common disorders of the rachitic, 
 are perhaps, in some instances, the exciting causes of the eclampsia. Similar 
 remarks may be made in reference to tetany, which, although it occurs in the 
 aduk and is comparatively rare, appears to be more frequent in rachitic than 
 in other children. 
 
 Those physicians who attend in institutions in which children coming from 
 tenement-houses are treated in a large city like New York have noticed the 
 fact that the various tissues of the body, besides those that are conspicuously 
 affected in rachitis, are more liable to inflammatory diseases than are the same 
 tissues in those who have sound constitutions. The frequency of the different 
 forms of dermatitis, of nasal, post-nasal, faucial, and bronchial catarrhs, and 
 of gastro-intestinal maladies, we must attribute to the fact that rachitis dimin- 
 ishes the resisting power to noxious agents in the various soft tissues, and ren- 
 ders them more liable to disease. 
 
 If the deformity in the thoracic wall — to wit, the lateral depression of the 
 ribs and anterior projection of the sternum — be great, we would naturally 
 expect that the two important organs underneath, the heart and lungs, would 
 receive some detriment. Upon the surface of the heart, at the point where it 
 supports the softened ribs, a white patch is often found, due to thickening of 
 the pericardium and proliferation of the endothelial cells, just as thickening of 
 the skin in the palm of the hand occurs from friction and pressure upon that 
 part. It is probable that in ordinary cases this pressure does not seriously 
 impair the function of the heart, but it may increase the weakness of its move- 
 ments in supervening asthenic diseases, which may occur during the rachitic 
 period. The injury sustained by the lungs is greater and more apparent. If 
 the lateral depression of the ribs be considerable, full inflation of the lungs 
 does not occur in those parts where the depression is greatest. The semi- 
 collapse of certain lobules is likely to occur, and even complete collapse of the 
 distant thin edges of the lungs. The stress of respiration falls unequally upon 
 different parts of the lung. The anterior portion, which ascends with the 
 sternum as that is propelled forward, is more fully dilated than the lateral and 
 posterior parts, and it may in consequence become emphysematous. If in this 
 state of the thorax and lungs severe bronchitis or broncho-pneumonia occurs, 
 the muco-pus, being expectorated with difficulty, clogs the tubes, produces 
 dyspnoea, and imperils the safety of the child. Even in comparatively mild 
 forms of inflammation the result may be unfavorable, owing to the lack of full 
 expansion in the lateral and depending portions of the lung — a condition 
 required to expel the mucus. Severe bronchitis and broncho-pneumonia are 
 the causes of death in not a few cases of 'rickets attended by marked deformity 
 of the thorax. 
 
342 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Rachitic Paralysis. — In not a few instances in the course of rachitis the 
 use of the limbs is greatly impaired, so as to resemble paralysis, and be desig- 
 nated by this name, though the term "paralysis" is probably a misnomer. 
 Cases like the following, related by Dr. H. W. Berg in the New York Medical 
 
 Record, which closely resemble paralysis, occasionally occur : J. S , aged 
 
 two years and eight months, was admitted into the Orthopaedic Dispensary 
 Sept. 23, 1885. The parents stated that the child had never walked or stood 
 alone. The legs were wasted, apparently from disease ; the patellar reflex was 
 good; there seemed to be some rigidity of the muscles about the knee; and 
 the patient was admitted with the diagnosis of "spastic paralysis." A closer 
 examination disclosed the fact that the disease was one of typical rachitis, and 
 bv the use of the proper diet, with iron and phosphorus, the patient was able 
 to walk in November, and in a few months was entirely cured. The British 
 Medical Journal, Jan. 4, 1890, contains the account of a case of rickets dis- 
 cussed by the Edinburgh Medical Society, Dec. 4, 1889. The patient, a boy 
 of three years, had the waddling gait and straddling pose of pseudo-hypertro- 
 phic paralysis. The rachitic nature of the malady was made apparent by the 
 symptoms of the case and its history. I have recently in private practice 
 observed two similar cases of pseudo-paralysis of the lower extremities from 
 the same cause. 
 
 Acute Rickets. — Occasionally rachitis occurs with the sudden develop- 
 ment of severe symptoms, so that the term "acute " is applied to it. Dr. Furst 
 relates such a case in the Jahrb. fiir Kinderh., Band xviii. p. 192 : The 
 patient, aged two years and one month, had been largely fed upon starchy 
 food, and at six months had dyspeptic symptoms and sweating. Dentition 
 began in the thirteenth month, and ability to walk several months later. Spas- 
 modic croup and swelling of the epiphyses appeared at this time. At the 
 above-mentioned age the child suddenly fell ill with acute febrile symptoms. 
 It had an open anterior fontanelle, craniotabes, and a rachitic chest; upper 
 extremities free from pain and not swollen. The left femur and both tibiae 
 showed diffuse cylindrical swelling. The appearance and feel of the limbs 
 were suggestive of diffuse cellular infiltration proceeding from the periosteum 
 in an attack of osteo-myelitis. The skin covering the limb was tightly drawn 
 and of a reddish hue. In a few days the right forearm was affected, and soon 
 after the right arm and left forearm, and the parts first attacked began to 
 improve. In four weeks the fever and pain had abated, but swelling of the 
 epiphyses and deformities of various bones continued. Cases like the above 
 establish the fact that although rachitis is ordinarily a chronic disease, insidi- 
 ous in its commencement, gradual and progressive in its development, occupy- 
 ing months, there is an acute form which is attended by more marked febrile 
 movement and tenderness than occurs in the usual type, and in which the 
 articular swelling appears more quickly. (See p. 350.) 
 
 Treatment. — Hygiene. — We recall the recent statement of Prof. Henoch 
 of Berlin that the spread of rachitis has been enormous in the cities of Central 
 and Northern Europe. The poor of these cities, among whom this disease 
 largely prevails, are emigrating in large numbers to the United States, but, as 
 I have observed in the asylums and dispensaries of New York, the severest 
 forms of imported rachitis come from Southern Europe (Italy). Evidently, as 
 long as the influx of this class of foreigners continues, and the present insani- 
 tary conditions exist in our cities causing rachitis in the native born, this 
 will continue an important disease, impairing the health and vigor of coming 
 generations. It is evident from the nature of rachitis that success in prevent- 
 ing it and in curing those who unfortunately exhibit its characteristic signs 
 
RACHITIS. 343 
 
 requires beyond anything else the employment of proper hygienic measures. 
 The details of the hygienic requirements may seem prolix and tedious, but we 
 cannot expect any marked diminution of rachitis until they are better known 
 and heeded by the masses. 
 
 The fact that inheritance is one of the recognized causes of rickets renders 
 it very important that the parents be in good health. The mother especially 
 should avoid all agencies or influences which impair the general health during 
 the procreative period. She should, so far as possible, encourage good appetite, 
 take plain, easily-digested, and nutritious food, and lead a quiet, regular life, 
 with sufficient out-door exercise to promote, so far as practicable, a state of 
 perfect health. Country residence, with quiet exercise in the open air, a diet 
 consisting of fresh vegetables, meats, fresh and abundant milk, early retirement 
 to bed and sufficient sleep, are much more conducive to the health of the mother 
 and her child than are the excitement and irregularities of city life. 
 
 We have seen that there is sufficient clinical and experimental evidence that 
 the common and predominating factor in causing rachitis is the use of a faulty 
 diet, but general insanitary conditions are also potent agents. The foul air and 
 noxious effluvia of the crowded tenement-house, so conducive to disease and fatal 
 to infants in New York, should, if possible, be avoided. Even if poverty compels 
 a residence in the small and dark apartments of a tenement-house, crowded by 
 families, many of them entirely neglectful of sanitary measures, yet parents 
 solicitous for the welfare of their children can do much to diminish the insani- 
 tary influences which surround them. Out-door air is everywhere available, and 
 every child after the age of two or three months, unless suffering from acute 
 disease, should in ordinary weather be in the open air one or more hours each 
 day, as a means of improving its digestion and of producing a more vigorous 
 state of the system. Any mother or nurse capable of the care of a child should 
 be able to employ such measures as will prevent its taking cold while in the 
 open air. 
 
 The room occupied by a child, whether rachitic or not, should be at a uni- 
 form temperature of about 70° to 73° F., and it should receive the sunlight 
 or the full daylight, which is often excluded by faulty construction. The under- 
 garments worn during infancy and childhood should be of wool, thin and light 
 during the summer, thicker and heavier in the winter. No intelligent mother 
 need be told of the need of personal cleanliness of her child as a means of 
 promoting its health as well as comfort. This is a hygienic measure, and we 
 need not repeat that the more complete the sanitary conditions the less the lia- 
 bility to contract rachitis or any disease dependent on cachexia. Bathing of 
 children should always be before the fire or in a warm room. The bath for an 
 infant under the age of six months should be at about 90°. As the age 
 increases the temperature of the bath should be gradually reduced to 80° in the 
 second year, to 75° in the third year, and to 70° subsequently. The bath 
 should be short, only long enough to ensure cleanliness. For weakly infants it 
 is sometimes best to dispense with the general bath, and employ the sponge 
 instead. I see no advantage in the use of saline or medicated baths. After 
 the bath the extremities should be warm, and to ensure a better peripheral cir- 
 culation friction of the surface by warm flannel or otherwise, or the application 
 of warmth to the limbs, is often useful. The extremities of a child should 
 always be warm, for the normal warmth of the surface not only promotes nutri- 
 tion of superficial parts, but it tends to prevent internal congestions and inflam- 
 mations, to which the rachitic are especially liable. A child that habitually 
 has cool extremities cannot be at the maximum of health, and this is often the 
 state of the poorly-fed and poorly-clad children of the tenement-houses. The 
 
344 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. 
 
 measures to promote their normal circulation and warmth, such as exercise as far 
 as practicable, artificial heat, exclusion of cold by woollen garments, friction of 
 the limbs, either dry or by the use of mildly stimulating lotions, should be 
 employed. But while the hygienic measures which we have detailed are 
 important as means of invigorating the system and rendering it less liable to 
 rachitis as well as other cachectic diseases, we repeat that the most common and 
 potent cause of the malady which we are considering is a faulty diet, so that 
 in the endeavor to prevent and to cure rachitis special attention must be given 
 to the feeding. 
 
 Clinical experience abundantly demonstrates the fact that in order to pro- 
 mote healthy nutrition the food of the infant should be breast-milk until the 
 age of ten or twelve months ; and subsequently, until childhood is well advanced, 
 its food should consist largely of cow's milk, properly preserved and prepared. 
 
 We need not state that human milk varies in its composition according to the 
 health, diet, mode of life, and temperament of the individual who furnishes it. 
 Many mothers possess the requisite moral traits to be good wet-nurses, and do 
 all in their power for the welfare of their infants, but have an inadequate lacteal 
 secretion. Many mothers, not only in the tenement-houses, but in the well-to- 
 do class, are unable to furnish sufficient breast-milk, and their infants, unless 
 they receive supplementary food, suffer from malnutrition and are liable to 
 become rachitic. I have seen during the last year infants wet-nursed by their 
 mothers, fretful, wasted, and at the verge of starvation, applied every half hour 
 to the breast during the hours of wakefulness. Mothers, deprived of the 
 needed sleep and sacrificing their own health in the constant endeavor to pro- 
 vide for the wants of their infants, usually have insufficient milk, as in the cases 
 alluded to. Under such circumstances a medicine designated nutrolactis, which 
 consists largely of the Galega officinalis, has been employed in the New York 
 Infant Asylum with apparent benefit as a stimulator of the lacteal secretion. 
 But if suckling by the mother continue inadequate and her infant be under 
 the age of six months, a wet-nurse should be employed. If this be impossible, 
 supplementary feeding will be needed. 
 
 In normal and sufficient wet-nursing the infant should go to the breast at 
 regular intervals of about two hours, but at longer intervals at night (ten times 
 in twenty-four hours). It should obtain what nutriment it requires in ten or 
 fifteen minutes, after which it falls into a quiet sleep. This allows the mother 
 time and opportunity to rest and recuperate between the nursings, so that she 
 furnishes milk more abundant and of better quality than when she is worried 
 and anxious and deprived of needed sleep. The subject is so important that 
 we may be allowed to repeat what we have elsewhere stated : An infant that 
 draws the breast at short intervals of two hours obtains not only more milk, 
 but richer milk, than when the intervals are longer. 
 
 There is no more important, and frequently no more perplexing, duty of 
 the physician than to direct the alimentation of infants. Many mothers 
 express the determination to wean for trivial reasons, and are found to be giving 
 one of the commercial foods without consulting the physician. On the other 
 hand, many mothers seriously declare that their babies are ravenous nursers, 
 and that their breasts furnish an abundance of milk, when only a few thin drops 
 can be obtained by the breast-pump, and the appearance of the nurslings 
 plainly indicates innutrition and progressive emaciation. In such cases addi- 
 tional nutriment is of course required. 
 
 The practice, which is too common, of early weaning with insufficient 
 reason and without consulting the physician, is very mischievous. Acute and 
 transient ailments of the mother may cause some diminution in her milk, but 
 
RACHITIS. 345 
 
 usually her health is not so injured by a short sickness that she is incapaci- 
 tated for wet-nursing ; of course the continued loss of appetite, with progressive 
 debility and anaemia, may be such that prompt weaning is imperatively required. 
 
 If it be impossible to wet-nurse the infant, or if it have reached the age of 
 ten or twelve months, at which time weaning is proper, it will be necessary to 
 determine what food shall be given. In New York City — and the same is prob- 
 ably true in other cities — the infant should not be weaned in the hot months, 
 since the change of diet from the natural to the artificial at this time is very 
 likely to cause that fatal disease, the summer diarrhoea. The infant should be 
 first removed to the country before weaning, or, if removal be impossible, wean- 
 ing should be postponed until after the heated term, even if it be at the age of 
 fifteen or sixteen months. But with a large proportion of infants after the age 
 of six months the mother's milk is not sufficient, and it is necessary to supple- 
 ment the wet-nursing by the use of other foods. 
 
 Notwithstanding the many commercial foods designed for infant feeding, 
 I have every year been more and more convinced that cow's milk, prop- 
 erly prepared, furnishes the best substitute for human milk, and should be 
 used to make up the deficiency when the latter is insufficient, and be the 
 main food or the basis of the food employed after weaning. I have observed 
 the occurrence of rachitis in children whose diet consisted chiefly of certain 
 proprietary foods ; and, in looking over the composition of these foods, one of 
 the chief causes of this result appears to be the small amount of fat which they 
 contain. Thus, according to Prof. Leeds's analyses, Mellin's Food contains 
 only 0.15 part in 144.74, and Nestle" s Food only 1.91 parts in 139.69, whereas 
 human milk contains 3.90 per cent, of fat, and cow's milk 3.66 per cent, of fat. 
 Especially in the selection of food designed to prevent or cure rachitis our 
 choice should fall on cow's milk next to human milk. But cow's milk contains 
 five times more casein than human milk, and is slightly acid, whereas the latter 
 is always alkaline. In the country, cow's milk obtained fresh and with proper 
 attention to cleanliness in its manipulation may not require sterilization by heat. 
 But that received and used in the city, exposed more or less to an atmosphere 
 containing numerous microbes, it is well to sterilize by steaming for a period 
 not exceeding twenty-five minutes. For infants with feeble digestion, who are 
 suffering from innutrition, digestion of cow's milk can be promoted by pepton- 
 izing by the peptogenic powder of Fairchild in the manner well known to the 
 profession. Inasmuch as observations relating to the causation of rachitis, 
 which we have quoted elsewhere, show that deficiency of fat in the food is a 
 common cause, I recommend, especially if any rachitic symptoms appear, the 
 use of the upper half or third of the can or bottle of milk, since this contains 
 a large percentage of cream. 
 
 A properly-prepared farinaceous substance, mixed with milk, not only has 
 nutritive properties, but also, by mechanically separating the particles of casein, 
 tends to prevent the formation of curds in the stomach. But as young infants 
 digest starch with difficulty, a flour, as barley, wheat, or oatmeal, in which the 
 starch is to a great extent converted into dextrin, or, better, into glucose, may 
 be advantageously added to the milk, especially for infants over the age of six 
 months. The conversion of starch into dextrin may be effected by a high heat, 
 and into glucose by the action of diastase. If a heaped teaspoonful of barley 
 flour be boiled in twenty-five teaspoonfuis of water, and when it is lukewarm 
 ten or fifteen drops of diastase (Forbes) be added to it, the gruel in a few min- 
 utes becomes much thinner from the digestion of starch, and it is a useful adju- 
 vant to the milk employed in the nursery, especially for infants over the age 
 of six months. 
 
346 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 But while healthy development in infancy and childhood requires a careful 
 choice of food suitable for the stage of growth and development, the frequency 
 of the feeding and the amount of food given are also matters of importance. 
 There can be no doubt that many infants are under-fed, some even to starva- 
 tion, and some infants are over-fed. MM. Vernois and Becquerel, in a careful 
 examination of 89 infants wet-nursed by mothers apparently in good health, 
 ascertained that 15 were insufficiently nourished. Did space permit I might 
 relate instances in which infants were applied to the breast even more fre- 
 quently than the prescribed rules allow by affectionate and devoted mothers 
 or by wet-nurses supposed to have sufficient milk, and yet they continued to 
 lose flesh and strength, were almost constantly fretful, and were finally reduced 
 to a precarious state by insufficient nutriment. On the other hand, overfeeding 
 sometimes occurs to the detriment of the child. A half century has elapsed 
 since the most distinguished New England physician of his day, Dr. James 
 Jackson, called the attention of the profession to the frequent, green, and 
 unhealthy stools, showing imperfect digestion occurring in children from over- 
 feeding. Among the cachexiae developed from abnormal digestion and malnu- 
 trition we recognize rachitis as one of the most frequent. 
 
 A few years ago Drs. Chadbourne, Parker, and myself made observations 
 in the New York Infant Asylum and New York Foundling Asylum in order to 
 determine how much food children require at different ages. Those selected 
 for observation were well nourished, and they were accurately weighed before 
 and after each nursing or feeding. Eleven infants under the age of three 
 weeks, who took the breast, with three exceptions, twelve times in the twenty- 
 four hours, were found to take on the average 12.55 ounces of the breast-milk 
 in the day and night. Therefore, according to these statistics, infants under 
 the age of three weeks, nourished at the breast and suckled twelve times in the 
 twenty-four hours, require only one ounce, or not more than one ounce and one 
 drachm, at each nursing; and the very small size of the stomach at this age 
 shows that it cannot receive much more than this without distention. After 
 the third week the amount of food required for healthy nutrition gradually 
 increases. 
 
 Children, like adults, in good health and well nourished, do not all require 
 or take the same amount of food. Some need more food than others, but the 
 following table indicates, I think, nearly the quantity required during the first 
 twelve months of infancy, either of breast-milk or of food prepared so as to 
 resemble as closely as possible breast-milk in consistence and nutritive proper- 
 ties. It will be observed that this table resembles closely that prepared by 
 Prof. Botch of the Harvard Medical School, and published in his instructive 
 paper on infant feeding in the Cyclopcedia of the Diseases of Children : 
 
 Quantity of Food required in the First Year of Infancy. 
 
 At each Feeding. Number of Daily Feedings. Total Daily Amount. 
 
 During the first week 1 oz. 10 10 oz. 
 
 At the third week H oz. 10 15 oz. 
 
 At the sixth " 2" oz. 8 16 oz. 
 
 At the third month 3 oz. 8 24 oz. 
 
 At the fourth " 4 oz. 7 28 oz. 
 
 At the sixth " 6 oz. 6 36 oz. 
 
 At the tenth to twelfth month . . . 8 oz. 5 40 oz. 
 
 The daily average of food for each child in an aggregate of twenty-eight healthy 
 children between the ages of two and three years was as follows: Bread, 7.5 oz. 
 avoir. ; butter, .98 oz. ; meat (beef), 4.6 oz. ; potatoes, 3.9 oz. ; milk, 32.6 fl. oz. 
 The daily average for each child in an aggregate of twelve children between the 
 
RACHITIS. 347 
 
 ages of three and six years was as follows: Milk, 48.6 fl. oz. ; beef, 12.1 oz. 
 avoir.; rice, 13.0 oz.; bread, 10.3 oz. ; butter, 1.08 oz. The daily average 
 for each child in an aggregate of twenty-four children between the ages of 
 four and ten years: Roast beef, 12.46 oz.; bread, 10.23 oz. ; potatoes, 10.03 
 oz. ; butter, .99 oz.; milk, 38.5 fl. oz. 
 
 The prevention and the cure of rachitis require strict enforcement of the 
 details of hygiene. Hence the above facts relating to the mode of life and 
 diet of children should be observed in order to prevent cachexia and promote 
 a healthy growth. 
 
 Medicinal Treatment. — Medicines which aid the digestion and assimila- 
 tion of properly-selected foods are sometimes useful. Irritability of the stomach, 
 imperfectly digested stools, flatulence, colicky pains, etc. indicate faulty diges- 
 tion, which may be improved by pepsin given with each feeding. Tonic reme- 
 dies designed to improve the appetite and digestion, of a kind suitable for the 
 age and condition of the patient, are often useful. In anaemia one of the 
 readily-assimilated preparations of iron should be given. The complications 
 which are so common require special management. The laryngismus stridulus, 
 eclampsia, and tetany should be promptly treated. 
 
 The bronchial catarrh to which rachitic infants are liable may be best 
 treated by remedies like the following: 
 
 1^. Ammonii chloridi 3J- 
 
 Syr. Tolutan f£j.— M. 
 
 Sig. Dose fifteen drops every hour or two hours for an infant of six to ten 
 months. 
 
 1^. Ammonii chloridi 
 
 Ferri et ammonii citratis da 3ss. 
 
 Syrupi fgj. 
 
 Aquae fgiij. — M. 
 
 Sig. Give one teaspoonful every two to four hours to a child of one year. 
 
 Some of the rachitic cases with protracted bronchial catarrh, especially 
 those which also exhibit scrofulous symptoms, may be most relieved by the 
 syrup of the iodide of iron and cod-liver oil administered three times daily, 
 with the inhalation of moist air containing turpentine vapor. 
 
 In the protracted intestinal catarrh of rachitic infants I have observed the 
 best results, so far as medicine is concerned, from the following prescription: 
 
 1^. Subnitrate of bismuth 3ij-iij. 
 
 Essence of pepsin (Fairchild's) f$j. 
 
 Distilled water f^iij. — M. 
 
 Sig. Shake bottle; give half to one teaspoonful, according to the age, 
 every two hours. 
 
 But a remedy is needed which will act promptly in the cure of rachitis so 
 as to prevent the evil consequences which its continuance is sure to produce. 
 It is the opinion of many of the best clinical observers who have had ample 
 experience that this has been discovered in the daily use of minute doses of 
 phosphorus. 
 
 Wegner fed young and growing animals (rabbits and fowls) for months 
 with small, non-poisonous, and easily assimilated doses of phosphorus, with 
 the result, he believes, of expediting ossification and producing firmer bone. 
 
348 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 He states that under the influence of phosphorus the large marrow spaces 
 diminish, by the formation of true bone, to the size of the Haversian canals 
 in normal bone. According to Wegner, the administration of finely-divided, 
 non-poisonous doses of phosphorus for a prolonged period to older fowls pro- 
 duced to a considerable extent the conversion of cancellous into compact 
 bone of normal chemical composition. Kassowitz has recently promulgated 
 his views at some length on the pathology and treatment of rachitis. He 
 states that the lime salts are not needed, since the ordinary food contains suf- 
 cient lime ; nor should the farinaceous foods be restricted. He adds that 
 phosphorus in small doses restricts the formation of vessels in the growing 
 bones of small animals. Hence it is useful as a means of overcoming the 
 hyperemia. Kassowitz administers about -3-33- of a grain in a teaspoonful 
 of cod-liver oil, the dose, of course, varying according to the age of the infant. 
 The distinguished podiatrist of Vienna, Dr. Widerhofer, says of this remedy 
 that its employment " impresses him with the belief that it is not without benefit 
 in the second year of life and upward." He thinks that it may be useful in 
 the hardening of long bones, but he has not been able to obtain good results 
 in craniotabes. Starker gives an analysis of 23 rachitic cases treated by Prof. 
 Thomas of Freiberg in his clinic. He used the following formula : 
 
 Jfy. Phosphori 1 centigramme (about \ grain). 
 
 01. morrhuse 100 grammes (about 3 ounces). — M. 
 
 A coffee-spoonful was administered twice daily, but variations in the dose accord- 
 ing to the age are not stated in the report, the patients being between the 
 ages of a few months and four years. Improvement occurred in the general 
 condition in 18 cases ; in the cranial development in 15 cases ; in dentition in 
 14 cases ; in the shapes of the epiphyses in 21 cases ; in locomotion in 17 
 cases ; but strict attention was bestowed upon the hygiene, and especially upon 
 the diet. Soltmann states that good results occurred from the use of phos- 
 phorus in 70 cases which he had under observation, and in no instance were 
 unfavorable results noticed. W. Meyer obtained similar results in 42 cases. 
 He regards phosphorus as a specific for rachitis. When properly given it always, 
 says he, produces positive results. Petersen has treated 200 cases with phos- 
 phorus, and regards it as a specific. Sigel concludes, from the observation of 
 40 cases in private practice, that constitutional treatment is of the greatest 
 importance, but instead of the administration of iron, lime, etc., phosphorus 
 should be prescribed. Unruh also made many observations in the treatment 
 of rachitic cases by phosphorus in the Dresden Hospital in 1885 and 1886, and 
 considers it more efficacious than other remedies. 
 
 Toplitz of Breslau treated 518 cases with phosphorus combined with cod- 
 liver oil. No ill effects were observed, and in all the cases improvement 
 occurred in the general condition. Of 208 cases of craniotabes, 176 were cured 
 in eight weeks. In 58 cases of laryngismus stridulus the attacks ceased in 
 eight to fourteen days, after having continued for months under other forms of 
 treatment. Dentition was also promoted. 
 
 In America, Dr. A. Jacobi, who has had a large clinical experience, also 
 highly recommends phosphorus in the treatment of rachitis. The dose should 
 be small, even minute, not more than -^ to tfo of a grain, according to the 
 age, three times daily. 
 
 As regards my own observations, I am not able to express a positive 
 opinion as to the value of the phosphorus treatment, for reasons which I think 
 also apply to many of the cases embraced in the favorable statistics of the dis- 
 
RACHITIS. 349 
 
 tinguished observers mentioned above — to wit, the simultaneous use of cod- 
 liver oil and improvement in the diet and general hygiene. 
 
 The following prescriptions may be employed — first, the oleum phospho- 
 ratum, made according to the following formula : 
 
 'Sf. Phosphorus 1 part. 
 
 Ether 9 parts. 
 
 Almond oil 90 « — M. 
 
 One minim contains y^o" °f a g ra i n of phosphorus. 
 
 Or. secondly, the following, known as Thompson's mixture : 
 
 ~fy. Phosphori gr. j. 
 
 Alcoholis (absolut.) til cccl. 
 
 Spts. menth. piperit ttlx. 
 
 Glycerini . fgij. — M. 
 
 Sig. Six drops, increased to 10, three times daily, to a child of two to four 
 years. Ten minims contain -j-J^ of a grain, and thirteen minims 
 contain y$~o °f a grain. 
 
 Phosphorus should, I think, be given after the meals, in order to prevent 
 irritation of the stomach. 
 
 Dr. H. H. Purdy, physician to the large class of children's diseases in the 
 out-door Department at Bellevue, has preserved statistics of the treatment of 
 rachitis during the last year. The cases which furnish the statistics numbered 
 about 80, and he gives a resume' of the results of treatment as follows : " Some 
 were given cod-liver oil alone, some, cod-liver oil with phosphorus, and others, 
 phosphorus alone, and of course all the mothers were given instruction in feed- 
 ing and hygiene. Those infants that received only phosphorus were the slow- 
 est to improve. Indeed, in several cases this method of treatment was aban- 
 doned because of the absence of the signs of improvement. The group treated 
 with cod-liver oil did the best. In fact, all of the infants that could tolerate 
 the oil derived much benefit from it. The group that were given cod-liver oil 
 with phosphorus did very well, but seemingly no better than those that were 
 given only cod-liver oil. The preparation that seems to be the most beneficial 
 is one that is used at the Church Hospital and Dispensary. It is an emulsion 
 of cod-liver oil made with the yolk of eggs. The formula for the emulsion is : 
 
 1^. Yolks of ten eggs. 
 
 Cod-liver oil Oij. 
 
 Syrup of wild cherry Oj. 
 
 Sherry wine Oj. — M. 
 
 Sig. One or more teaspoonfuls administered three or more times daily." 
 In my opinion the treatment by phosphorus is still tentative, notwithstand- 
 ing its recommendation by so many distinguished physicians ; and the old 
 remedies, cod-liver oil and iron, should not be abandoned, although trial may 
 be made of phosphorus at the same time. 
 
 Care should be taken to prevent deformities while the bones are soft and 
 yielding. The patient should not be encouraged to stand or use the limbs until 
 they become firmer. He should lie upon a soft and even mattress. Uniform 
 support of body and limbs is requisite in order to prevent curvature. In 
 craniotabes the pillows should be soft, and care should be taken that the yield- 
 
350 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ing parts of the cranium be not unduly pressed upon. Profuse perspiration may 
 be relieved by sponging with vinegar and water. The patient may be bathed 
 in water a little cooler than the body, and rock salt may be added to the bath. 
 
 The attacks of laryngismus stridulus, eclampsia, and tetany which so fre- 
 quently complicate rachitis should be promptly treated by the remedies which 
 are appropriate when they occur under other circumstances. Constipation may 
 be treated by enemata of glycerin and water if not relieved by change of diet. 
 
 The surgical treatment of rachitic deformities is sometimes important, but 
 Prof. Ogston of the University of Aberdeen and other surgeons who have given 
 special attention to this subject state that in young patients these deformities 
 frequently diminish during growth, so as to cause little inconvenience in adult 
 life. The measures employed by surgeons in order to cure or minimize the 
 deformities are fully set forth in surgical treatises. 
 
 [Acute Rickets. — It is now generally accepted by American and English 
 observers, that the condition sometimes described as "acute rickets" is in 
 reality scorbutic in nature. This is certainly true of the cases reported by 
 Moller, Bohn, Forster, and Senator. The case of Fiirst, quoted by Dr. Smith 
 on page 342, which showed diffuse cylindrical swelling of both tibiae and of 
 the left femur, is certainly very suggestive of scorbutus, despite the fact that 
 the statement is distinctly made, " no scorbutus, no stomatitis." In this case 
 it can only be said that " acute rachitis " is " not proven." — Ed.] 
 
RHEUMATISM. 
 
 By J. M. DaCOSTA, M. D., LL.D., 
 
 Philadelphia. 
 
 I. Acute Rheumatism. 
 
 Acute rheumatism, or rheumatic fever, is a specific febrile malady 
 characterized by inflammation of fibrous tissues, particularly those surrounding 
 the joints, of which many are apt to become affected simultaneously or in suc- 
 cession. There is also in rheumatism a strong tendency for the serous mem- 
 branes, especially those of the heart, to become involved, and in children we 
 frequently find these bearing the brunt of the disease while the articular 
 affection is very slight. 
 
 Etiology. — The cause of rheumatism is the accumulation of some poison- 
 ous matter in the blood which irritates specially the fibrous and serous tissues. 
 The most commonly held opinion is that this poison is lactic acid, though the 
 evidence is far from conclusive. The lactic acid may be the result merely of 
 the morbid process, not the cause. Though sought for, specific micrococci have 
 not been demonstrated, nor has the origin of acute rheumatism in disorder of 
 the nervous system been proved. 
 
 But, whatever the remote cause, it is certain that chilling of the surface is 
 in the majority of instances the immediate cause producing the attack. A 
 history of exposure to cold and damp can be almost always obtained. In 
 instances, on the whole infrequent, the poison of scarlet fever produces pain, 
 swelling of the joints, and even cardiac symptoms indistinguishable from 
 acute rheumatism. 
 
 The most potent predisposing cause of acute rheumatism in the young is 
 hereditary tendency. Out of 492 cases Cheadle found a distinct history 
 of its occurrence in near blood relations in 173. The strong hereditary tend- 
 ency is also illustrated by the experience of Steiner : of 12 children of a 
 mother who had suffered from acute rheumatism and heart complication, 11 
 had the disease before they were twenty years of age. Besides the complaint 
 running in rheumatic families, I have noticed that the children of gouty parents 
 develop rheumatism in greater proportion than found in those free from 
 gouty taint. With reference to sex, unlike what happens in adult life, acute 
 rheumatism is more common in girls than in boys. It is not often seen before 
 six years of age. Yet August Seibert met with rheumatism in 13 children 
 under one year of age, and cases of its occurrence in very young infants are 
 recorded by Henoch, Senator, and Koplik. A case of acute rheumatism in an 
 infant eleven days old is reported by Guthrie, and two remarkable instances of 
 its manifesting itself soon after birth are mentioned by Jaccoud : one showed 
 itself three days, and another twelve hours after birth, the mothers at the time 
 being ill with acute rheumatism. I have myself met with a case of acute 
 rheumatism under two years of age. This happened in a girl the daughter of a 
 
 351 
 
352 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 highly gouty father. She has now grown to womanhood, having had three 
 severe attacks of rheumatic fever, but without the heart becoming affected. 
 
 Morbid Anatomy. — The joints show an injected synovial membrane, and 
 there is effusion of fluid into them and into the surrounding tissues ; the fluid 
 contains blood-cells and sometimes leucocytes. Minute haemorrhages into the 
 membrane are not uncommon ; the cartilages are swollen, but it is very rare 
 for them to suppurate or to ulcerate. Near the affected joints and tendons 
 fibrous nodules similar to those found on the valves of the heart are met with, 
 and the parts around the joints, as Henoch has called attention to, may be 
 infiltrated with inflammatory exudation that even becomes as hard as bone. 
 Nodules growing from the bone, a nodular periostitis, have been described by 
 Angel Money. In the heart inflammatory lesions are usual, both in endocardium 
 and in pericardium. The pericarditis in the acute rheumatism of childhood, 
 Cheadle has pointed out, frequently extends to the anterior mediastinum, 
 the connective tissue of which becomes extensively thickened. The extent of 
 pericardial effusion is not generally great, but there is much plastic exudation 
 in the membrane. Fibrinous coagula are found in the heart and great vessels. 
 Pleurisy with or without effusion is often seen. 
 
 Symptoms. — The symptoms of acute rheumatism in childhood are the same 
 as those of adult life : redness and swelling of the larger joints, pain, fever, per- 
 spiration, heart involvement. ■ But these symptoms do not occur in the same 
 degree. The joint affection is apt to be slight — certainly the swelling and red- 
 ness are — while stiffness and tenderness may be marked. The joints become 
 successively involved, but in children it is not uncommon to find the rheu- 
 matic inflammation limited to a very few joints, such as the ankles or the 
 wrists. Even there it may be pain and tenderness rather than swelling that 
 arrests attention. It is on account of the slight joint affection that acute rheu- 
 matism in children is often overlooked, and the pain and tenderness are attri- 
 buted to a fall or a sprain until the damaged heart tells the story. 
 
 The fever is not high or long-continued ; it is seldom above 102° F. Of 
 those terrible cases with high temperature — temperature reaching from 107° to 
 110° — of which I have met with many in adults, I have never seen an instance 
 in childhood. Fagge observed in 14 cases of the dreaded complication not one 
 less than eighteen years of age ; Wilson Fox, in 22 cases none less than seven- 
 teen years ; Barlow records a fatal case in a girl of thirteen. Hyperpyrexia is 
 certainly most unusual ; and so are the cases with delirium and other signs 
 of cerebral disorder, and the cases with typhoid symptoms, whether associated 
 with high temperature or not. Where the febrile rise is high and protracted 
 there is apt to be delirium, and the morbid signs generally depend upon a 
 heart affection, especially pericarditis. The tongue is not so coated as it is 
 in adults ; the urine is high-colored, dense, with an excess of lithates. From 
 among the usual symptoms of rheumatic fever we miss in children the profuse 
 acid sweats. The skin is moist, but not bathed in perspiration. 
 
 The heart symptoms of the rheumatic fever of childhood occur very com- 
 monly ; indeed, in children endocarditis and pericarditis are more usual 
 attendants on acute rheumatism than in adults. Endocarditis shows itself by 
 increased restlessness, hurried breathing, dry cough, uneasiness or pain in the 
 cardiac region, a rise in temperature or at least a sustained fever tempera- 
 ture, and the development of a murmur, which is generally at or near the 
 apex and systolic. This mitral murmur is followed by an accentuated second 
 sound, or its reduplication, at the apex ; in rarer instances in place of a mitral 
 an aortic murmur is present ; in yet rarer instances there is a diastolic aortic 
 murmur, or a diastolic or a presystolic mitral murmur. The impulse is some- 
 
RHEUMATISM. 353 
 
 -what increased in force, slightly in extent, but the percussion dulness, diffi- 
 cult to ascertain in a child, is not distinctly altered. The pulse becomes 
 more tense, and its beats are not equal. As the case advances, impaired pul- 
 monary resonance and fine rales indicative of congestion may be noticed, and 
 restlessness and anxiety and irregularity of the circulation augment. Where 
 ulcerative endocarditis takes place, recurring chills like those of malarial fever, 
 followed by high temperature and profuse sweats, are apt to occur. And 
 both in this form and in the simple form of endocarditis masses of fibrin may 
 be washed from the vegetations into the vessels of the brain or elsewhere, 
 and cerebral embolism or embolic pneumonia or other kinds of embolism thus 
 happen. 
 
 Besides the marked forms of endocarditis we may encounter only dulness 
 of the first sound, giving it a murmurish character, without decided general 
 symptoms attending the ill-developed cardiac changes. These are instances of 
 mere swelling and slight inflammation, and rarely result in persistent alteration 
 of the valves, as the cases with well-defined murmur commonly do. Then, 
 again, it must be borne in mind that there are many cases in which the 
 general symptoms are so slight that the endocarditis readily escapes detection. 
 Indeed, it is alone the recognition of the changes in the heart-sounds that 
 makes sure of the presence of the malady. 
 
 Pericarditis, owing to the greater difficulty of its recognition, is more often 
 overlooked than endocarditis. This is especially the case in very young chil- 
 dren, in whom, however, it is not common. It may occur at any stage of rheu- 
 matism: sometimes it precedes the joint affection; often it pursues a sub- 
 acute, irregular course, subsiding and breaking out anew as fresh joints 
 become involved. The symptoms are those of endocarditis, but there are 
 greater restlessness and distress, more marked signs of nervous disorder, a 
 tendency to higher temperature, more cardiac pain. The physical signs are 
 the same as in the adult ; prominent among them is the friction-sound, fol- 
 lowed, when effusion takes place, by increased percussion dulness, by dispro- 
 portionate distinctness of the sounds at the base as compared with those of the 
 apex, by muffled sounds at the apex, and its upward displacement. It is much 
 more difficult in children than in adults to make out the dulness, or to deter- 
 mine its triangular shape or its existence in the fifth interspace to the right 
 of the sternum ; and very often the dulness is of irregular shape, and dependent 
 upon thick layers of plastic pericarditis, indicating its existence by coarse 
 friction and by the sounds of the heart being much the same at the apex and 
 at the base. This form of pericarditis without liquid effusion is, indeed, com- 
 mon in childhood. 
 
 So is pleurisy as an attendant upon acute rheumatism common, and not 
 only single pleurisy, likely then to be left-sided, but double pleurisy. One of 
 the dangers o'f left-sided pleurisy is that the inflammation is apt to spread to 
 the pericardium ; at all events, whether from contiguity or from simultaneous 
 action of the rheumatic poison, pleurisy and pericarditis are often combined, 
 and both may be of the exudative plastic variety rather than attended with 
 effusion. Still, effusion does happen in rheumatic pleurisy, and may be of 
 slow absorption or become purulent. Pneumonia rarely complicates the 
 pleurisy ; when it does, it may only reveal itself by rise of temperature, with- 
 out marked cough or expectoration, and by the physical signs. Cheadle 
 believes that these are different from those of pneumonia in the absence, 
 except in the embolic form of the malady, of fine crepitation. 
 
 Chorea bears a very close relation to the rheumatism of childhood. Rheu- 
 matic children are very apt to be irritable, nervous, emotional children, and 
 
 23 
 
354 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 therefore with nervous systems predisposing to chorea. The chorea associated 
 with acute rheumatism has, in my experience, most generally shown itself 
 toward the end of the attack and when the acute symptoms have disappeared. 
 In the majority of instances there has been pericarditis or endo-pericarditis. 
 Sometimes the choreic movements begin at the height of the malady, or the 
 chorea even precedes the joint affection. It must further, in estimating the 
 relation of chorea to rheumatism, be borne in mind that chorea does not always 
 follow an acute attack, but may come on in those of rheumatic taint, without 
 previous well-defined rheumatic manifestations. 
 
 Cutaneous eruptions are often seen in the rheumatism of childhood. The 
 most common form is erythema, which appears on the limbs and the body, and 
 is of the papulated or marginated form, or shows itself as urticaria, less often 
 as erythema nodosum ; in rare instances it is purpuric and associated with sub- 
 cutaneous haemorrhages. Barlow has pointed out that the erythematous rashes 
 may appear simultaneously with pericarditis, or precede this and the articular 
 symptoms. 
 
 But more important than these rashes, and much more strictly linked to 
 rheumatism, are the fibrous nodules. Of extreme rarity in adults, they are 
 not uncommon in children. They are mainly to be found about the joints, are 
 hard and painless or slighly tender on pressure, of size varying from a pin's 
 head to a cherry, and are chiefly to be ascertained by the touch. They come 
 and go in a few weeks, though they may last for months. It is not unusual 
 to have them appearing in crops, and, though these subcutaneous nodules may 
 project from the surface, the skin over them is not discolored. They are almost 
 constantly associated with endocarditis or with pericarditis, and when abun- 
 dant and frequently recurring imply a progressive cardiac affection. 
 
 Among disorders we frequently meet with in the rheumatism of child- 
 hood is tonsillitis. It is often antecedent to the rheumatic attack or occurs in its 
 course, and is combined with decided rise of temperature and pain in swallow- 
 ing. It is not followed by either ulceration or suppuration. 
 
 The anaemia that attends the rheumatism of childhood is very pronounced, 
 and persists long after the attack. Where successive rheumatic seizures occur 
 it becomes more and more decided, and is often associated with marked irrita- 
 bility of the nervous system and emotional disturbance. In its persistence it 
 may become a factor in the mischief wrought by a heart disease and in the 
 development of dropsy. 
 
 Diagnosis. — The diagnosis of acute rheumatism in a child is more difficult 
 than in an adult, because the joint affection is often very slight, and may be 
 nothing more than mere stiffening attended with moderate fever, or pain in 
 moving certain muscles and tendons. Under these circumstances we have 
 to lay great stress on the family history, on the character of previous seizures, 
 on the occurrence of attacks of tonsillitis. Signs of endocarditis or pericar- 
 ditis, or pleurisy, or erythematous rash, or nodules, would be conclusive. In 
 some instances, too tf epistaxis, an occasional symptom of the rheumatism of 
 childhood, is very significant ; so is chorea. Endocarditis or pericarditis in 
 a doubtful case would be, however, the most certain of proofs. 
 
 When the joint affection is distinct, scarlatinal rheumatism is the disease 
 most likely to be confounded with ordinary acute rheumatism. As regards 
 the symptoms I know no difference ; heart affections in scarlatinal rheumatism 
 are less common, but they arise. I have sometimes thought the absence of 
 sweating diagnostic, but the acid sweats of rheumatic fever are also often 
 absent in the rheumatism of childhood. Nothing but the antecedent his- 
 tory makes the case absolutely certain. The severe pain and the swelling 
 
BHE UMA TISM. 355 
 
 of the joints sometimes observed in cerebro-spinal fever may cause this to 
 be mistaken for rheumatism. But the violent headache, the retracted head, 
 the rosy or petechial eruption, the irregular temperature and pulse, are very 
 different from the combination of symptoms noticed in rheumatic fever. In its 
 earlier stages rickets may mislead, on account of the swelling near the joints, 
 the pain, the sweats, the fever. Yet the absence of redness of the joints, 
 the size of the epiphyses, the undisturbed heart, the cachexia, the pale urine, 
 and the fact that the wrist-joints are apt to be the ones first disturbed, or that 
 the swelling shows itself chiefly on the dorsum of the foot and on the back of 
 the hand, are full of significance. 
 
 From pyaemia, rare in children, rheumatism differs by the irregular fever 
 of the former, the sweats, the great pain and swelling that are found in only 
 one or in a few joints, and the course of the disease. There is a pyremic arthri- 
 tis to which infants are liable, that Townsend has well described, which runs 
 an acute course, is mostly confined to the hip or knees, and in which the effusion 
 speedily becomes purulent. Its occurrence in infants at the breast or when 
 gonorrhoeal ophthalmia or vaginitis is present also distinguishes it. 
 
 Scurvy may present pain and swelling of the joints ; the absence of fever 
 and the condition of the gums tell us that it is not rheumatism. In congenital 
 syphilis the state of the bones near the joint may lead to the thought of rheuma- 
 tism, but the characteristic eruption, the snuffles, the emaciation, the enlarge- 
 ment of the spleen, the rarity of fever, and the fact that the symptoms arise 
 in early infancy are diagnostic. 
 
 The diagnosis of the most dreaded affection in rheumatism, the endocar- 
 ditis, presents the same points for consideration as it does when it is not of 
 rheumatic nature, and is discussed in another part of the volume. I will only 
 here mention how important it is to remember the anaemic state that rheuma- 
 tism develops in the young, and not to regard every murmur arising in its 
 course, and especially when it has nearly run its course, as organic and as 
 likely to lead to permanent valve-injury. These soft, systolic blood-murmurs 
 are unconnected with change in valve or in muscular texture, and gradually 
 pass away. 
 
 Course and Duration. — The course of acute rheumatism in childhood 
 depends very much upon the complications, especially upon the cardiac lesions. 
 Nor do we find as many frank cases running their course in a definite time ; 
 the cases are mostly subacute, with subsidences and fresh outbreaks. On the 
 other hand, in infants there are instances of very rapid progress. Jaccoud's 
 cases in infants soon after birth terminated, one in eight days, the other in 
 little more than two weeks. As a general rule, the rheumatic fever of child- 
 hood lasts between two and three weeks. Slight cases, Steiner estimates, get 
 well in from ten to fourteen days. Goodhart's results in ten cases, of which 
 he stated that the longest duration was four days, is not the general experience. 
 It is difficult to be precise in this matter of duration, since much depends upon 
 how early the patient has come under treatment and how well he responds to 
 treatment. Under the salicylates we see the duration often much abridged, in 
 instances particularly of joint affection without internal lesions. Where the 
 heart is affected the case frequently runs on for five or six weeks. Frank 
 relapses are not common. But a succession of subacute attacks in rapid suc- 
 cession, affecting the joints but slightly while adding to the mischief in the 
 heart, is not uncommon. 
 
 Prognosis. — This is favorable ; few die in the disease. Certainly this is 
 true of the first attack ; if the attacks be repeated, there is much more danger 
 during the acute seizure. And the danger, again, depends rather upon the 
 
356 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 condition of the heart than upon the mere recurrence of the rheumatic fever. 
 The liability to cardiac disease increases with the number of attacks. Yet 
 this does not always happen. I have mentioned a case in which three severe 
 attacks happened without heart implication ; and A. Clark tells of one in a boy 
 of twelve in which eight attacks occurred, the heart remaining sound. Such 
 instances are, however, very exceptional. Age has something to do with the 
 prognosis. Of cases between one and ten years of age, 83 per cent., McPhe- 
 dran calculates, have heart lesions ; between ten and twenty, 69 per cent. 
 In 54 fatal cases of rheumatic heart disease Sturges encountered none under 
 two vears of age ; 42 out of the 54 happened between six and twelve years. 
 Embolism and thrombosis are rare, but very grave. 
 
 The chief concern where cardiac affections exist is as regards the amount of 
 mischief that will remain after the acute symptoms have subsided. A murmur 
 indicative of mere roughening of the valve may in the course of a few months 
 disappear. But very often it persists, and gradually, if the lesion have been more 
 than mere roughening of the valve, the signs of hypertrophy with dilatation 
 become manifest. This may not happen from the first attack ; but during 
 slight recurring rheumatic seizures — slight at least so far as the joints are con- 
 cerned — the heart affection is little by little added to ; or this is aggravated by 
 a more severe attack, in which a fresh extensive endocarditis occurs. From 
 pericarditis we may have the same consequences as in adults — adherent peri- 
 cardium with hypertrophy or dilatation ; considerable effusions are very rare. 
 Rheumatic pericarditis by itself has a better prognosis, both at the time and in 
 its ultimate consequences, than endocarditis. But with reference to the latter 
 it must be borne in mind that it is mostly associated with some pericarditis, 
 really an endo-pericarditis ; for few are the cases where endocarditis of rheu- 
 matic origin alone exists. Persistent anaemia after rheumatic endocarditis or 
 pericarditis is always a bad sign. The hypertrophy or dilatation, which under 
 any circumstances happens more rapidly in children than in adults, gains at 
 increased rate. The frequent occurrence of fibrous nodules is a sign of 
 danger, as fresh mischief is apt at the same time to be wrought in the heart. 
 It is then here, as it is throughout in acute rheumatism, the heart, after all, that 
 chiefly determines the prognosis. Chorea is rarely a serious complication. The 
 joint affection mostly passes off completely; rheumatic thickening and anky- 
 losis are very seldom seen in childhood. 
 
 Treatment. — The treatment of acute rheumatism in a child is the same as 
 in the adult. The greatest care must be taken to keep the patient at rest and 
 from being chilled, and with this view the child should be kept in bed in a 
 flannel night-dress or between blankets. The diet should be at first chiefly 
 farinaceous, with bread and moderate amounts of milk ; later in the disease 
 broths and fish may be allowed. Of medical remedies, the most prominent is 
 salicylic acid or its compounds ; among these, salicylate of sodium or of 
 ammonium is well adapted. The dose to a child five years of age is thirty to 
 forty grains in divided doses in twenty-four hours ; to a child of ten, sixty to 
 eighty grains. It may be given in syrup of orange, or in simple syrup with 
 spirits of lavender. The salicylates relieve the joint affection and the pain, 
 and their action is rapid ; after the third or fourth day the dose may be dimin- 
 ished one-half or more. If no result be seen from them in three or four days, 
 they are not likely to produce any, and some other remedy had better be 
 administered. Nor ought they to be trusted to where heart complications exist. 
 Further experience, indeed, both in children and in adults has only added to 
 my conviction, expressed some years since, that the salicylates neither prevent 
 pericarditis or endocarditis, nor benefit its course after it has set in. Their 
 
BHE VMA TISM. 357 
 
 chief use is where there is much pain and the joint affection decided; and it 
 is always well in any case to give also alkalies from the start. When the 
 circulation becomes depressed, or buzzing in the ears or giddiness occurs, the 
 salicylates should be at once discontinued. Salicin is by some recommended as 
 less objectionable, in doses of from five to eight grains every third or fourth 
 hour to a child of five, after the salicylates have been administered for a day 
 or two, or even from the beginning. 
 
 Under any circumstances, in instances of heart complication or where a 
 heart lesion has existed from a previous attack, the alkalies are vastly prefer- 
 able remedies. It is, indeed, to decided doses of the alkalies that we must trust. 
 Fifteen to twenty grains of bicarbonate of sodium in simple syrup and mint- 
 water every third or fourth hour to a child eight or ten years of age, or two 
 drachms of the acetate of potassium in divided doses in the twenty-four hours, 
 form the proper average dose. These alkalies should be administered until the 
 urine becomes alkaline or neutral, and then enough be ordered to keep it 
 neutral. 
 
 Quinine is very valuable. It may be given in decided doses when the tem- 
 perature tends to run high, as, however, it is not apt to do in children unless 
 there be endocarditis or pericarditis. In doses of about six grains daily to a 
 child five years of age it is an excellent remedy when the more acute symptoms 
 have subsided, whether the alkaline or the salicylate treatment be the one 
 pursued. 
 
 Opium is another remedy of great value. It allays restlessness and pain 
 and procures sleep. In coexisting endocarditis or pericarditis it may be directed 
 in small, continuous doses, and is indispensable. The bromides relieve rest- 
 lessness and excitability, and are not without influence on the course of the 
 disease. Conjoined to chloral, they give rest at night; and Goodhart lauds the 
 combination of five grains of the bromide of potassium and one or two of 
 chloral as almost a specific for the nightmare of rheumatism in young children. 
 
 The treatment of the main internal lesions, the endocarditis and the peri- 
 carditis, is discussed in another part of this volume. I will only here speak 
 of my favorable experience in pericarditis with brandy or whiskey in decided 
 quantities, and with opium. The pleurisy is treated as all pleurisies are ; the 
 iodides are especially applicable to the plastic form. The salicylate of sodium 
 has been recently highly spoken of in this kind of pleurisy ; I have had no 
 experience with its use. In the tonsillitis of rheumatism the salicylates give 
 quick results. 
 
 The local treatment of rheumatism consists in wrapping the affected joints 
 in cotton wool, or, where they are very painful, in a flannel bandage saturated 
 with a solution of nitrate of potassium, one to two drachms to the ounce, to 
 which laudanum, twenty drops to the ounce, has been added. For lingering 
 swelling of the joints the rubbing in of iodine, ten to twenty grains to half an 
 ounce of lanolin and half an ounce of belladonna ointment, is well adapted. 
 During convalescence iron is strongly indicated ; and there should be then, as 
 always in rheumatic children, the greatest care exerted with reference to warm 
 clothing, to the food being of easily digestible kind, and to the avoidance of 
 exposure to cold and damp as well as to fatigue and over-exertion. 
 
 II. Muscular Rheumatism. 
 
 This is met with in children, as it is in adults, mostly following cold and 
 exposure, especially exposure to draughts, or fatigue. The disorder is generally 
 subacute, and attended with but little constitutional disturbance. The prom- 
 
358 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 inent symptom is pain in moving the parts involved. It is very rarely a general 
 disorder, but is limited to particular groups of muscles. We find it in the del- 
 toid ; or in the muscles of the loins, as lumbago ; or giving rise to stiff neck, 
 as torticollis ; or involving the intercostal muscles and restricting the acts of 
 breathing, as pleurodynia ; or in the muscles of the head, as cephalodynia. 
 Wherever it is, it has the same characteristics — pain on motion, slight tender- 
 ness, little if any fever. Not unfrequently the urine is high-colored and full 
 of urates. 
 
 Diagnosis. — In the diagnosis of the affection we have to distinguish it from 
 neuralgia. The stricter limitation of the pain of neuralgia to particular spots, 
 and its passing along special lines of nerve-distribution, the far less influence 
 motion has on it, form, broadly speaking, the traits of distinction. We must 
 also not be misled in considering as muscular rheumatism "growing pains," or 
 the pains of aching muscles after unusual exercise. 
 
 Prognosis. — The prognosis is always favorable. The main object, when 
 the immediate attack has been remedied, is to prevent recurrences. 
 
 Treatment. — Rest of the affected muscles, the application of warmth by 
 hot fomentations or the hot-water bag, the use of liniments containing chloral, 
 chloroform, or opium, are all beneficial. Atropine and morphine hypoder- 
 matically, so valuable in adults, cannot be so generally employed in children. 
 Diaphoretics are always serviceable ; a combination of nitrate of potassium and 
 Dover's powder is eminently so ; and in lingering cases the bromide of ammo- 
 nium or the iodide of potassium or of ammonium is of distinct benefit. So is 
 the continuous current. Jacobi considers that the best preventive is the habit- 
 ual use of cold water. 
 
 m Chronic Rheumatism. 
 
 Chronic rheumatism, as we see it in adults, is rare in children ; certainly 
 long-continued stiffness of muscles and chronic enlargement of joints are rare. 
 As already pointed out, recurrence of short attacks with stiffness and pain is 
 the form in which the persistency of rheumatism in childhood much more 
 generally shows itself. 
 
 The few cases that present the same appearances noticed in the chronic 
 rheumatism of adults may be mistaken for rheumatoid arthritis — a disease 
 which is not unknown in childhood, though it is rarely spoken of. The 
 previous history of the case, the occurrence of rheumatoid arthritis in those of 
 feeble health, the wasting of the muscles, the enlarged, crepitating, or fixed 
 joints with the gradually developing characteristic distortion of the fingers and 
 toes, and the absence of all tendency to cardiac affection, are significant in the 
 distinction. 
 
 In the treatment of chronic rheumatism the chief remedies are the 
 iodides, the muriate of ammonium, and arsenic, with great attention to general 
 health and thorough protection by dressing warmly. Using iodine to the 
 affected joints or rubbing them with ammoniated liniments, or, if there be 
 effusion or bony thickenings, small blisters applied from time to time, will give 
 the best results. Good is also done by massage, and by warm baths with carbo- 
 nate of sodium dissolved in them, or by a recourse to the sulphuretted and 
 alkaline mineral-water springs that have been found to be of real service in the 
 chronic rheumatism of adults. 
 
PART V. 
 
 DISEASES OF THE BLOOD. 
 
 AMMIA, SPLENIC ANEMIA, LYMPHATIC 
 AMMIA, AND LEUKEMIA. 
 
 BY FREDERICK A. PACKARD, M. D., 
 
 Philadelphia. 
 
 While in most respects the blood of infants and children resembles that 
 of adults, there are in the blood of the new-born a few variations from the 
 adult standard which require mention. 
 
 During the first twelve days of life the blood has a somewhat venous 
 appearance when seen in bulk. 
 
 In the new-born child the red blood-corpuscles are of much more unequal 
 size than they are in older children and in adults, the largest of them being 
 larger, and the smallest, smaller. During the first four days of life there are 
 to be found a varying number of nucleated red cells. These soon disappear, 
 although some observers claim that they are to be found up to the second or 
 third year. 
 
 Owing, presumably, to the ready solubility of the haemoglobin in young 
 infants, numerous "shadows," or red blood-cells that have lost their haemo- 
 globin, are present. The red cells are more easily aiFected by reagents than 
 is the case in adults, moisture in particular causing them to very readily 
 assume the spherical form. The number of red cells is proportionally larger 
 in the newly-born, the count varying, according to different observers, from 
 4,300,000 (Bouchut, Dubrisay) up to 7,500,000 (Gundobin) per cubic milli- 
 metre. The daily variations in their number are very marked. 
 
 There is marked increase in the number of colorless blood-cells in young 
 infants as compared to adults. The subject of the relative number of the dif- 
 ferent forms has been most carefully studied by Gundobin (Jahrb. f. Kinder- 
 heilk. u. phys. Erziehung, Bd. xxxv. Hft. 1 and 2, Jan., 1893). According to 
 this author, the relative percentage of lymphocytes in sucklings is three times 
 as great as in adults, while the neutrophiles are relatively twice as small in 
 number. From the seventh to the tenth day is the period at which the rela- 
 tive and absolute numbers attain the proportions maintained in later life. 
 
 The amount of hsemoglobin is greater in young infants than in adults. 
 This relative increase is maintained for some weeks, at the end of which time 
 it begins to diminish, until at about the middle of the first year it has reached 
 its lowest point, thereafter slowly increasing to the normal of adult life. 
 
 The specific gravity is said to be high immediately after birth (1.066). but 
 it soon sinks to a little below that of adult blood. 
 
 Plethora. — It is now granted that, while this term may be used as a con- 
 venient means of describing certain conditions, it is not accurate, in so far as 
 
 359 
 
360 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 it implies an actual increase of the total mass of blood or of its corpuscular 
 elements. The term was employed to indicate a condition formerly supposed 
 to be due to "full-bloodedness," but now known to be a condition wherein the 
 appearance of vascular turgescence is due not to any over-richness in blood, 
 but to local changes in the superficial vessels. That a relative increase above 
 the normal of the number of red blood-corpuscles can exist is true only in 
 conditions where the watery constituents are decreased, as in cholera. To 
 this condition the term "plethora " is manifestly inapplicable, the loss of fluid 
 merely increasing the number of corpuscles in the drop. 
 
 ANEMIA. 
 
 Anemia is a condition of the blood due to a decrease in its richness in 
 either corpuscular elements or haemoglobin, either from primary disease in the 
 blood-making or blood-destroying organs, or, secondarily, from general or local 
 disease that interferes with normal absorption, metabolism, and assimilation, or 
 is productive of abnormal loss of nutritive material from the body. 
 
 In the above definition anaemia is spoken of as a condition instead of as a 
 disease, since in the vast majority of instances it is merely a symptom of some 
 well-recognized disease of the whole body or of individual organs. The anae- 
 mias produced by morbid processes that are recognizable as distinct diseases 
 are spoken of as secondary, whereas those occurring without apparent cause 
 save disease of the blood-making or blood-destroying organs are spoken of as 
 primary. In the latter class we must still place chlorosis, progressive per- 
 nicious anaemia, splenic anaemia, lymphatic anaemia (Hodgkin's disease), and 
 leukaemia. 
 
 SECONDARY ANiEMIA. 
 
 Etiology. — Our knowledge of the process of blood-formation and blood- 
 destruction is not sufficiently advanced to explain the production of anaemia 
 in all cases in which it occurs. Where actual escape of blood from the blood- 
 vessels takes place, the explanation is, of course, manifest ; but it is far from evi- 
 dent in exactly what manner prolonged high temperature, loss of albumin from 
 continued suppuration or Bright's disease, the rheumatic poison, and certain 
 toxic influences produce decrease in the richness of the blood in corpuscles or 
 haemoglobin. In childhood the chief causes of secondary anaemia, aside from 
 those operative equally in adult life, are due to improper hygiene as to diet, 
 exercise, and ventilation. A frequent cause is mucous disease, which seems to 
 act by preventing the proper digestion, absorption, and assimilation of nutri- 
 tive material. Improper articles of diet and improperly prepared food may act 
 in practically the same way ; that is, by a failure to supply nutritive material 
 proper to the needs of the body. Too rapid growth is capable of causing anae- 
 mia, the frame seeming to outgrow the quantity of blood manufactured, just as 
 it is apt to become too large for the functional capacity of certain organs. In 
 addition, we must recognize the fact that in some individuals a condition of 
 anaemia seems to be a constitutional characteristic, and to be not incompatible 
 with a fair degree of health. Malaria, as a cause of anaemia, seems to act 
 with even greater intensity in children than is the case in adults, while the 
 anaemia of acute rheumatism at times reaches an extreme grade. Further 
 than in these respects the secondary anaemia of childhood differs in no way etio- 
 logically from that in adult life. 
 
ANAEMIA. 361 
 
 Symptoms. — The general appearance of a child with simple anaemia is 
 too well known to require description. The white skin, pallid mucous mem- 
 branes, waxy appearance of the nails, and blueness of the white of the eye 
 are seen in children as plainly as in adults, if not more so. The subjective 
 symptoms of anaemia do not attain much prominence in childhood, as not only 
 is the child less well able to express its sensations than is the adult, but also 
 because it simply ceases to play around or to exert itself when it feels the sub- 
 jective sensations produced by anaemia, instead of being compelled, as is the 
 adult, to struggle against discomfort in the endeavor to continue the duties 
 of life. 
 
 One of the most frequent symptoms observed in children is the tendency 
 to syncopal attacks. These may occur apparently causelessly, or may be 
 readily induced by violent emotion, slight pain, or confinement in a poorly 
 ventilated apartment. Shortness of breath upon exertion is also frequently 
 present, although in children too young to feel the stimulus of competition this 
 may be shown merely by an indisposition to exertion. Rarely, except in cases 
 of extreme degree, is any oedema discoverable. 
 
 The haeinic murmur at the apex or base does not seem to be produced in 
 children so readily as is the case with adults. 
 
 The examination of the blood shows a reduction in the red blood-cor- 
 puscles, with a corresponding diminution of haemoglobin ; that is to say, the 
 valeur globulaire does not differ from the normal. In extreme cases poikilocy- 
 tosis may be observed. A relative increase of white blood-cells as compared to 
 the red may be present, owing to the reduction in number of the latter. 
 
 Diagnosis. — There is, as a rule, no difficulty in determining the existence 
 of simple anaemia, but the diagnosis cannot be considered as complete until 
 the cause of the poverty of the blood has been detected. The question 
 of the causative factor in simple anaemia of the young requires not only a 
 careful examination of the child itself, but a minute scrutiny of all of the 
 hygienic surroundings. 
 
 The differential diagnosis between simple, secondary anaemia and that of 
 chlorosis and of pernicious anaemia is readily made by an examination of the 
 blood. In simple, secondary anaemia blood-corpuscles and haemoglobin are 
 reduced together, and to an almost equal extent, whereas in chlorosis the 
 haemoglobin reduction far exceeds that of the corpuscles, and in progressive 
 pernicious anaemia the corpuscular poverty exceeds that of haemoglobin. From 
 splenic anaemia the diagnosis must be made by the detection of a cause other 
 than the enlarged spleen. 
 
 Prognosis. — This depends entirely upon the cause. The anaemia itself 
 rarely reaches a degree sufficient to cause anxiety. 
 
 Treatment. — While removal of the cause, when possible, is the prime 
 object of treatment, we may frequently combine our symptomatic treatment 
 of the anaemia with the hygienic and medicinal treatment of the previous 
 affection. Good, nourishing food in quantity and quality to suit the age of the 
 patient and the condition of the digestive organs, abundance of fresh air, and 
 an amount of exercise adapted to the primary disease and to the strength of 
 the patient are all-important aids in treatment. 
 
 For the purpose of increasing the richness of the blood in corpuscles and 
 coloring matter we have two drugs upon which reliance can be placed, iron and 
 arsenic. In employing iron it is important to remember its marked tendency 
 to interfere with digestion, and in cases dependent upon gastro-intestinal dis- 
 turbances we can frequently increase the lacking blood-elements more rapidly 
 by first correcting the digestive troubles, when, indeed, the iron may not be 
 
362 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 required at all. The best forms for its administration to children are the syrup 
 of the iodide of iron, reduced iron, or one of the vegetable salts of iron. The 
 dose of whatever preparation may be selected should be carefully regulated to 
 the age of the patient, and the drug should be discontinued or its amount 
 lessened when it produces constipation or when the stools are distinctly dark- 
 ened. In this form of anaemia it is unwise to give more iron than can be 
 absorbed and utilized, whereas in chlorosis even the iron that is voided with 
 the faeces seems to have been of some utility. 
 
 Arsenic is of great value as a restorer of the red corpuscles, probably by its 
 action upon the blood-making organs. It is pre-eminently useful in the 
 anaemia of chronic malarial poisoning, and is of marked value in the later 
 treatment of mucous disease with anaemia. It is often well to combine iron and 
 arsenic, as they seem to virtually assist each other in many cases ; some such 
 form as the following may be employed : 
 
 1^. Liquor, potassii arsenitis fej. 
 
 Syrup, ferri iodidi f%ix. — M. 
 
 Sig. Ten drops thrice daily. 
 
 THE PRIMARY ANiEMIAS. 
 
 Chlorosis. 
 
 While essentially a disease of youth as opposed to childhood and infancy, 
 this disease is occasionally met with before the former period of life is reached. 
 It is therefore proper that it should find a place in a work upon pediatrics. 
 
 Etiology. — While much has been written upon the essential cause of this 
 condition, it cannot as yet be said that the etiology is by any means definitely 
 settled. The theories regarding it are too numerous to be even enumerated. 
 The most satisfactory explanation is that the excessive destruction or imperfect 
 formation of haemoglobin is due to either the defective absorption and assimila- 
 tion of iron from the intestinal tract or to the absorption from the bowel of 
 poisonous principles with haemolytic properties. The view advocated by Vir- 
 chow that it is caused by congenital hypoplasia of the vascular system, and the 
 view that it depends upon developmental imperfection of the genital apparatus, 
 cannot be considered as tenable considering the rapid and complete cure fol- 
 lowing the employment of proper hygienic and medicinal treatment. 
 
 Age is an etiological factor of great importance, most of the cases occurring 
 between the thirteenth and twentieth years of life. Instances have been 
 observed, however, in individuals even below the former age. 
 
 Sex has a strong determining influence, the vast majority of cases occur- 
 ring in females, and but light grades of the affection being seen in boys. Hered- 
 ity cannot be said to have any but a predisposing influence, and even that is 
 doubtful, although Trousseau and others claim that the disease is very frequent 
 in tuberculous families. 
 
 Habits of life play an important part in its production, the overworked 
 with but little opportunity for the enjoyment of fresh air, exercise, and mental 
 relaxation being those most frequently affected. Depressing emotions, sexual 
 abuse, and fright seem to act as causes, either directly or remotely. The 
 menstrual disturbance so frequently seen in connection with this particular 
 alteration in the composition of the blood must be looked upon as a result 
 rather than as a cause. 
 
 Symptoms. — The complaint that induces a patient with chlorosis to seek 
 
ANJ3MIA. 363 
 
 medical advice is variable. Sometimes it is the shortness of breath upon 
 exertion, at times the interruption of the menstrual periods, and at times the 
 cephalalgia. The usual history given is that the patient has suffered from 
 vertical headache for a variable time, with shortness of breath upon exertion, 
 palpitation, marked lassitude, and frequent fainting-spells. The date of appear- 
 ance of the several subjective sensations is as variable as is their relative 
 intensity. The symptoms above enumerated are those most constantly present. 
 Constipation is usually marked, and a desire for unnatural articles of diet is 
 at times a prominent feature. Gastralgic attacks are frequently present. 
 
 The appearance of the patient is extremely characteristic. The skin has a 
 peculiar olive tint, which, taken in connection with the pale lips, is imitated by 
 no racial peculiarities of coloring. There is apt to be a certain ashy appear- 
 ance about the angles of the mouth. The expression is usually languid with 
 an appearance of sadness, while the features frequently show some heaviness 
 of outline. There is a variety of chlorosis, first described by Wendt, wherein 
 the cheeks retain an abnormally red color — chlorosis florida sen rubra. Occa- 
 sionally a deposit of pigment in the neighborhood of joints is observed. The 
 mucous membranes are pallid to a varying degree according to the extent of 
 the anaemia. There may be slight puflmess beneath the eyes, and the feet or 
 ankles may show slight oedema with but little pitting upon pressure. Marked 
 oedema is, however, rare. There may be visible pulsation of the vessels of the 
 neck. The subcutaneous fat is seldom decreased ; in fact, the condition of 
 embonpoint is that most frequently seen. The pulse is usually rapid and 
 compressible. The apex-beat of the heart is usually plainly visible, and more 
 diffuse than in health. Auscultation reveals, in all marked cases, a soft 
 blowing murmur at either the apex or base, or both, with sharply-defined and 
 somewhat valvular first sound. Over the veins of the neck there is almost 
 always to be heard a loud venous hum. Thrombosis is apparently rather 
 favored by the condition of the blood. 
 
 The examination of the blood is of itself sufficient for a diagnosis. The 
 characteristic change is a marked decrease of the percentage of haemoglobin. 
 With a corpuscle count of 4,500,000, or even over 5,000,000, per cubic mil- 
 limetre the haemoglobin may be decreased to 50 or 40 per cent, of the normal. 
 Less characteristic appearances are the pallor of the drop as it flows from the 
 finger and the variety in the size and shape of the red blood-cells when seen 
 through the microscope. 
 
 The genital apparatus is usually said to be undeveloped. I have, however, 
 seen within the past year a chlorotic, aged fifteen years, with mammae, areolae, 
 and nipples of the size and appearance of those seen in adult life. The urine 
 presents no changes of note save in that it is of low specific gravity and pale 
 in color, contrasting strongly with the low specific gravity and dark color of 
 the urine in cases of pernicious anaemia. . Albumin in small quantities is occa- 
 sionally found. 
 
 Morbid Anatomy. — There have been no distinctive lesions found in the 
 few fatal cases that have come to autopsy. The narrowness of the arteries 
 with the small size of the heart noted by Virchow, and the presence in some 
 cases of a poorly-developed uterus and its appendages, are all that have been 
 noted aside from the apparent bloodlessness of the organs and the retention of 
 a fair amount of adipose tissue. In some cases the left ventricle has been 
 dilated. No alterations in the blood-forming organs have been reported. 
 
 Diagnosis. — As has been said, the appearance is characteristic. The tint 
 of the skin is quite different from the yellowish-brown stain of jaundice and 
 from the lemon-yellow tint of pernicious anaemia and the cachexias. The 
 
364 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 sclerotics are of a clear blue color, in contradistinction to the yellowish colora- 
 tion of icterus. 
 
 From these as well as other diseases the blood-examination will separate 
 this affection at once. From pernicious anaemia and Bright's disease the 
 absence of retinal disturbances would readily distinguish it ; while in the for- 
 mer the examination of the blood is as characteristic as it is in chlorosis, and 
 in the latter the presence of tube-casts and absence of oligochrornaemia are 
 points of plain significance. 
 
 Prognosis. — The outlook is extremely favorable, providing only that 
 patients can be persuaded to continue treatment until absolute cure is estab- 
 lished. The tendency to relapse is very marked, and patients frequently cease 
 their visits when their most marked symptoms have been relieved, only to 
 return in their former condition after the lapse of a few weeks. The disease 
 is but very rarely fatal, and the unfavorable result is due to the onset of some 
 incidental affection. The only complication of note is gastric ulcer, and this 
 is seen but rarely. Permanent disease of the heart may result in protracted 
 cases. 
 
 Treatment. — This is most satisfactory if the patient persist in treatment 
 until cure is complete. 
 
 Hygiene plays an extremely important part. Plenty of fresh air, with 
 moderate exercise and a plain but nourishing diet, will do much to hasten the 
 cure. In some cases absolute rest in bed with milk diet seems to act well, par- 
 ticularly in the more severe and obstinate cases. 
 
 The daily use of the flesh-brush upon rising in the morning is of value, not 
 only in relieving the coldness of the extremities that is often present, but in 
 improving the general nutrition. In vigorous subjects cold sponging before 
 breakfast will help to increase the general tone of the system. The bowels 
 must receive careful attention. Daily evacuations should be procured by regu- 
 lation of the diet, the use of " cannon-ball " massage to the abdomen, and, if 
 necessary, by the use of tonic laxatives. Of the latter, the best by far is aloes 
 or aloin. The latter may be made up into a pill with extract of nux vomica 
 and extract of belladonna, and should be taken at bed-time. The pill of aloes 
 and myrrh of the United States Pharmacopoeia is an excellent combination 
 for older subjects. 
 
 The specific remedy for the disease is iron. The simpler the form in which 
 it is given, the better. The most satisfactory is in the combination known as 
 Blaud's pill (IJ*. Ferri sulphat. exsiccat., Potas. carb. (pur.), da gr. iij). 
 This may be given after meals, increasing from one to three times a day, to 
 two pills three times daily in the first ten days, and maintaining or even 
 increasing this number until the haemoglobin has reached the normal amount. 
 Where objection is made to taking pills, as is frequently the case among the 
 class in which this disease is most prevalent, powdered iron may be readily 
 given. The great point is to give the drug steadily and unremittingly until 
 the oligochromaemia has been absent for one or two weeks or even longer. 
 
 Progressive Pernicious Anemia. 
 
 This is an intense, generally progressive, alteration of the blood arising 
 spontaneously, characterized clinically by the symptoms and signs of marked 
 anaemia, by diminution of the number of the red blood-corpuscles without cor- 
 responding decrease in the amount of haemoglobin, and by an almost invariably 
 fatal result. 
 
 The name of this condition must be looked upon as being provisional. It 
 
ANJEMIA. 365 
 
 is probable that in the future some more definite knowledge may be obtained 
 that wiD enable us to separate the cases now grouped together under the above 
 title into separate classes depending upon etiological factors that are at present 
 unknown. Formerly cases were grouped under this title that are now known 
 to be separate pathological processes, of which the anaemia was merely a 
 symptom, notably those of atrophy of the gastric mucosa and those due to 
 intestinal parasites. At present, however, we must include under one name a 
 class of cases that have no apparent causation in organs other than those 
 immediately concerned in blood-formation, and which still present a uniform 
 grouping of symptoms. 
 
 Etiology. — The actual cause of this disease is as yet unknown. The 
 researches of Quincke and Peters upon the excess of iron found in the liver 
 of patients dying of it, and the observations of Hunter upon the dark color 
 of the urine from the presence of pathological urobilin, would point to the 
 existence of some cause for an increase of haemolysis. Whether this be a 
 poison created within the body has not as yet been proven, but from the 
 remarkable resemblance between this and the anaemia from atrophy of the 
 stomach it is at least possible to suppose that the haemolysis may be produced 
 by the absorption of some toxic principle from some portion of the alimentary 
 tract. 
 
 Age is a marked etiological factor, inasmuch as the large majority of 
 cases occur during middle life. That it does occur in young persons with 
 moderate frequency is shown by the fact that cases have been collected by 
 Griffith, 1 wherein the disease has occurred at the ages of sixteen months, three, 
 five, seven, eight, ten (2 cases), eleven (2 cases), twelve, fifteen, and eighteen 
 years, and in one other boy in which the age was not given ; while I have 
 found additional cases reported as pernicious anaemia, without an exhaustive 
 search of the literature, at ages of eleven months, 2 one year and four months, 3 
 two, 4 four, 5 eleven (2 cases), 6 thirteen, 7 fifteen, 8 sixteen, 9 seventeen, 10 and twenty 11 
 years. 
 
 The female is rather more prone to the disease than is the male sex. 
 
 In one of Escherich's cases the appearance of the disease followed close upon 
 vaccination with animal lymph, but whether there was any relation between the 
 two events it is impossible to say. 
 
 Symptoms. — The most striking subjective symptom is extreme and pro- 
 gressive weakness. Shortness of breath and vertigo soon become prominent 
 symptoms. While feeling extremely ill, the patient retains a fair amount of 
 fat, and save for extreme pallor has the appearance of a well-nourished indi- 
 vidual. 
 
 The weakness and pallor increase gradually with, at times, temporary short 
 intervals of apparent improvement. Dyspnoea increases, the extremities 
 become oedematous, and the patient is at length compelled to remain in bed, 
 
 1 Keating' s Cyclopaedia of Diseases of Children, 1890, vol. iii. p. 809. 
 
 2 D'Espine and Picot {Revue de Med., 1890, p. 859) : blood-count not given, doubtful. 
 
 3 Ibid. : blood-count not given, probably a true case. 
 
 4 Escherich {Wiener klin. Wochenschr., 1892, No. 13, p. 193). 
 
 5 Mott, Practitioner, Aug., 1890. 
 
 6 Ashby and Wright {Diseases of Children, 1892, p. 337) : no bkx>d-count, urine of low spec, 
 grav., and pale, therefore doubtful. 
 
 7 D'Espine and Picot {loc. cit.) : no blood-count given. 
 
 8 Taylor {Guy's Hosp. Rep., 1878) : doubtful, no blood-count. 
 
 9 Wilks {Guy's Hosp. Rep., 1857, p. 203) : probably a case of pernicious anaemia, though 
 described as a case of " idiopathic fatty degeneration." 
 
 10 Handford (Br. Med. Jour., 1891, p. 445). 
 
 11 Eoosevelt (N. Y. Med. Record, 1888, p. 407). 
 
366 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 the whole body being sometimes water-logged with anasarca. Occasionally 
 irregular elevations of temperature arise without apparent cause. Gastro- 
 intestinal disturbance may be present, but in cases unassociated with gastric 
 and intestinal atrophy they sink into insignificance in comparison with 
 the intense languor and shortness of breath. Haemorrhages from the mucous 
 membranes and beneath the skin are sometimes present and may be profuse. 
 
 As a result of treatment or without apparent cause, the condition may for 
 a time improve, but the course is usually progressively downward until death 
 occurs from simple asthenia, possibly hastened by an attack of intestinal dis- 
 turbance or by the onset of some acute inflammatory trouble. 
 
 The appearance of the patient is almost pathognomonic. The skin is of a 
 peculiar pale-lemon tint, the lips almost white, the conjunctivae of a pearly 
 whiteness. Areas of pigmentation may be present on various parts of the 
 body. The retention of a fair degree of embonpoint with the extreme pallor 
 at once suggests this disease to one who has seen a case thereof. 
 
 Upon physical examination nothing abnormal may be found save soft 
 haemic murmurs at the apex or pulmonary cartilage and venous murmurs in 
 the neck. The pulse is soft, readily compressible, and gives an impression to 
 the finger similar to that of aortic regurgitation, which disease this also some- 
 what resembles in the occasional presence of a capillary pulse. The urine is 
 peculiar in that with low specific gravity the color is quite decided — due, 
 according to Hunter, to the presence of pathological urobilin. Upon ophthal- 
 moscopic examination streaks of haemorrhagic extravasation are frequently to 
 be seen. 
 
 The examination of the blood is of itself sufficient to determine the dia- 
 gnosis. The blood as it exudes from the finger is usually of a paler color than 
 normal, and may be obtained only with great difficulty. Upon examining a 
 fresh specimen there is found to be extreme irregularity in the size and form of 
 the red cells. There are seen in the same field numerous red cells smaller 
 than the normal, side by side with others of double the size of the latter. 
 Nucleated red cells of large size are also seen. There is little tendency to 
 the formation of rouleaux. The red blood-cells are far below the normal 
 average per cubic millimetre. Their number varies much with the duration 
 and severity of the individual case : it may sink to below 500,000 per cubic 
 millimetre. The estimation of haemoglobin shows that this is in excess of the 
 amount corresponding to the cellular reduction. This disproportion of the 
 number of red cells and the amount of haemoglobin is characteristic of the 
 disease — the valeur globulaire is exceedingly high. 
 
 Morbid Anatomy. — The skin is generally of a markedly yellowish-white 
 color. The subcutaneous fat is usually remarkably well preserved and is of a 
 light-yellow color. The muscles are peculiarly red, in marked contrast with 
 the pallor of other tissues and of the muscular tissue in other forms of anaemia. 
 All of the internal organs look blanched, but upon the various serous mem- 
 branes ecchymotic areas are frequently seen. Punctiform haemorrhages may 
 also be present in the skin, mucous membranes, connective tissue, muscles, 
 heart-wall, bone-marrow, lymph-glands, spleen, liver, pancreas, lungs, and 
 dura mater. They are due, according to Bermer, to fatty degeneration of the 
 capillaries, although other observers have failed to find the change described. 
 In the serous cavities a varying amount of clear serum is present. The heart 
 is usually large and soft, its walls flabby, its chambers almost empty of blood. 
 " Tabby-cat mottling" of fatty degeneration is frequently present, or the 
 whole tissue may be pale and fatty-degenerated. The spleen "shows no constant 
 changes. The gastric mucosa may be found atrophied in some cases of appa- 
 
' ANJEMIA. 367 
 
 rently true idiopathic pernicious anaemia ; but these cases should not be classed 
 under the name of the disease under consideration unless the view that atrophy 
 of the gastric and intestinal glands is one of the results thereof. The liver 
 is fatty, and shows the only really characteristic change of any of the organs. 
 Upon microscopic examination there is found an excess of free iron in the 
 cells of the outer and middle zones when the sections are treated with proper 
 reagents. The kidneys may be the seat of marked fatty degeneration, and 
 iron has been occasionally detected in the renal cells. The marrow of the 
 shaft of the long bones is of a deep brick-red color, resembling the foetal con- 
 dition, but the appearance is not characteristic, as it has also been found 
 in other forms of anaemia. In the posterior columns of the spinal cord there 
 has been found a process resembling in every respect that seen in locomotor 
 ataxia. 
 
 Diagnosis. — The chief difficulty in diagnosis lies in the exclusion of a 
 primary cause for the anaemia. The appearance of the patient, the subjective 
 symptoms, and the progressive course will usually lead to a correct diagnosis. 
 An examination of the blood definitely decides the question. The diseases 
 which most resemble pernicious anaemia are atrophy of the gastric tubules and 
 malignant disease of the internal organs, particularly those of the digestive 
 tract. Careful examination will usually exclude the latter even without an exam- 
 ination of the blood. Certain cases of atrophy of the gastric tubules have so 
 resembled pernicious anaemia as to render a distinction between them an impos- 
 sibility. Unfortunately, in these cases the chemical examination of the gastric 
 contents is of but little aid, as Ewald has found that hydrochloric acid is absent 
 from the gastric juice in pernicious anaemia as well as in gastric atrophy, and 
 the peptonizing power is diminished in both conditions. 
 
 Prognosis. — The outlook is extremely grave. As a rule, death comes, in 
 spite of all our efforts. A fatal result occurred one month after the first 
 appearance of pallor in the two-year-old child reported by D'Espine and 
 Picot, and in Kjellberg's case of a boy aged five years death occurred six 
 weeks after development of symptoms. Recovery may be considered impos- 
 sible if the red cells number 500,000 per cubic millimetre or less. Since the 
 discovery of the value of arsenic in this disease the prognosis is somewhat less 
 hopeless than formerly. By its use apparently hopeless cases may be at least 
 temporarily relieved. Too often, however, the improvement is but temporary, 
 and relapse soon takes place. Death comes from exhaustion or from the onset 
 of some intercurrent disease. A sharp attack of diarrhoea or an inflammatory 
 disease of the respiratory tract is frequently the immediate cause of death. 
 Haemorrhage is rarely of sufficient amount to cause death. Litten reports a 
 case that apparently passed into leukaemia. 
 
 Treatment. — Absolute rest with freedom from worry and excitement is of 
 prime importance. A diet selected with care and adapted to the needs and 
 capacity of the individual is to be directed. 
 
 Among drugs none can equal arsenic in value. By its means the number 
 of red blood-cells may be increased to within a fair degree of normal, and with 
 corresponding amelioration of symptoms. It should be given freely up to the 
 point of tolerance. It is better to begin with small doses well diluted, and to 
 increase as rapidly as is consistent with the avoidance of toxic symptoms : upon 
 the appearance of gastro-intestinal disturbance or of oedema either the use of 
 the drug should be entirely discontinued for a time or the dose should be much 
 reduced. The pigmentation occasionally seen in the course of the disease should 
 not cause needless fear of arsenical pigmentation. Iron is but seldom of value. 
 It may, however, be used in cases showing an intolerance to arsenic. Rectal 
 
368 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 injections of blood prepared in various ways are no longer considered worthy 
 of the hope that was at one time placed in them. 
 
 The inhalation of oxygen may relieve the dyspnoea that is at times severe, 
 but nothing more than palliation can be expected to result from its use. 
 
 If the theory of intestinal absorption of ptomaines in the causation of this 
 disease be correct — and there seem many reasons for believing it to be so — 
 rendering aseptic the intestinal canal would be a rational means of cure. It 
 is well, therefore, to keep the bowels opened regularly, and to administer in 
 appropriate quantities salol, thymol, or ^-naphthol in order to accomplish what 
 we can in this direction. 
 
 Splenic Anemia. 
 
 In a considerable number of children there is found a marked degree of 
 anaemia associated with no appreciable lesion save enlargement of the spleen. 
 Rendu has reported a case wherein, after the lapse of two years, an increase 
 in the number of white blood-corpuscles occurred, and Gilbert saw a case that 
 later was transformed into lymphatic leukaemia. 
 
 Etiology. — Much discussion has been indulged in as to the cause of this 
 form of anaemia in childhood, and even now it cannot be said that any uni- 
 formity of opinion has been obtained. Malaria is certainly capable, when long 
 operative, of producing both anaemia and chronic splenic enlargement in chil- 
 dren, just as in the case of adults. The cases presenting a malarial history 
 comprise, however, but a very small minority of the cases in which this affection 
 has been observed. 
 
 The two diseases that appear to have most claims as etiological factors are 
 rickets and inherited syphilis. Out of 30 cases, Carr found 27 with other 
 distinctly rachitic lesions ; in 14 cases syphilis played at least a prominent part. 
 In 60 rachitic children Kuttner found a palpable spleen in 44, in 33 of which 
 the organ was markedly enlarged. In only 2 of the 60 cases was there a clear 
 history of syphilis, but in 13 there was a history that the mother had had mis- 
 carriages or stillbirths. In 63 cases examined by them, Fox and Ball found 
 that rachitic symptoms were present in almost all ; and in one series of 
 105 consecutive cases of rickets the spleen was enlarged in 14 per cent. ; in 
 another series of 84 cases of very marked rickets, enlargement was present in 
 40 per cent. That inherited syphilis may be more than a predisposing factor 
 is rendered highly probable from further statistics furnished by the last-named 
 authors. In 63 cases of enlargement of the spleen with anaemia they found 
 inherited syphilis in 41 per cent. ; while in 155 cases of inherited syphilis the 
 spleen was enlarged in 48.4 per cent. The influence of hereditary syphilis in 
 causing rickets should not be overlooked, and it seems more than likely that 
 the most potent factor is rickets. It is interesting in this connection to learn 
 that Sutton (according to Fox and Ball) has found both liver and spleen con- 
 stantly enlarged in monkeys, where rickets is produced by causes other than 
 syphilitic taint. 
 
 The disease would appear to be frequently found in members of the same 
 family, partly due, no doubt, to the fact that the individuals were all subject 
 to the same conditions of life. 
 
 Boys are more often affected than girls, Kuttner having found it in 37 boys 
 out of 60 cases. The disease has been seen at the age of two months (Carr) 
 and in adult life, so that no definite statement can be made as to age as a 
 predisposing factor. 
 
 Pathological Anatomy. — The only characteristic lesions found relate 
 to the spleen. The organ is enlarged, the capsule thickened and adherent, the 
 
ANAEMIA. 369 
 
 parenchyma firm, with marked increase of fibrous tissue. The microscopic 
 examination shows increase of fibrous tissue, with atrophy of Malpighian bodies 
 and disappearance of adenoid tissue (Peter). The marrow of the long bones 
 may have become lymphoid in character. In the other organs various changes 
 are to be found as coincidental affections. These are practically the lesions 
 discovered after death in children with rickets or inherited syphilis. The most 
 frequent abnormal conditions found relate to the respiratory organs. There 
 may be bronchitis, atelectasis, pneumonic consolidation, or the deposition of 
 tubercles. The gastro-intestinal tract may show the lesions of a chronic catar- 
 rhal inflammation. 
 
 Symptoms. — Lassitude and general weakness on the part of the child 
 may be the causes of medical treatment being sought. In other cases the 
 peculiar pallor may have called the attention of the parents to the child's 
 condition. The enlarged spleen may have caused anxiety, or the child may 
 have been brought for treatment on account of the catarrh of the respiratory 
 or digestive tract that is a frequent accompaniment of the condition. The 
 existence of the disease may be discovered accidentally in examining a child 
 presenting other manifestations of rickets. The complexion is of a peculiar 
 waxy, pallid hue, with rather a muddy tint. The mucous membranes are 
 blanched, the tongue pale and flabby. 
 
 Upon examination of the trunk there are found in rachitic children not 
 only the prominent abdomen that is usually seen in children of this class, but 
 there may be visible tumor in the hypochondriac and lumbar regions of the 
 left side. Frequently the enlargement of the spleen may not be discovered 
 until palpation reveals a resisting mass. In marked cases the spleen can be 
 readily felt as a sharply-defined solid tumor, with its anterior edge notched in 
 one or two places. The organ can be made more prominent by pressure with 
 the free hand upon the left hypochondriac and lumbar regions. In less well- 
 marked cases careful palpation, with firm pressure upon the left flank, may 
 be required in order to bring the anterior edge forward sufficiently to be felt 
 through the abdominal wall. Testi heard a vascular murmur over the enlarged 
 spleen. 
 
 Examination of the blood reveals a reduction in the number of red corpuscles. 
 Kuttner found the number in 10 cases to vary from 1,020,000 to 4,080,000, 
 with a haemoglobin value of 35 per cent, in the former instance and 73 per 
 cent, in the latter. There is no absolute increase in the number of white blood- 
 corpuscles, although in fatal cases there may be at times an increase in these 
 elements toward the close of life. 
 
 Irregular fever is frequently present, possibly owing to the frequent catar- 
 rhal complications. In some cases epistaxis may be present, in some sub- 
 cutaneous haemorrhages. Albuminuria seems to be rare, although Carr found 
 it present in two of his cases. The liver is frequently enlarged, and there may 
 be some enlargement of the deeper sets of lymphatic glands. Catarrhal inflam- 
 mation of the bronchial mucous membrane and in the gastro-intestinal tract is 
 frequent, but it is impossible to attribute it to the condition of splenic anaemia, 
 owing to the frequent coexistence of the rachitic condition. 
 
 Diagnosis. — When the spleen is much enlarged the history of the case and 
 the examination of the blood render the diagnosis a matter of ease. The 
 absence of increase of white blood-cells would differentiate the disease from 
 splenic leukaemia, and an examination of the blood for the plasmodium malariae 
 would cast out malarial enlargement. From enlargement of the spleen from 
 amyloid infiltration the absence of a history of the influences causative of that 
 affection, and the failure of evidence of a similar infiltration of the liver and 
 
 24 
 
370 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 kidneys, would differentiate this disease. From an enlarged left kidney the 
 diagnosis is to be made by the presence of notches in the anterior border, by 
 the direction of enlargement, by the greater motility of the tumor upon biman- 
 ual examination, and by the absence of urinary changes. The acute enlarge- 
 ments from typhoid fever, embolic abscess, and acute malarial poisoning are 
 readily excluded by the history of the case. Enlargement from cirrhosis of the 
 liver would be but little apt to cause embarrassment in arriving at a diagnosis. 
 
 Prognosis. — While fatal cases are not rare, the prognosis is not, as a rule, 
 bad if proper hygienic conditions can be enforced. Of Carr's 30 cases, 10 
 died, 6 disappeared from sight, 13 recovered, and 1 remained stationary. The 
 chief cause of death is the occurrence of acute respiratory or digestive inflam- 
 matory complications. 
 
 Treatment. — Of prime importance is the securing of proper hygienic sur- 
 roundings. Plenty of fresh air, well-ventilated sleeping apartments, and a 
 proper amount of outdoor exercise are essential. The diet must receive care- 
 ful attention. The food should be plain and nourishing, with absence of excess 
 of farinaceous articles. The clothing also should be regulated. 
 
 Of drugs, cod-liver oil, arsenic, and iron are the most useful. Phosphorus 
 may be used in those markedly rachitic. In cases that have a distinct history 
 of inherited syphilis mercury may be given, but even in the manifestly syph- 
 ilitic the splenic enlargement is apt to undergo no diminution from its use. 
 The judicious administration of cod-liver oil by either internal means or by 
 inunction, or by both methods combined, with the use of a combination of 
 iron and arsenic, such as was mentioned in the section upon Secondary 
 Anaemia, will be found to be the best line of treatment in connection with 
 careful correction of insanitary conditions. 
 
 The application of electricity over the spleen may produce lessening in the 
 size of the organ. 
 
 Lymphatic Anemia. 
 
 This affection is a more or less generalized condition of the lymphoid 
 tissue of the body, characterized by enlargement of groups of glands or 
 increase in the normal lymphoid structures of a part, accompanied by oligo- 
 cythemia and a varying amount of enlargement of the spleen. 
 
 The disease bears in many respects a close resemblance to the lymphatic 
 form of leukaemia, and, in fact, the leucocytosis that frequently is present to a 
 marked extent has been seen to pass into a condition of true leukaemia. The 
 whole subject of the relation between these two diseases of the lymphoid tissues 
 of the body, and also between them and diffuse sarcomatous disease of the 
 lymphatic glands, still needs further study, in spite of the work that has 
 already been done in attempting to assign them to their proper position. 
 
 Etiology. — This is still far from decided. Inherited syphilis has been 
 supposed to play a certain role, but it is doubtful whether the association has 
 been more than a coincidence. Age certainly exerts some influence, as the 
 disease is very common in the young. Males are more frequently attacked 
 than females. Heredity has not been shown to exert any influence. The 
 action of continued local irritation or inflammation would seem to be a strong 
 etiological factor, and it may be owing to the frequency of long-standing 
 lesions of the skin, of the face and head, of the jaws and ears, that the 
 cervical chains so frequently are the earliest and most markedly involved 
 groups. 
 
 Symptoms. — The disease begins insidiously with enlargement of some 
 group of lymphatic glands, with increasing anaemia with its accompanying 
 
ANJEMIA. 371 
 
 subjective symptoms, and with progressive weakness. The glands most fre- 
 quently attacked are those in the posterior cervical triangle, but the axillary 
 or inguinal glands may be first involved. Deeper sets of glands, as those 
 in the thoracic or abdominal cavities, may be involved before the exter- 
 nal tumors appear, or even without involvement of the superficial groups. 
 The external glands may form large masses, producing much disfigurement. 
 The cervical glands may obliterate the outlines of the neck or may encircle the 
 front portion of the neck like a collar, and produce marked dyspnoea. The 
 axillary group may be enlarged sufficiently to prevent the apposition of the 
 arm to the side, while the inguinal glands may enlarge sufficiently to embarrass 
 locomotion. Pressure of these masses may produce various secondary results, 
 such as pain radiating down the trunks of the nerves running near to the tumors, 
 and oedema from pressure upon the venous trunks. When the visceral sets 
 of glands are involved, there may be no outward signs of their presence, 
 although the retroperitoneal and mesenteric groups may be enlarged so much as 
 to be both seen and felt. By pressure upon various organs, blood-vessels, or 
 ducts they may produce effects varying with the part involved. Dyspnoea may 
 be produced from pressure upon the bronchi ; cyanosis or oedema of the face 
 from pressure upon the superior vena cava. Dyspeptic symptoms, constipa- 
 tion, anuria, ascites, and oedema of the lower extremities may be caused by 
 enlargement of the groups within the abdominal cavity. Secondary involve- 
 ment of the spinal cord may produce paraplegia from pressure. 
 
 The lymphoid tissue in the tonsils, tongue, pharynx, skin, and intestinal 
 wall is occasionally the seat of the same outgrowth, producing symptoms vary- 
 ing with the situation involved. 
 
 Either continued mild pyrexia, alternating periods of pyrexia and apyrexia, 
 or distinctly intermittent fever is usually present during some period of the course. 
 
 The general symptoms are those due to the anaemia. Vertigo, headache, 
 lassitude, and dyspnoea may be obtrusive symptoms. The patient is usually 
 very pale, and the white skin with thickened neck forms a picture that could 
 with difficulty fail to suggest the presence of this disease. 
 
 The examination of the blood shows a decrease of the number of red 
 blood-cells to a varying degree. Poikilocytes are common, and nucleated red 
 blood-corpuscles are occasionally seen. There is leucocytosis, which in some 
 cases attains to such a degree that the case must be classed as a lymphatic 
 leukaemia. 
 
 The patient usually succumbs after a period varying from less than a year 
 to five years (Gowers) from asthenia. Obstinate diarrhoea may occur at any 
 time, even without involvement of the intestinal canal. Death may occur 
 from pressure upon the air-passages before the general condition of the patient 
 would excite alarm. 
 
 Morbid Anatomy. — The skin is pale, the subcutaneous layer of adipose 
 tissue more or less decreased. The post-mortem findings vary much in dif- 
 ferent cases in accordance with the glands involved. Usually there are masses 
 of enlarged superficial glands in the neck, axillae, or groins. These are found 
 to be composed either of isolated, enlarged nodules varying from the size of a 
 pigeon's egg to that of a hen's egg, or of masses of lymphatic glands welded 
 together or even infiltrating neighboring structures, from which they may be 
 separated either with difficulty or not at all. Upon section the individual 
 glands present various appearances even in the same case. They may be soft 
 and of a color not differing much from the normal, and may yield an abundant 
 milky juice, or they may be hard and firm, showing a clear white color of the 
 cut surface without any juice. 
 
372 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Any of the lymphatic glands in various parts of the body may be involved 
 in the same way. The groups of glands in the ruediastina, the bronchial 
 glands, the retroperitoneal, or the mesenteric, may each or all of them be 
 enlarged and more or less matted together. The thymus gland has been found 
 either uniformly enlarged or the seat of lymphoid tumors. 
 
 The spleen is enlarged in the great majority of cases, either from simple 
 hypertrophy or from the presence of tumors of lymphoid tissue. The liver and 
 kidneys may show nodules of lymphoid tissue. The lungs are sometimes 
 affected from encroachment of growths from the bronchial group of glands or 
 by the growth of independent foci of lymphoid tumors. The heart rarely 
 shows similar growths in its substance. 
 
 Various secondary morbid changes are produced by the pressure of the 
 masses of glands upon neighboring structures. 
 
 The marrow of the long bones may have a puriform appearance or may be 
 of an intense red color. 
 
 Histologically, the lymphoid tissue of the enlarged glands and of the isolated 
 tumors is found to be composed of a delicate reticulum enclosing round cells. 
 In some glands there is also an increase of fibrous tissue. 
 
 Diagnosis. — In many cases it is impossible to state whether the case in 
 hand should be classed as one of pseudo-leukaemia or as a true lymphatic 
 leukaemia. In the latter disease the spleen more frequently attains a con- 
 siderable size than in the cases now classified as pseudo-leukaemia. As this 
 disease may pass into a true leukaemia, in so far as the blood-estimation forms a 
 criterion, and as the treatment is practically the same for the two affections, 
 the differential diagnosis makes but little practical difference. The name 
 "pseudo-leukaemia " should, however, be applied only to those cases wherein 
 the proportion of white to red cells does not exceed one to thirty. 
 
 From tubercular adenitis, the so-called scrofulous enlargement of the glands, 
 the differential diagnosis must be based partly upon the family and past per- 
 sonal history, partly from the appearance of the patient, but chiefly from the 
 more localized character of the glandular swelling and the tendency to casea- 
 tion and suppuration in the tubercular disease. 
 
 Secondary involvement of the lymphatic glands by cancer will not enter 
 into consideration in those below adult life. 
 
 Prognosis. — The outlook is extremely unfavorable. The progressive 
 tendency of the disease may sometimes be combated by treatment, but cure 
 can be expected but rarely. In the early stages, where the involved glands 
 are accessible to the surgeon, the disease may be cured by operative treatment. 
 The degree of asthenia and the extent of the anaemia offer some means of 
 forming a prognosis as to duration. 
 
 Treatment. — In early cases, where superficial glands are alone attacked, 
 the chance of cure by surgical means should not be neglected. In cases of 
 doubtful nature, where the diagnosis between this affection and an essentially local 
 disease of the affected glands is difficult, the safest course is to avail ourselves 
 of surgical means of cure. Of drugs, arsenic is the only one upon which 
 dependence can be placed. It should be administered in ascending doses until 
 the point of tolerance is reached. Iron is of secondary value as a haematonic, 
 but may be combined with arsenic, preferably in the form of the officinal syrup 
 of the iodide of iron. External applications to the affected glands can only be 
 of value where the integrity of the skin is in danger. 
 
 Tracheotomy may be necessitated by pressure upon the trachea or if the 
 enlarged glands interfere with the nerve-supply of the vocal cords. 
 
LEUKEMIA. 373 
 
 LEUKEMIA. 
 
 LEUKAEMIA is a disease of the blood-making organs, characterized, clin- 
 ically, by the symptoms of anaemia, excessive increase in the number of white 
 blood-cells, and a tendency to hemorrhagic extravasation ; pathologically, by 
 enlargement of the spleen and lymphatic glands and by changes in the bone- 
 marrow, either separately or in combination. 
 
 The condition of the blood in this disease is mimicked in health after eat- 
 ing (physiological leukocytosis) and in various organic diseases wherein there 
 is an intense local lesion (pathological leucocytosis), as in pneumonia, empyema, 
 etc. The term "leukaemia," however, must be limited to cases wherein leuco- 
 cytosis is more or less constant, is of marked degree, and is associated with 
 the characteristic lesions of spleen, lymph-glands, or bone-marrow. 
 
 As to the nature of the disease there is much diversity of opinion. The 
 term "leukaemia" is at present the most applicable, because non-committal, 
 name that we can apply to it. 
 
 Various divisions have been made in respect to the part chiefly or solely 
 involved in the disease — splenic, lymphatic, or medullary (myelogenous). 
 Rarely is any one form present alone, but the cases usually fall into the classes 
 lieno-medullary or lieno-lymphatic. Cutaneous, intestinal, and tonsillar forms 
 are curiosities. 
 
 The disease bears, in many respects, a close resemblance to sarcomatosis. 
 
 Etiology. — The precise etiology of the disease has not yet been decided. 
 It is preceded by malaria and syphilis in a number of cases sufficient to render 
 it possible that these diseases have at least a predisposing influence. Trauma 
 in the splenic region has been followed by its appearance. Some of the more 
 acute cases pursue a course that is strongly suggestive of an infectious origin. 
 Fermi, Powlowski, Bonardi, Kelsch and Vaillard, Klebs, Roux, and others 
 have reported the finding of various micro-organisms in the blood or tissues of 
 cases of the disease. Negative results were reached in Westphal's case in an 
 attempt to obtain cultures from the spleen during life and from the blood and 
 bone-marrow after death. Gilbert unsuccessfully attempted to inoculate 
 healthy dogs with lymphatic glands from a dog affected with the disease. 
 Mosler failed to produce the disease by the injection of leukaemic blood into 
 dogs and rabbits. Bollinger met with a similar result in attempting to pro- 
 duce the disease in healthy animals by the injection of blood from leukaemic 
 animals of the same species. Apparent infection occurred in Obrastzow's 
 experience, where an attendant upon a case died after fourteen days' illness 
 with purpura, haemorrhages, fever, albuminuria, and a proportion, in the blood, 
 of one white to nine red blood-cells. 
 
 The disease is seen at all ages from birth up to the seventy-fifth year. It is 
 most frequent between the ages of thirty and fifty years. It is not rare in 
 childhood, many cases having been reported in infants less than two years of 
 age, while Sanger has reported its existence in a stillborn child. It is more 
 common in males than in females. Heredity has not been proven to be an 
 etiological factor. Horses, oxen, dogs, pigs, cats, and mice suffer from a sim- 
 ilar affection. 
 
 Symptoms. — The usual symptoms that impel the patient to seek advice 
 are the general weakness, the pallor, the shortness of breath, haemorrhages 
 from the mucous membranes, the enlargement of the abdomen, or the super- 
 ficial lymphatic tumors. The disease usually arises gradually, so that, as a 
 rule, marked changes in the organs and blood have occurred before the patient 
 is brought for treatment. 
 
374 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The symptoms produced by the abnormal condition of the blood are similar 
 in the different forms of the disease, but the examination of the patient yields 
 results varying with the type. Breathlessness upon exertion is usually a very 
 marked feature. It may be accompanied by marked vertigo upon change of 
 posture. The bodily strength is impaired to a great degree, but in some cases 
 it is remarkably well preserved in view of the serious changes in the composi- 
 tion of the blood. Haemorrhages may have occurred from the nose, throat, 
 stomach, or intestines, or there may be hemorrhagic extravasations beneath 
 the skin. Hemorrhages in the fundus oculi may produce sufficient interfer- 
 ence with vision to attract the attention of the patient. Edes has recorded a 
 case wherein priapism was the first symptom. During the course of the 
 disease occasional rises of temperature may be noted. 
 
 Upon examination there is found more or less pallor of skin and mucous 
 membranes. The pulse is soft and compressible, with increased rate. If the 
 anaemia be marked, there may be heard a haemic murmur over the position 
 of the apex-beat or in the second left intercostal space. The lungs usually 
 present no morbid signs save toward the close of fatal cases, when oedema, 
 congestion, or a fluid accumulation in the pleural cavity may be found. In 
 some cases there is found in the lung what clinically resembles lobar pneu- 
 monia, but histologically is found to present features differing from the 
 ordinary form. 
 
 Diarrhoea may be persistent, and in some cases a species of dysentery is 
 present. Vomiting is not a frequent symptom. The occasional occurrence of 
 haematemesis has been mentioned above. 
 
 The urine is usually unaltered save for an increase in the amount of uric 
 acid excreted. 
 
 On the part of the nervous system we may have no symptoms. Vertigo 
 and cephalalgia are at times marked. Death may occur from intracranial 
 haemorrhage. Vision may be much impaired, due to the presence, as revealed 
 by the ophthalmoscope, of retinal haemorrhages or of leukaemic deposits. 
 Hearing may be impaired. Suchamick has noted a peculiar brownish discolora- 
 tion of the nasal mucous membrane in one case. 
 
 The usual course of the disease is slowly progressive, covering a period of 
 months or years. There have been reported some cases running an extremely 
 rapid course, as in that of Guttmann, where a fatal termination occurred after 
 an illness of four and a half days. 
 
 The examination of the blood is all-important in determining the nature of 
 the disease. The constant feature is an increase, both relative and absolute, 
 of the white corpuscles. This may attain to an extreme degree, the relative 
 number of white to red cells having even been as two to one in a case reported 
 by Robin. The average ratio of white to red cells is as one to fifty or 
 twenty, in cases without great reduction in the latter elements, as opposed to 
 one to 500 or 700, the average ratio of health. The various forms of white 
 blood-cells are present in different proportions in the lieno-medullary and in 
 the lymphatic varieties. In the former the eosinophilous cells of Ehrlich are 
 the predominant form, whereas in the acute lymphatic variety the lymphocytes 
 form the main proportion of the colorless elements. Where the lymphatic, 
 splenic, and medullary varieties exist together in the same patient, the propor- 
 tion of the forms of leucocytes will produce variations from the two types 
 mentioned. Myelocytes may be present in large numbers. Charcot's crystals 
 are said to form after the blood has remained upon the slide for a short time. 
 
 In the splenic form a prominent feature is the gradual enlargement of the 
 spleen. This occurs to a varying degree, the organ in extreme cases even 
 
LEUKEMIA. 375 
 
 reaching to or beyond the median line of the abdomen. The splenic enlarge- 
 ment takes place chiefly in a diagonal direction, downward and toward the 
 right. When the hand is placed over the mass, a rub may be felt and tender- 
 ness be elicited by pressure. Spontaneous pain or sense of pressure may 
 be an annoying symptom, while the weight of the organ may produce dis- 
 order of digestion or marked constipation. 
 
 When the marrow of the bones is affected, there may be tenderness over 
 the affected parts, with localized swellings on the shafts of the long bones or 
 the ribs or sternum. 
 
 The lymphatic glands are less frequently involved than is the spleen. 
 The superficial glands show enlargement and can be readily felt, or even 
 seen as isolated groups or chains. The deep glands of the abdominal cavity 
 may be affected. 
 
 Morbid Anatomy. — The skin is pale, the subcutaneous fat usually much 
 diminished. The blood has a chocolate color, or may even almost resemble 
 sanious pus. When clotted it has a greenish-yellow color. On the serous 
 membranes there may be areas of hemorrhagic extravasation. In the serous 
 cavities there is usually an excess of fluid. 
 
 The heart is frequently found distended with clotted blood. The lungs present 
 no constant changes, although posterior congestion is often seen. Rarely are 
 there any changes in the thymus gland. 
 
 The spleen is almost invariably enlarged to a greater or less degree. 
 Adhesion to neighboring organs is common, explaining the sharp attacks of 
 pain sometimes experienced in the left hypochondriac region. The organ is 
 usually symmetrically enlarged, is of increased density, and on section may 
 show either a brownish color throughout the surface, or there may be scattered 
 areas of a white color due to localized infiltration with lymphoid cells, either in 
 the Malpighian follicles or in the pulp. Hemorrhagic areas may be present. 
 The spleen may enlarge so rapidly as to cause a rupture of its capsule. 
 
 The intestines show at times evidences of lymphoid infiltration, either in 
 the glands of Peyer or in other parts, by thickening without ulceration. The 
 tonsils, pharynx, and stomach have been found to show signs of the over- 
 growth of lymphoid tissue. 
 
 Lymphoid tumors have been found in the liver in sufficient number to 
 notably increase the size of the organ, while the kidneys also may present 
 whitish areas of lymphoid infiltration, as in the case reported by Frankel. 
 The lymphatic glands of the superficial sets or of deeper parts, as near the 
 root of the mesentery, are in some cases much enlarged, although rarely to so 
 great an extent as in pseudo-leukaemia. 
 
 The marrow of the bones is affected in a considerable number of cases, 
 chiefly in conjunction with splenic involvement. In these cases it is found 
 to be of a puriform appearance or to be of a dark-red color. Hemorrhagic 
 areas may be present. The shaft may be found expanded and the wall thinned. 
 Microscopically, the marrow shows large numbers of nucleated red blood-cells, 
 eosinophiles, and myelocytes. 
 
 Diagnosis. — The only diseases with which leukemia is apt to be con- 
 founded are pseudo-leukemia, splenic anemia, and scrofulosis. From these 
 the diagnosis may readily be made by an examination of the blood. The 
 numerical increase of the white blood-cells is alone sufficient to make the dia- 
 gnosis, save in cases of non-leukemic leucocytosis. From this the diagnosis 
 cannot be made with certainty by the hemocytometer alone, as in leucocytosis 
 the relative increase of white cells may be greater than in some cases of 
 leukemia. For the differentiation of these two conditions we may employ the 
 
376 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 method of differential staining according to Ehrlich's procedure. While some 
 question has been raised as to the value of the eosinophile cells as diagnostic 
 criteria, this objection cannot now be said to be of weight save in the lym- 
 phatic variety, where the cells having eosinophile granules are not present in 
 large number. 
 
 Prognosis. — The prognosis as to recovery is grave, although cases have 
 been known to recover. The disease is usually fatal within a few years. In 
 some cases of acute lymphatic leukaemia, as in the case reported by Guttmann, 
 death may occur within a few weeks or days. 
 
 Treatment. — Rest is of prime importance. The dietary should be selected 
 with care, and should be suited to the digestive power of the individual. 
 
 Arsenic is almost the only drug that can be said to be of any real value. 
 It should be pushed up to the verge of tolerance, and its use should be per- 
 sisted in until either it is evident that no result is being obtained or until the 
 patient is, mayhap, relieved of the disease. 
 
 Quinine should be tried in cases giving a malarial history, but it will rarely 
 be productive of much benefit. 
 
 Injections of arsenic into the spleen are not likely to materially benefit the 
 patient, and are not without risk. Westphal's case died after a puncture of the 
 spleen for diagnostic purposes, the organ being surrounded by a large blood- 
 clot at the autopsy. Splenectomy cannot be considered justifiable, in spite 
 of Franzolini's successful case, in view of the large mortality attending the 
 operation. 
 
HAEMOPHILIA. 
 
 By WILLIAM PERRY NORTHRUP, M. D., 
 
 New York. 
 
 Hemophilia is a tendency to obstinate bleeding ; inherited ; often asso- 
 ciated with swelling of the joints. 
 
 Etiology. — The haemorrhages may be traumatic or spontaneous in origin. 
 Certain families are known as " bleeders," the hemorrhagic diathesis manifest- 
 ing itself at any time from early infancy to the end of life. Hereditary trans- 
 mission takes place mostly through the mother and to her male offspring. If a 
 woman descended from bleeders marry a healthy man, the sons will inherit the 
 hemorrhagic diathesis, the daughters escaping. In the succeeding generations 
 the sons in whom hemophilia is manifest will not transmit the diathesis, 
 whereas the daughters, who show in themselves no signs of it, will transmit the 
 diathesis again to their sons. The maternal transmission so continues to many 
 generations, the hemorrhagic condition appearing in the males, the females 
 escaping, but transmitting the diathesis to their sons. Bleeders usually have 
 large families, some of whom may escape the disease. They are to be found 
 in all localities, in all conditions of life ; are healthy in appearance, commonly 
 having fine, soft skins. The Hebrew race is said to be particularly liable to it. 
 
 The real cause of hemophilia is unknown. It is believed that the condi- 
 tion has in some individual instances been acquired. 
 
 Pathological Anatomy. — The post-mortem findings do not explain the 
 nature of the affection. An unusual thinness of the walls of the vessels has 
 been observed, though the microscope fails to reveal any essential and constant 
 alterations. The tissues are blanched from loss of blood. Petechie and 
 bruised patches are frequently observed upon the surface of the body. The 
 swelling of the joints is due to hemorrhages into the articulations and the 
 surrounding tissues. Occasionally there is evidence of joint inflammation. 
 At present it has not been determined whether the hemorrhage is due to some 
 fault in the walls of the vessels, or whether there is some peculiarity in the 
 character of the blood on account of which thrombi are not formed. 
 
 Symptoms. — At birth there is nothing in the appearance of the child to 
 indicate the peculiarity of his inheritance. He is usually healthy and bright, 
 and may in the first year develop no signs of hemophilia. The severing of 
 the umbilical cord does not usually give occasion for obstinate bleeding, and 
 not until his growth and strength lead him into accidents, such as bruises, cuts, 
 scratches, and punctures, does the hemorrhagic tendency become apparent. 
 Epistaxis is the most common experience which calls attention to the diathesis. 
 This may be acute, obstinate, and alarming. Besides, there may be petechie, 
 ecchymoses, hematomata, interstitial and external bleeding, traumatic or spon- 
 taneous. 
 
 A common symptom is swelling of the joints closely resembling rheumatism. 
 It is not uncommon to find hemorrhage of the gums at the eruption of the 
 second crop of teeth. Slight cuts give rise to troublesome hemorrhage, slight 
 
 377 
 
378 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 blows to marked ecchymoses, and a blister may contain blood instead of serum. 
 Prolonged and dangerous bleedings may follow the extraction of a tooth in 
 spite of the application of the strongest styptics. 
 
 The bleeding is from the capillaries, most often an oozing, which may con- 
 tinue from hours to weeks. The subjects of haemophilia are very sensitive to 
 cold, and suffer from joint-pains apart from those dependent upon haemorrhage. 
 Such patients pass through the exanthemata and other diseases of childhood 
 without special dangers, and have no marked proneness to phthisis. Sloughing 
 and gangrene are not uncommon accidents of this condition. 
 
 Prognosis. — From the nature of the disease it must be considered a con- 
 stant menace to life. However mild the tendency in the infant, the prognosis 
 should be considered very serious. Of 152 cases of haemophilia traced by 
 Grandidier, more than half died before completing the seventh year, and only 
 19 attained majority. The exhaustion of repeated haemorrhages, or, more 
 commonly, the draining away of blood by continued oozing, may destroy life. 
 The most difficult of control and the most frequently fatal are the haemorrhages 
 following extraction of teeth or from epistaxis. 
 
 There are examples of bleeders who have attained a good age and led busy 
 lives. To this class belongs a very busy practitioner of the writer's acquaint- 
 ance, who is never without fresh petechiae of the face, and constantly carries a 
 large red handkerchief for accidental epistaxis. 
 
 In females the prognosis is good, neither menstruation nor childbearing 
 being complicated by this capricious example of atavism. 
 
 Treatment. — Prophylaxis avails somewhat to diminish the accidents of 
 haemorrhage. The system may be fortified by abundant fresh air and tonics, 
 by judicious exercise and general hygiene. The child should be guarded, so 
 far as possible, from bruises, cuts, and punctures. Vaccination, though not 
 historically accounted a dangerous procedure in bleeders, should be accom- 
 plished rather by scarification than by incision. Slight operations should be 
 seriously considered before they are undertaken, and every needed means 
 of haemostasis should be at hand. The extraction of teeth should be avoided. 
 Nearly every practitioner has had at least one trying experience with obstinate 
 haemorrhage from such cause in a person not haemophilic, and can well under- 
 stand the importance of this advice. 
 
 It is well to have the diet properly regulated for haemophilics, giving vege- 
 tables and generally wholesome mixed meals, without excess of meat. The 
 bowels should be regulated so as to correct any tendency to a "full-blooded " 
 condition. Where premonitory symptoms indicate an impending haemorrhage, 
 it is well to relieve the bowels by a mercurial purge, followed by a saline. 
 
 In case of haemorrhage treatment will necessarily be modified by the region 
 in which it takes place. Cuts and bruises should be cleansed and bound up, 
 with ice, perchloride of iron, or nitrate of silver applied to the point of bleed- 
 ing. In epistaxis the nasal cavities may be treated by irrigating the parts with 
 cold water or by an absorbent-cotton plug saturated with peroxide of hydrogen ; 
 if need be, the cavities may be tightly plugged with cotton soaked in an iron 
 solution. If the haemorrhage arise from the socket of an extracted tooth, 
 apply crystals of subsulphate of iron or a cotton pledget soaked in Monsel's 
 solution, or apply caustics. Haemorrhages from the bowel should be treated 
 with opium to secure quiet and rest, and by cold-water injections. 
 
 Haemophilics should be dressed warmly, should avoid cold, damp climates, 
 and all so-called rheumatic surroundings. The joint affections may be treated 
 much like similar conditions in chronic rheumatism, perfect rest and soothing 
 applications being primarily indicated. 
 
PURPURA HEMORRHAGICA 
 
 By GEORGE ROE LOCKWOOD, M. D. 
 
 •J 
 
 New York. 
 
 Under the term " Purpura Haemorrhagica " we include a clinical group of 
 cases characterized by the association of purpura with haemorrhages from any 
 of the mucous membranes, less frequently into serous membranes and joints or 
 into the substance of the viscera. First described by Werlhof in 1775, it is 
 often known as " Werlhof 's disease." It is also known as "morbus macu- 
 losus." 
 
 A careful study, however, of the cases embraced by this definition shows 
 such a variety in their clinical course and in their etiological factors that it 
 seems impossible to regard them even as different types of the same disease. 
 Their symptoms, in a general way, may be alike, but in some cases they appear 
 suddenly and peracutely without assignable cause, associated with symptoms of 
 acute sepsis, often causing death within a few hours or days. In other cases 
 without known cause the symptoms appear subacutely, and are less marked, 
 the constitutional symptoms being mildly septic in character. In still others 
 the symptoms occur either as a complication of some coexisting disease or as 
 the result of a well-known cause. It seems better, therefore, to regard the term 
 purpura haemorrhagica as one purely clinical in its scope, including a number 
 of cases distinct in their clinical course, pathology, and etiology, but which 
 present, in common, symptoms of sufficient similarity to be included under one 
 general name. 
 
 The study, then, of purpura haemorrhagica is rendered more clear by dividing 
 the cases of this disease into two groups: I. essential, and II. symptomatic pur- 
 pura hemorrhagica ; the essential group including those cases in which the 
 disease begins without known cause, the haemorrhages and purpura being asso- 
 ciated with more or less marked septic symptoms, and running a course 
 resembling that of an infectious disease ; the symptomatic group including 
 those cases in which the symptoms arise from a well-known cause (as poisoning 
 from over-use of potassium iodide), or as a complication of a severe blood or 
 infectious disease (as in profound anaemia or in the exanthemata). 
 
 The essential cases seem to the author to constitute the only true group to 
 which the term purpura haemorrhagica should be rightly applied, and these will 
 therefore be described more fully than the symptomatic cases, which should 
 more properly be classed among the symptoms of the diseases which they 
 complicate. 
 
 I. Essential Purpura Hemorrhagica. 
 
 This form occurs both subacutely and acutely, the former being far the more 
 common, and about which we know most. 
 
380 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Subacute Purpura Hemorrhagica. 
 
 This variety of the disease is seen more frequently in females than in 
 males. While no age is exempt, it usually attacks children and young adults. 
 Food deficient in quantity and quality, poor hygiene, and a weak, sickly 
 constitution predispose to the disease, but not as markedly so as in scurvy. 
 Often it attacks those who are healthy, well fed, and well housed. There is 
 rarely a family history of any hemorrhagic disease, although in two cases in 
 young girls under the author's observation the father of each had been subject 
 to severe attacks of epistaxis in early life. The subacute cases occur in two 
 clinical forms : (1) ordinary cases, and (2) cases of Henoch's disease. 
 
 Ordinary Subacute Cases. — This form usually begins with prodromal 
 symptoms, anorexia, malaise, chilly feeling, and irregular rise in temperature, 
 especially at night. These may precede the onset by several days or even 
 weeks. In other cases there is no prodromal period. When the disease is 
 fairly developed we have both hsemorrhagic and constitutional symptoms. 
 
 Symptoms. — Hemorrhagic Symjrtoms. — There appear purpuric spots, 
 usually first noticed on the extremities, though they may be generally dis- 
 tributed. Their size varies from that of a pinhead to that of the palm of the 
 hand. In severe cases we may have large areas of ecchymoses, which may be 
 extensive enough to cause gangrene of the skin. Successive crops of purpura 
 appear during the disease, and they may be often produced by rubbing or 
 scratching the skin. Rarely we have associated with the purpura and ecchy- 
 moses hemorrhagic vesicles and bullae. 
 
 There are free haemorrhages from any of the mucous membranes — nose, 
 mouth, gums, bronchi, stomach, intestines, and pelvis of the kidney. There 
 may be also metrorrhagia. The most frequent sources of haemorrhage are from 
 the nose, pelvis of the kidney, intestines, and uterus respectively. 
 
 These haemorrhages occur spontaneously, and not from traumatism alone, 
 as is the case in haemophilia. They may be moderate in their severity or 
 profuse enough to cause the death of the patient. 
 
 Pain and swelling of the joints, especially those of the hands, feet and 
 knees, are frequently noticed. The symptoms are identical with those of pur- 
 pura rheumatica. There may be swelling of the fibro-serous tissues about the 
 joint, or the joint-cavity may be filled by an effusion either serous or fibrino- 
 serous. In severe cases the joint may become ankylosed or an arthritis may be 
 caused. The primary symptoms are due to haemorrhages either into or around 
 the joints. 
 
 Internal haemorrhage may occur at any time and into the substance of any 
 of the viscera, especially the brain and its membranes, the suprarenal capsules, 
 or the lung. These internal haemorrhages, however, are rare in the subacute 
 form, though more common in acute cases. 
 
 The gums may be normal or swollen, although this is denied by many 
 writers. They may be covered by blackish scabs, and may bleed even when 
 they are not swollen. The teeth, however, are not loosened as in scurvy. 
 
 In no case are ulcers of the intestine, due to submucous haemorrhages, ever 
 seen. Free haemorrhage from the skin does not occur. Although the kidneys 
 are frequently the source of haemorrhage, nephritis has not been observed. 
 
 Constitutional Symptoms. — These appear in varying intensity, and are due 
 both to the anaemia from the haemorrhage and also to moderate sepsis. A dis- 
 tinct chill at the onset is rare, but chilly feelings are common and may continue 
 through the attack. The temperature varies from 100° to 103°, or even 104°, 
 being higher in severe cases and in children. It is higher at night. After the 
 
PURPURA HEMORRHAGICA. 381 
 
 severity of the attack is over the temperature gradually returns to normal : a 
 sudden fall in temperature, with a subsequent rapid rise, is noted in cases of 
 sudden severe haemorrhage, especially if such occur into the viscera. 
 
 The pulse is of low tension and somewhat rapid. It may become rapid, 
 small, and weak. Attacks of syncope are common. 
 
 General anaemic symptoms are always present, even in cases in which the 
 haemorrhages are slight, but they are more severe when the haemorrhages are 
 profuse. They appear early in the attack and continue throughout its dura- 
 tion : after the attack subsides the recovery is long and tedious, and often it 
 takes weeks or months before the blood returns to its normal condition. 
 
 Examination of the blood during the attack shows rapid diminution of the 
 number of red blood-corpuscles, and a corresponding diminution in the amount 
 of haemoglobin. The white cells are at first increased in number, as is the 
 case after acute haemorrhage, but later their number steadily diminishes, even 
 during early convalescence, while the number of red corpuscles and the amount 
 of haemoglobin are steadily increasing. 
 
 These points are well shown by the records of blood-examinations made in 
 a case reported by Osier : 
 
 
 Number of red cells. 
 
 Number of white cells. 
 
 Per cent, of 
 haemoglobin. 
 
 1st dav, 
 
 5,350,000 (107%) 
 
 8,000 
 
 95 
 
 2d day, 
 
 3,000,000(60%) 
 
 12,500 
 
 50 
 
 8th day, 
 
 2,500,000 (50%) 
 
 12,500 
 
 37 
 
 14th day, 
 
 3,000,000(60%) 
 
 7,000 
 
 47 
 
 50th day, 
 
 4,000,000 (80%) 
 
 2,500 
 
 62 
 
 70th day, 
 
 4,250,000 (82J%) 
 
 • • 
 
 72 
 
 Prostration is a prominent symptom, and is always more marked than can 
 be accounted for by the haemorrhage and constitutional symptoms. It remains 
 usually for some weeks after all other symptoms have disappeared. In severe 
 or long-continued cases it may be so profound that the patient passes into the 
 " typhoidal condition," with rapid and feeble pulse, dry brown tongue, stupor 
 alternating with mild delirium, or even coma and death. 
 
 The spleen and liver are usually enlarged during the attack. The enlarge- 
 ment of the liver in some cases is well marked, and may be distinctly appre- 
 ciable for weeks or months after the subsidence of the disease. The conges- 
 tion and enlargement of the liver often cause a mild catarrhal jaundice, which, 
 added to the anaemic appearance of the patient, gives a bright fawn-yellow 
 color to the skin. 
 
 The duration of the attack varies from a few days to several weeks, but the 
 disease may be protracted for weeks, months, or years by the appearance of 
 similar attacks (or "relapses" of some authors). These attacks may recur at 
 regular or irregular intervals, their usual number being four or five. In one 
 unique case under the author's observation the attacks have persisted for fifteen 
 years, the patient showing no signs of improvement at the end of this time. 
 The next case of longest duration is one reported by Hryntschak, in which the 
 attacks lasted for seven years. 
 
 Nature and Pathology. — For the blood to escape from its vessels and 
 cause haemorrhage we must naturally conclude that the vessel-wall must first 
 rupture. As this does not normally occur, except from traumatism, we must 
 also conclude that its wall is weakened either from inflammation or from 
 degeneration due to disease, to poor blood-supply, to toxic blood, or to 
 thrombi. 
 
 Much light has been thrown on this subject by Silberman, who gave fifteen 
 
382 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dogs small steady doses of pyrogallic acid until there appeared areas of stasis in 
 the small arteries, capillaries, and veins. After pressing out the stasis-blood 
 he injected fibrin ferment into the arteries. The dogs had abdominal tender- 
 ness, purpura, bloody vomiting, and bloody stools. Autopsy showed in the 
 hemorrhagic areas thrombi in the small arteries and veins, whose walls had 
 undergone hyaline degeneration with areas of necrosis, thus allowing the free 
 escape of blood. 
 
 Many attempts have been made to discover a specific bacterium, but before 
 the time of Letzerich the examinations were so incomplete as to be entirely 
 without value. Letzerich, however, in 1889 made scientific bacterial exam- 
 inations, and discovered a bacillus which he believes to be the specific germ 
 of the disease. Although his experiments have not been corroborated by others, 
 their success still remains of the greatest value. His patient was a girl suffer- 
 ing from the subacute form. Bacterial examinations, scientifically performed 
 in every detail, showed in the purpuric spots the presence of long bacilli 
 capable of growth in gelatin, the pure cultures of which, injected into the 
 abdomen of rabbits, reproduced the original clinical symptoms in all of the 
 twelve cases, and in these a bacillus was found identical with that in the pure 
 culture injected. An examination of the purpuric spots in the rabbits showed 
 dilatation of the capillaries, emigration of white cells, and rupture of the capil- 
 lary wall, permitting the escape of red cells. The capillaries were filled with 
 the bacilli with abundant spore-growth. (The bacilli and spores had been 
 previously described by Petrone, in his examinations of a case of Werlhof 's 
 disease, but he considered the disease to be due to a mixed infection.) 
 
 Upon squeezing the section Letzerich found that little plugs resembling 
 hyaline casts containing bacilli emerged from the capillaries, and these he con- 
 sidered the result of the action of the bacillus in its products upon the fibrino- 
 plastic elements of the blood. The liver in the rabbits was regularly enlarged, 
 and the portal capillaries were almost occluded by an extraordinary growth of 
 the bacilli. Letzerich considers the liver to be the breeding-place of the 
 bacilli, the liver being to this disease what the spleen is to malarial fever. If 
 he be correct in his conclusions, it explains both the scattering of the lesions — 
 a bacterial embolism of the capillaries causing hyaline thrombi within them 
 with rupture of the capillary wall — and also the tendency of the disease to 
 relapse. While conducting his experiments Letzerich was himself seriously 
 attacked by this disease, attributing his infection to handling his cigar while 
 at work. This case of infection seems to prove the advisability of disinfection 
 after an attack. 
 
 Prognosis. — This is generally good, almost all patients recovering from 
 the primary and secondary attacks. Recovery, however, is slow, the anaemia 
 and prostration often lasting for months after the disappearance of other symp- 
 toms. The occurrence of the secondary attacks cannot be foretold. In rarer 
 cases the disease terminates fatally, the cause of death being either profound 
 anaemia, fatty degeneration of the heart, with or without dilatation, from long- 
 continued anaemia, visceral haemorrhages, or exhaustion. 
 
 Treatment. — This is unsatisfactory, both in shortening and mitigating the 
 attack and in the prevention of subsequent relapses, as there is no specific 
 known that acts in this disease as quinine does in malarial fever. Our treat- 
 ment, then, must be entirely symptomatic, and consists in treatment during the 
 attack and prophylactic treatment destined to prevent future attacks. 
 
 The treatment during the attack consists in efforts to check the haemor- 
 rhage and in the relief of constitutional symptoms. To check the haemor- 
 rhages no one drug is certain. We employ, in turn, a number, until we find 
 
PURPURA HEMORRHAGICA. 383 
 
 one that is efficacious, but we may run through the entire list of haemosta- 
 tics -without result. The drugs which are most frequently used are aromatic 
 sulphuric acid, ergot, turpentine, digitalis, quinine, and gallic acid. During 
 a haemorrhage the patient must be kept absolutely quiet, even if morphine be 
 required for this purpose. In all cases and at all times care should be taken 
 to guard against traumatism, over-exertion, and excitement. Alcohol and 
 highly-seasoned food may also give rise to a haemorrhage. Epistaxis may be 
 checked by astringent sprays or by plugging the nares. Uterine haemorrhage 
 should be treated by firm tamponage. 
 
 If the joints be affected, salicylic acid is often of service. The pain may 
 be relieved by anodyne applications, as lead-and-opium wash, ichthyol or iodine 
 ointment, or by the application of heat and cold. Firm compression is often 
 grateful. 
 
 Constitutional symptoms are treated on general principles. The patient 
 must be put to bed and on a low diet during the attack. Later he may be 
 about the room, and a more generous diet may be allowed, vegetables and vege- 
 table acids and fruit being especially indicated. In all cases the patient should 
 be kept quiet and free from excitement or exertion. The bowels must be kept 
 open, and any digestive errors corrected. Should the pulse become rapid and 
 feeble, cardiac stimulants are indicated, especially digitalis and strychnine. 
 Alcohol in large doses should not be used. 
 
 During the close of the attack tonics are to be given, quinine, strychnine, 
 and arsenic being the best combination. Iron is contraindicated, as, by experi- 
 ence, we know that its early administration may bring on a fresh attack. 
 
 If the anaemia be marked during the attack, arsenic is the drug most 
 efficient. It is to be given in increasing doses to the point of tolerance, then 
 stopping its use for a day or so, and then increasing its dose as before. 
 
 If symptoms of sudden profound anaemia occur, we apply warmth to the 
 body, hot applications over the heart, and give cardiac tonics, especially opium 
 in small, repeated doses. Inhalation of pure oxygen gas is of the greatest 
 service. In severe cases we employ, in addition, rectal or hypodermatic injec- 
 tions of a warm sterilized saline solution. Several pints can be given in this 
 way with great improvement of the symptoms, although this may be but tem- 
 porary. Arterial transfusion is not to be used, because of the danger of trau- 
 matic haemorrhage. Elevation of the foot of the bed and ligatures applied to 
 the extremities are often followed by good results. 
 
 The prophylactic treatment employed during and after convalescence is 
 intended to lessen the chances of subsequent attacks. 
 
 The patient must live and work in airy, sunny rooms and take graded 
 exercise in the open air, for fresh air and moderate exercise are of the first 
 importance. The plumbing must be in perfect sanitary condition. The diet 
 should be wholesome and varied, and every digestive error corrected. 
 
 For the anaemia, arsenic in small continued doses is by far the best treat- 
 ment. It should be continued until the blood becomes normal. It may be 
 combined with quinine and strychnine. Iron is not to be used at first, but 
 several weeks after the primary attack has subsided it should be given in small 
 doses at first, then slowly increasing. Should a relapse threaten, the iron must 
 at once be stopped. 
 
 Prostration is to be treated on general principles by rest, fresh air, graded 
 exercise, and change of climate. The climate most suitable is one in which 
 the air is light, dry, and bracing ; and the location must be inland, as we find 
 that the disease more extensively prevails on the sea-coast. 
 
 As the disease is probably due to an infectious specific germ, and as the sub- 
 
384 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 sequent attacks are also probably due to reinfection, it seems certainly better 
 to disinfect the room and the clothes of the patient after the illness. The more 
 we study this disease, the more we incline toward such disinfection. 
 
 Henoch's Disease. — The severe form of the subacute cases was first 
 described by Henoch, and is known as " Henoch's disease" or " Henoch's 
 purpura hemorrhagica." This form occurs with greater frequency in children, 
 especially between the ninth and twelfth years. It has been observed, however, 
 between the third and forty-sixth years. It occurs five times more frequently 
 in males than in females. It is a rather rare form. 
 
 Symptoms. — There is usually a short prodromal period with malaise, slight 
 fever, and sometimes with pains in the joints. 
 
 The onset is manifested by the appearance of purpura, in severe cases 
 accompanied by ecchymoses, these differing in no way from those described 
 under the first form. Immediately after the purpura, appear the severe abdomi- 
 nal symptoms which characterize the disease. There is marked pain and ten- 
 derness over the abdomen, the pain being of a colicky character, with exacer- 
 bations of great intensity. The abdomen is rigid and retracted. There is 
 severe rectal tenesmus with bloody stools and severe vomiting, the vomited 
 matter being either like that of acute gastritis or containing blood. These abdom- 
 inal symptoms seem to be due to submucous haemorrhages or to hemorrhagic 
 infarctions caused by thrombi in the small blood-vessels of the gastro-intestinal 
 wall, which become degenerated and rupture, allowing free haemorrhage. 
 Patches of intestinal ulceration result in rare cases, and rupture into the peri- 
 toneal cavity with fatal peritonitis may occur even after apparent recovery. 
 
 These symptoms continue with great intensity for one or two days, and 
 then gradually subside. They may continue longer, but in such cases there are 
 periods of temporary improvement. Joint symptoms may appear as in the 
 first form. Hematuria is seen in one-fifth of the cases. The spleen is usually 
 enlarged, and there is a slight rise of temperature during the attack. 
 
 After such an attack the patient is liable to have a series of similar ones, 
 usually at short intervals. There are generally four or five such, but their 
 number has been recorded as high as twenty. 
 
 The nature of the disease is unknown. No specific micro-organism has 
 as yet been found, but as the reported cases are few, it is possible that in time 
 one will be discovered, either Letzerich's bacillus or some other bacterium pro- 
 ducing the same results. 
 
 The duration varies according to the length of the attacks, their number, 
 and the intervals between them. It is usually six to twelve weeks, but may be 
 limited to a week or be extended to nine months. 
 
 Prognosis. — This is fairly good, being better in children (mortality, 5 per 
 cent.) than in adults (mortality, 25 per cent.). The possibility of intestinal 
 rupture and peritonitis, though rare, must be taken into account. 
 
 Treatment during an attack is purely symptomatic. Between the attacks 
 we improve the general condition in every way. 
 
 Acute Purpura Hemorrhagica 
 
 is far more rare than the subacute form. The same symptoms are present, 
 but run an acute and more severe course, overwhelming the patient by their 
 violence and the rapidity of their onset. The acute form differs, moreover, 
 from the subacute in the severity of septic symptoms, in the frequency of 
 visceral hemorrhages, and its disposition to attack pregnant women. We can 
 
PURPURA HEMORRHAGICA. 385 
 
 broadly subdivide the acute cases into three groups : (1) cases with marked 
 sepsis ; (2) cases with visceral haemorrhages ; (3) cases complicating preg- 
 nancy. 
 
 1. Cases with marked Sepsis. — These present both severe hemorrhagic 
 and septic symptoms, but the latter are so predominant that the course of the 
 disease is essentially that of acute septicaemia. 
 
 The attack usually begins by a chill or chilly feelings, with a rise in tem- 
 perature to 103° or 104° F. Hemorrhagic symptoms soon develop, purpura 
 and haemorrhages from any of the mucous membranes. These are severe, and 
 are not readily controlled by treatment. Septic symptoms are marked from 
 the onset — severe prostration, mental apathy, stupor, or semi-coma, alternating 
 with periods of restlessness, anxiety, and mild delirium, and finally, in fatal 
 cases, complete coma. The temperature remains high, 103° to 104°, but in 
 severe cases it may rise to 105° or 106°. The pulse becomes rapid, feeble, 
 and irregular ; and the patient usually dies early in the disease, either from 
 sepsis or from acute anaemia. 
 
 The following case, personally observed, illustrates most typically the clin- 
 ical course of this form : 
 
 L. M , female, nineteen years, had always lived in most affluent circumstances ; 
 
 had never been sick except from slight anseinia for the past two years. Father when a 
 boy would bleed severely from slight causes. No further haemopnilic history. 
 
 March 7th, 1 A. M., slight chill without rise in temperature. Very nervous and 
 anxious. 12.45 p. m., marked chill, fever rising to 103.5°, and epistaxis becoming more 
 and more profuse in spite of every effort to check it. 
 
 March 8th, 1 p. m., first seen by author. T. 98.4°; P. 130, irregular and weak; 
 marked pallor of skin ; prostration profound ; complete mental apathy, though her mind 
 was clear when she was aroused. New purpuric spots appearing. Gums normal. No 
 evidence of endocarditis nor of any other appreciable disease. Spleen enlarged ; epis- 
 taxis still continuing, the blood being dark and not coagulating. Profuse uterine haemor- 
 rhage. Haemorrhages were checked by plugging posterior and anterior nares with cotton 
 dipped in collodion and by firm tamponing. 8 P. M., T. 102.8° ; P. 130-180, weak and 
 irregular ; semi-coma, alternating with periods of restlessness and mild delirium. Still 
 slight haemorrhages from nose and uterus in spite of former treatment. 10 P. M., about 
 a pint of warm sterilized saline solution was given by rectum and by hypodermatic 
 injections, with slight but temporary improvement. Cardiac tonics, whiskey, and digit- 
 alis were freely administered. 
 
 March 9th, 9 a. m., T. 104.8°; P. 148 ; R. 32. Large offensive tarry stool of altered 
 blood. Injection of saline solution continued. 6 p. m., complete coma. T. 106.2° ; 
 pulse weaker and flickering. 
 
 March 10th, 2 a. m., she died, two and a half days after the onset of the disease. No 
 autopsy was permitted, and bacterial examinations could not then be made. 
 
 Etiology. — There is no known cause for this disease. It occurs more fre- 
 quently in men than in women. The average age of the males affected is 
 twenty-eight years ; of the females, twelve years. It has been observed, how- 
 ever, between one and seventy years of age. 
 
 The average duration of the attack is about one week, although it may last 
 from one to twenty days. 
 
 Prognosis. — The prognosis is bad, 75 per cent, of the cases terminating 
 fatally. 
 
 Treatment consists in — (1) checking the haemorrhages by plugging the 
 nares, by firm tamponage, or by the use of haemostatics, as described in the sub- 
 acute form. (2) In controlling the sepsis. This is often more than we can do, 
 although in some cases alcohol in large doses seems to do good. (3) In the 
 treatment of dangerous symptoms. Heart-failure is to be treated by hot appli- 
 cations over the precordium and by cardiac stimulants. The restlessness and 
 anxiety are best controlled by opium given in small doses. Profound anaemia 
 
 25 
 
386 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 is to be treated by external warmth, rectal and hypodermatic injections of a 
 warm sterilized saline solution, elevation of foot of the bed, and ligatures 
 applied to the extremities. Arterial transfusion is contraindicated. 
 
 2. Cases with Visceral Hemorrhage. — In these cases the brain and 
 the suprarenal capsules are the organs most frequently involved. 
 
 In the brain cases the disease begins with the ordinary symptoms of acute 
 purpura haemorrhagica. After several days these are followed by those of 
 meningeal or cerebral haemorrhage, usually multiple, and without any especial 
 seat of selection. It is seen far more frequently in males than in females. 
 
 Illustrative Cases : 
 
 1. Girl, aged two years. For two days diarrhoea and vomiting ; then 
 purpura, fever, and collapse. Death in a few hours from multiple haemorrhages 
 into the medulla. (Zuelchauer, Berl. Jclin. Wochensch., 1869, No. 17.) 
 
 2. Young man. General acute symptoms. Death on fourth day from 
 haemorrhages into left Sylvian fossa, pons, and ventricles. (Kurkowski, V. 
 und H. Jahresbericht, 1885, ii. p. 493.) 
 
 In cases of haemorrhage into the adrenals the course of the disease is exceed- 
 ingly acute, and death results in a few hours after the onset. 
 Illustrative Cases : 
 
 1. Soldier, aged twenty-two. Purpura ; haemorrhage from mouth, lungs, 
 and kidneys. Death in seven hours from adrenal haemorrhage. (Bourrieff, 
 V. und H. Jahresber., 1878, ii. p. 275.) 
 
 2. Male, aged two years and nine months. Purpura, fever, and collapse. 
 Death in fifteen hours from adrenal haemorrhage. (Wolff, Berl. Jclin. Wochensch., 
 1879, No. 18.) 
 
 3. Cases Complicating Pregnancy. — In the cases in which the disease 
 attacks pregnant women we have the ordinary acute symptoms at first, fol- 
 lowed by miscarriage and post-partum haemorrhage. It may also follow labor 
 at term. The disease runs a rapid course, and recovery is rare. 
 
 Illustrative Cases : 
 
 1. Female, aged twenty-one, six months pregnant. Purpura four days ; 
 then rapid onset of increasing purpura, with haemorrhages from nose, gums, 
 kidneys, and stomach. Miscarriage sixth day, with post-partum haemorrhage. 
 Death on eighth day, four days after the acute onset. (Puech, Annales de 
 Gynecologies xvi., 1887, p. 273.) 
 
 2. Female, aged thirty. Five previous normal labors. Seven months preg- 
 nant. Purpura, with miscarriage in a few hours with post-partum haemorrhage. 
 Death on second day. (Phillips, Brit. Med. Journal, Nov. 13, 1886.) 
 
 3. Female, aged thirty-two. Seven previous normal labors. Seven months 
 pregnant. Purpura, haemorrhages from nose and mouth. Miscarriage on 
 third day, with placental haemorrhage. Recovery in two weeks. (Phillips, 
 loc. cit.) 
 
 When we study these acute cases together, we are struck with their similar- 
 ity to the class of acute infectious diseases. The absence of assignable cause, the 
 rapidity of the onset, the multiplicity and scattering of the lesions, the enlarge- 
 ment of the liver and spleen, and the constitutional symptoms out of propor- 
 tion to the lesions, seem to prove by analogy the assertion that we are dealing 
 with an acute infection, the nature of which is at present unknown. Compar- 
 ing these cases, however, with those of the subacute form, the identical symp- 
 toms are found in each, and it seems most probable that in both forms we are 
 dealing with the same disease in all essential features, differing only in the 
 intensity and rapidity of the infection. As the infection in the subacute cases 
 seems to be due to the presence of Letzerich's bacillus, it is more than possible 
 
PURPURA HEMORRHAGICA. 387 
 
 that the acute cases may be due to a more intense infection by the same germ. 
 Much attention has been called to the relationship of essential purpura hemor- 
 rhagica to two diseases of the haeniorrhagic group — purpura simplex and pur- 
 pura rheumatica. 
 
 Purpura simplex is due to a variety of causes. In some cases the cause 
 is apparent, as in severe anaemia, debility, after certain drugs, or occurring in 
 infectious diseases. In other cases no cause can be found and the nature of 
 the disease is obscure. In either we may have mild or severe constitutional 
 symptoms. 
 
 In purpura rheumatica we have not only simple purpura, but also pain and 
 swelling of the joints. Formerly it was regarded as a separate disease from 
 purpura simplex, but of late efforts have been made to associate them, purpura 
 rheumatica being considered either as a purpura occurring in rheumatic sub- 
 jects, thus accounting for the joint symptoms, or as a severe purpura simplex, 
 in which haemorrhages occur in and around the joints. The author regards 
 the latter supposition as the more correct, as in all haemorrhagic diseases, pur- 
 pura haemorrhagica, as well as scurvy, multiple sarcoma, etc., the joints may 
 be affected, together with the appearance of purpuric spots. If this view be 
 correct, why regard them as separate diseases? Is it not justifiable to consider 
 purpura rheumatica as an intenser form of purpura simplex with haemorrhagic 
 joint lesions? 
 
 If purpura haemorrhagica be due to an infection, may not the cases of pur- 
 pura simplex occurring without known cause, and cases of purpura rheumatica 
 not associated with rheumatism, be considered as lighter forms of the same infec- 
 tion, especially as in some cases of subacute purpura haemorrhagica, purpura or 
 purpura with joint symptoms may be the most marked features, the free 
 haemorrhages being of very slight importance, often not appearing for several 
 days after the other symptoms? Even in the acute form is this seen, as the 
 case of Puech's, cited on the preceding page, illustrates, the purpura alone 
 existing four days before the onset of acute symptoms. 
 
 In support of this theory may be cited cases of secondary purpura haemor- 
 rhagica, such as those occurring after the administration of certain drugs, in 
 which small doses in some patients produce merely purpura, while large doses 
 cause, in addition, free haemorrhages and marked constitutional symptoms. 
 The only difference seems to be that in one case we are dealing with a cause 
 unknown, though probably bacterial, while in the other the cause is known, 
 and by its intensity we have all grades, from simple purpura to purpura haemor- 
 rhagica, even of an acute type. 
 
 II. Secondary Purpura Hemorrhagica. 
 
 Under this class we include those cases of purpura and free haemorrhages 
 which complicate some existing disease or to which a definite cause can be 
 assigned. In nearly all of these cases we may have either a simple purpura or 
 purpura haemorrhagica with constitutional symptoms of a mild or severe charac- 
 ter, in some even running a fatal course. Only a brief mention can be made 
 of these cases. 
 
 (1) Cases due to the Administration of Certain Drugs, potassium iodide. 
 chloral, quinine, and salicylic acid being the ordinary drugs causing such a 
 result. There is a great difference in their action in different patients, some 
 developing no symptoms, others a simple purpura, while in still others we have 
 a striking exhibition of spreading purpura, free and internal haemorrhages, with 
 coma, collapse, and even death. These various types can proceed from the 
 
388 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 same cause acting more intensely upon some patients than upon others, either 
 from a maximum of cause on the one hand or the minimum of personal resist- 
 ance on the other. 
 
 (2) Cases which Accompany or closely Follow Severe Infectious Diseases, 
 such as acute atrophy of the liver, snake-bites, typhoid fever, pneumonia, and the 
 exanthemata ("black measles," etc.). In these cases we have various grades, 
 from simple purpura up to acute purpura hemorrhagica. Many authors attrib- 
 ute such a complication to an added infection of essential purpura hemor- 
 rhagica complicating the primary disease. Henoch, for example, reports a 
 case of a child with lobar pneumonia in whom a supposed infection of pur- 
 pura hemorrhagica occurred two days after crisis, causing death from collapse 
 in twenty-four hours. If a drug like potassium iodide will so disorganize the 
 blood or render pervious the blood-vessels, why may not the poison of an 
 infectious disease produce the same result without supposing an added infection 
 of a new disease ? It is no argument against this view that purpura hemor- 
 rhagica may appear after the crisis, because we know that a temperature 
 crisis does not mark the end of the disease, but only, as Fraenkel has recently 
 demonstrated in pneumonia, the end of the fever-producing quality of the 
 infecting germ. 
 
 (3) Cases of Severe Jaundice may be accompanied by purpura and hemor- 
 rhages. These seem to be due to the disorganization of the blood from the 
 cholemia. 
 
 (4) Cases of Profound Anosmia, Leukaemia, or Pseudo-leukoemia, and of 
 Exhausted and Cachectic Conditions. — In these we may have simple purpura, 
 purpura hemorrhagica, or continued hemorrhage after operations or injuries. 
 We do not know whether to attribute these hemorrhages to blood-changes or 
 to changes in the wall of the small arteries. 
 
 (5) Cases of New-born Infants with Congenital Syphilitic Changes in the 
 Arterial Walls, producing purpura, bloody sweating, and free hemorrhages, 
 especially from the umbilicus. 
 
 (6) Cases of New-born Infants without Syphilitic Parentage. — This form, 
 according to Partridge, occurs in about 1 per cent, of cases, with a mortality 
 of 60 to 75 per cent. He attributes its causes to the change of functional 
 activities and to the altered circulation, allowing a brief interruption of the 
 nutrition of the vessel-walls sufficient for the transudation of their contents. 
 
 (7) Cases complicating Malignant Endocarditis, the purpura and hemor- 
 rhages being probably due to embolism of the capillaries by vegetation-frag- 
 ments, and their subsequent degeneration and rupture. 
 
 (8) Cases of Multiple Sarcomata, with Purpura, with free hemorrhages, 
 purpura, rheumatic pains, and fever. It is hard to say whether these result 
 from malignant cachexia, with blood-changes, or from emboli of sarcomatous 
 fragments lodging in the small blood-vessels, causing their degeneration and 
 rupture. 
 
 (9) Cases occurring after Fright, Deep Emotion, Hysteria, and Hypnotism. 
 In these cases the hemorrhages seem to be due to vaso-motor relaxation or to 
 enfeeblement of the arterial walls sufficient to allow of the escape of their con- 
 tents. This latter explanation is warmly endorsed by Weir Mitchell. 
 
SCORBUTUS. 
 
 By WM. PERRY NORTHRUP, M. D. and DAVID BOVAIRD, M. D., 
 
 New York. 
 
 Infantile scurvy is a constitutional disease produced by improper 
 feeding, characterized by swelling, disability, excessive tenderness and pain 
 on motion in the lower extremities, and spongy gums : it is further charac- 
 terized by rapid recovery under corrected regimen. 
 
 The first case of infantile scurvy was reported by Jalland, and the report 
 summarized in Virchow's Jahresberieht for 1873, but England has been the 
 source of most of the reported cases and most of the literature of scurvy in 
 children. To W. B. Cheadle and Thomas Barlow of Great Ormond Street 
 Hospital is due the credit of " having first shown on clinical grounds the 
 true affinities of this form of infantile cachexia ' ? (Cheadle), and of demon- 
 strating the anatomical nature of the disease from post-mortem examinations 
 (Barlow). Prior to the work of these observers infantile scurvy had been 
 regularly regarded as acute rickets or gone astray as purpura hsemorrhagica. 
 
 The first case of infantile scurvy in the United States was met with upon 
 the autopsy table of the New York Foundling Hospital. A second was soon 
 afterward recognized in consultation, treated, and recovered. At the time of 
 the publication of the first edition of this work 11 cases were on record, and 
 were made the basis of the first article on infantile scurvy in an American text- 
 book. In 1894, 36 cases were collected and reported by Crandall and North- 
 rup. Since that time cases have been reported from all parts of the country. 
 One observer alone (Rotch of Boston) has seen 60 or 70 cases. The subject 
 of infantile scurvy can, therefore, rightly claim the attention of the general 
 practitioner. 
 
 Etiolog-y. — The cause of scurvy in children is persistent feeding with 
 improper foods. Examining the dietaries of scorbutic children, we find 
 enumerated almost everything that could possibly be employed as food for a 
 child — all manner of proprietary foods, condensed milk, porridge, oatmeal- 
 and barley-water, various mixtures of cow's milk and cream. They agree 
 only in one respect : they all lack or have been deprived of the quality which 
 we designate as fresh or "live." 
 
 When milk or cream has been given it has regularly been deprived of 
 this quality by sterilization. For some time there has been active debate 
 whether prolonged sterilization of the food could of itself cause scurvy. The 
 writer has recently seen 2 cases of typical scurvy developed in children fed 
 upon perfectly proper milk mixtures which had been sterilized by prolonged 
 boiling. Both recovered promptly on the same food when the over-steriliza- 
 tion was stopped ; moreover, one of them has now gone for several months 
 upon the same food unsterilized, without any return of the symptoms. Like 
 experience has been recorded by Starr and Holt. 
 
 Scurvy among nursing infants is very rare. In the first case met with 
 
 389 
 
390 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 in this country the child had been nursed by a woman who suckled her own 
 child as well. The latter thrived ; the foster-child developed scurvy. There 
 is little doubt in such a case that the child was starved into scurvy. 
 
 Southgate has also recorded a case of scurvy in a nursling. Moreover, 
 the analysis of the milk made in this case shows it to have been rich in 
 quality. In the light of all other observations we can only say that this 
 case stands unique and unexplainable. 
 
 The patent baby-foods are, by all means, the most frequent offenders in 
 the production of scurvy. The measure of the responsibility of any partic- 
 ular one seems to rest only on the extent of its popularity. Those most 
 widely used are most often met with in the scurvy records. 
 
 As the number of reported cases increases the stronger becomes the 
 indictment against the patent foods. There seems no greater surviving fal- 
 lacy in medical practice than the routine feeding of infants with patent prod- 
 ucts of commercial firms. Condensed milk deserves to rank with the other 
 proprietary foods. 
 
 Surroundings seem to have little influence upon the production of this 
 cachexia. Most of the reported cases have been observed in private practice. 
 In the great majority the surroundings have been good, in many luxurious. 
 The affection has been met with in all parts of the land, both in cities and in 
 the country, along the seaboard and on the mountains of Montana. Per- 
 sistent feeding with improper food can produce scurvy anywhere. The dis- 
 ease is usually met with after the sixth month and under two years, but 
 these limits cannot be regarded as absolute. It takes time to develop scurvy, 
 no matter how bad the diet, and after the second year the diet usually 
 becomes so general that all danger is removed. 
 
 We are still unable to reach the ultimate cause of scurvy. It seems un- 
 questionably to be deprivation, but of w T hat has not yet been determined. 
 All that we can say is that the missing elements are found in fresh milk and 
 fresh fruit-juice. 
 
 Pathology. — The lesions of infantile scurvy are well set forth in North- 
 rup's report of the autopsy on his first case. The child was emaciated, 
 its eyelids swollen and ecchymotic. The gums were prominent, spongy, 
 dark, covered with dried blood, the lips blood-stained. The pale, thin face, 
 with two black eyes, gave a most striking appearance to the dead baby. 
 The main interest lies in the condition of the legs. Left thigh symmetrically 
 enlarged, larger than the right, although both were obviously above normal 
 in size. Left femur was normal at its upper extremity, epiphysis, and end 
 of shaft. The lower half was invested by a black, grumous, subperiosteal 
 layer of blood two or three millimetres thick. The lower epiphysis was 
 detached ; the lower end of the shaft macerated, eroded, and soft, lying loose 
 in the black, disintegrating blood-clot. The femur of the right leg was sur- 
 rounded for its lower two-thirds by a thinner, black, subperiosteal blood- 
 layer. The lower epiphysis was not detached, though both it and the shaft 
 were congested. No haemorrhage into joints. The right and left tibiae were 
 surrounded by a thin, dark, hemorrhagic layer beneath the periosteum, and 
 the proximal portions of both were congested. The fibulae and bones of the 
 upper extremity were normal. Microscopical examination of the bone dis- 
 closed no syphilitic or rachitic changes, and no inflammatory changes in 
 bone or periosteum. The softened, macerated bone gave no evidence of 
 suppuration, but there was moderate congestion of the fellow-femur and 
 upper extremities of the tibiae. A small amount of blood, dark and dis- 
 integrated, was found in the intestines ; no lesion discovered. The accom- 
 
SCOBBUTUS. 
 
 391 
 
 Fig. 1. 
 
 panying illustration (Fig. 1) was drawn from a specimen which consists of 
 a lateral half of the side less affected. 
 
 To this we need only add that subperiosteal haemorrhages may occur 
 upon any of the bones — those of the upper extremity, of the cranium, of 
 the thorax. There may also be haemorrhages 
 from various mucous membranes — the nose, the 
 stomach, bladder, etc. 
 
 Symptoms. — The characteristic symptoms 
 of infantile scurvy are the swollen, spongy, 
 purple, and easily bleeding gums, and extreme 
 pain on motion, tenderness, swelling, and dis- 
 ability in one or both lower extremities. Ex- 
 amination of the affected extremities reveals a 
 fusiform or cylindrical swelling about the long 
 bones. The affection is usually most marked 
 about the femur, but the bones of the leg or 
 ankle may be involved. The affection is usually 
 bilateral, but not symmetrical, one extremity 
 presenting more marked changes than the other. 
 In a few cases the upper extremities have been 
 involved, but these cases are rare, and in almost 
 all thus far reported there was an antecedent 
 affection of the legs. The joints themselves are 
 not involved in the process. The affected limbs 
 are usually held in a semi-flexed position (Fig. 
 2), and no attempt is made to use them, so that 
 the disease is often mistaken for a paralysis. 
 This disability is spoken of as pseudo-paralysis. 
 " Rheumatism of the legs " is another favorite 
 diagnosis for this scorbutic affection of the ex- 
 tremities, but, as already noted, the joints 
 themselves are not involved in infantile scurvy. 
 The pathological lesions already described ren- 
 der these symptoms readily explicable. 
 
 In addition to the characteristic symptoms, 
 subcutaneous ecchymoses or haemorrhages are 
 of frequent occurrence. They may be seen 
 upon any part of the body, but are especially 
 characteristic about the orbit, giving the little 
 patient a typical "black eye." 
 
 Haemorrhages may also occur from mucous 
 membranes other than the gums, so that there 
 
 may be bleeding from the nose, stomach, intestine, or bladder; but such 
 haemorrhages are seen only in the severer types of the cachexia. 
 
 For weeks before the development of the evidences of scurvy the child 
 may suffer from gastric or intestinal disturbances, with vomiting, colic, diar- 
 rhoea, or constipation. In the severer cases a sallow, muddy complexion, 
 due to severe anaemia, is often met with. The examination of the blood 
 shows the changes of simple anaemia. Many of the cases are marantic, but 
 scurvy may also be seen in children who have suffered from no gastric or 
 intestinal disorder and are well nourished and ruddy. 
 
 The affection of the gums is seen only about the teeth. If the child has 
 no teeth, the gums will appear normal. In the report of Crandall and 
 
 Specimen from a case of Infantile 
 Scurvy, showing subperiosteal 
 haemorrhage about femur and tibia 
 of the side less affected. (Drawn 
 from the specimen preserved in 
 the Museum of the College of Phy- 
 sicians and Surgeons, N. Y.) 
 
392 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Northrup the condition of the gums was noted in 32 cases. Of these, 2 
 had no teeth ; the gums were normal. Of the remaining 30, 24 had what 
 was termed " spongy " gums, 3 had ulcerated gums, in 3 they were described 
 as "bleeding." In 34 other cases of which the records are available, 31 had 
 spongy gums ; in 3 the gums were normal. Of the latter, 2 had no teeth. 
 One, although it had two teeth and presented a typical scorbutic affection 
 of the extremities and subcutaneous ecchymoses, had no mouth-symptoms 
 whatever. The affection of the gums, although regularly present, cannot, 
 therefore, be considered essential to the diagnosis. 
 
 The constitutional disturbance of scurvy may be of any degree of severity, 
 depending upon the gravity of the affection and the time of observation. In 
 the mildest cases the baby may appear perfectly well, except for the pain on 
 motion of the extremities. In the severer types there are marked anaemia, 
 emaciation, fever, and prostration, which may result in death. Fever, if 
 
 Fig. 2. 
 
 Infantile Scurvy : characteristic attitude of the legs. 
 
 present, is usually slight, but may reach 102° or 103° F. It is apparently 
 dependent upon accompanying disturbances, and not upon the scurvy itself. 
 Relation to Rickets. — The relation of scurvy to rickets has long been 
 the subject of debate. Previous to the work of Barlow and Cheadle infantile 
 scurvy was regularly described as "acute rickets," and in the early days of 
 observation rickets was supposed to constantly precede or accompany the 
 appearance of scurvy. In the report previously quoted rickets was referred 
 to nineteen times. Five cases showed marked rickets, 6 slight ; in 8 it was 
 definitely not present. In 34 other cases, of which the records are available, 
 rachitis was noted as present only in 5, and in most of these the only evidence 
 of rachitis was "beaded" ribs. Rickets and scurvy are both developed dur- 
 ing infancy. Improper diet is a causative factor in both, but either may be 
 developed without the other. The lesions of rickets are found in the bones ; 
 those of scurvy are evidently in the blood-vessels. The subperiosteal or 
 subcutaneous haemorrhages of scurvy may be promptly absorbed and the child 
 left perfectly well. The changes of rickets are more or less permanent. The 
 correction of diet sufficient to cure scurvy in a few days makes no impression 
 
SCOBB UTUS. 393 
 
 upon rickets. The two affections may be comrades ; they are not generically 
 related. 
 
 Illustrative Cases. — Three cases representing the several types of infan- 
 tile scurvy will be presented : 
 
 Case I. — A mild case. A boy, aged twelve months; only child, birth 
 normal. Parents both very well and surroundings good. Child artificially 
 fed from birth. For first two months he was given diluted condensed milk. 
 Thereafter the food consisted of a mixture of cow's milk regularly boiled for 
 fifty minutes. Upon this the child throve, became fat, rosy, and vigorous. 
 He had no gastric or intestinal disturbance. The bowels moved twice a day ; 
 the passages were quite normal. In short, he had been considered a remark- 
 ably healthy and vigorous baby until he was ten months old. His mother 
 then noticed that he would no longer attempt to stand or use his legs in any 
 way. At the same time he began to cry whenever moved or touched, and 
 sweated a great deal. He became more and more fretful, and cried a great 
 deal, especially at night. These symptoms persisted and became worse up 
 to the time he was brought to the clinic of the New York Orthopedic Dis- 
 pensary. 
 
 Examination. — A large, well-nourished baby, of good color, and with no 
 evidence of rachitis. Lying perfectly quiet in his mother's lap, he would 
 smile and play as though perfectly well, but the first suggestion of a touch 
 or any motion called forth piteous wails. The four incisors were present. 
 About the upper pair the gums were purple, the mouth otherwise normal. 
 Both lower extremities were swollen from the ankle to the knee. Although 
 the least attempt at examination made him scream with pain, he made no 
 effort to withdraw the legs or move them in any way. To touch there was a 
 sensation of deep thickening about the long bones of the legs. In every 
 other way the child was perfectly normal. 
 
 For treatment the mother was directed to give him the same mixture of 
 milk unboiled, with two or three teaspoonfuls of fresh orange-juice daily. 
 Two days after beginning this treatment the baby slept all night for the first 
 time in two months. In five days he ceased to cry and the legs could be 
 moved without pain. In two weeks he was able to stand, and since that time 
 has been the "picture of health." 
 
 Case II. — A typical case. A girl sixteen months old, a second child. 
 At the time of the consultation the father and mother of the little patient 
 were present ; both were w T ithin the thirties, healthy and vigorous, the father 
 looking like a hardy yachtsman. The family history on both sides was good. 
 The home was located in the most hygienic surroundings of up-town New 
 York. When the child was in its fourth month the mother's milk failed 
 to be of sufficient quantity, and soon thereafter ceased altogether. One of 
 the proprietary foods was then given. By some misunderstanding this food 
 was diluted with water and milk, the proportion of the latter being too small. 
 For a time the child apparently thrived very well, although it was rather back- 
 ward. Its digestion was good, its bowels were reasonably satisfactory, and it 
 seemed satisfied with its food. It never gave any evidence of rickets ; teeth 
 in normal number made their appearance at the usual time. 
 
 Three weeks before the visit spoken of (this fact was subsequently elicited 
 after close questioning) the nurse had noticed some change in the child's gums. 
 The change was not marked. 
 
 One week later the patient developed trouble in the right lower limb, evi- 
 denced by worrying, sensitiveness on handling, and a tendency to keep the limb 
 nearly straight. There seemed no reason why the case should not speedily 
 
394 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 come out of its condition of slight depression, as the food was improved and 
 antirheumatic treatment instituted. 
 
 During the succeeding week very little is known concerning the child ; 
 the parents were absent from home ; the family physician was not called ; 
 the nurse drew no conclusions from the now rapidly changing gums, and as to 
 the " rheumatism " the progress was slow. 
 
 The child cried on seeing a strange face, becoming alarmed also for the 
 safety of its lame leg. In the wry face of crying the little patient fairly 
 unbuttoned from between its lips two rows of irregularly nodulated, purplish 
 gums, from the summits of which the points of its teeth barely protruded. 
 In the upper spongy row was a depression with ulcerated ivalls and sloughing 
 shreds. The gums were dark, and bled freely in the act of crying from com- 
 pression of the lips alone. There was nothing further abnormal about the 
 face beyond a worried expression ; no ecchymoses, no petechia ; conjunctivae 
 were normal; no evidence of unhealthy condition of the mucous membrane 
 of the nose. There was no history of nose-bleeding, no hematuria, no haem- 
 orrhages from the bowels. The child was now stripped of all clothing and 
 laid upon its back on the bed. It continued to whimper, throw its arms about 
 freely, draw up its left leg ; as for its right, it could move it slowly, but only 
 a little, and could not be induced to flex it. The right thigh was distinctly 
 larger than the left to observation ; by measurement it showed a difference 
 of about two and a half inches, which, considering the thin thighs of the small 
 patient, augured a marked difference. The enlargement was fusiform, great- 
 est just above the knee. Apart from the spongy gums and swollen thigh 
 there were no external manifestations. 
 
 This case promptly recovered on corrected regimen. 
 
 Case III. — Fatal scurvy ; child of eighteen months ; autopsy. This 
 child was an inmate of the New York Foundling Hospital, and was what is 
 called a "nurse-baby;" that is, she was nursed by a mother, who, in addition 
 to her own baby, nursed a second of about equal age. Her own child thrived ; 
 the second furnished the example of malnutrition and the pathological speci- 
 men already referred to. Since we are considering a case of scurvy develop- 
 ing in a breast-fed (sic) child, it is well to bear in mind the above facts, and 
 the added fact that nearly all babies nursing two at one woman require more 
 or less artificial food. We are justified in forming our own conclusions as to 
 which was nursed more and which less ; we know which baby was hers and 
 which was not, which thrived and which developed fatal scurvy. 
 
 Briefly, the history of the illness was as follows : The foster child when 
 sixteen months old was observed to be failing, and, as the history reads, "on 
 account of impaired nutrition was taken from the breast and was given vege- 
 table acids." In the seventeenth month of life, which was one month before 
 death, the right leg and knee became swollen and tender. Temperature was 
 101° F. After two days the symptoms seemed temporarily to disappear. 
 Two weeks before death, and six weeks after the weaning, the child appeared 
 to be very sick ; her gums were swollen, smoky-black, and bled freely ; two 
 days later her left eyelid became swollen, black, having the appearance of 
 the classical "black eye." Temperature thus far continued about 101° F. 
 One week later there developed the physical and rational signs of pneumonia. 
 At this time her other eyelid became ecchymotic and the other thigh markedly 
 swollen. 
 
 During the remaining days of life the little patient became excessively 
 anaemic, having a metallic pallor, which gave a particularly wretched appear- 
 ance w T ith the contrasting ecchymoses about the eyes. Her passages were 
 
SCORBUTUS. 395 
 
 black and pasty ; no petechias ; the child failed rapidly and died with pro- 
 nounced symptoms of pneumonia. (For autopsy see "Pathological Anatomy.") 
 
 Prognosis. — When recognized and properly treated scurvy disappears 
 with almost magical rapidity. Unrecognized and improperly treated, it may 
 readily prove fatal. The outcome depends upon the diagnosis. Under 
 proper treatment complete recovery ought to be obtained in three weeks. 
 
 Diagnosis. — Scurvy in infants is most frequently mistaken for "rheuma- 
 tism of the legs," infantile paralysis, acute rickets, or an osteomyelitis. Sar- 
 coma of the femur and simple stomatitis have also been recorded in the 
 category of erroneous diagnoses, and the limbs have been laid open for pus 
 only to find pure blood. 
 
 Four points suffice for an absolute diagnosis : 
 
 1. The age of the child — over six months, under tw T o years. 
 
 2. The history of improper feeding, especially proprietary foods, con- 
 densed milk, or milk mixtures sterilized by prolonged boiling. 
 
 3. The painful, swollen extremities, without local heat or redness, and 
 without involvement of the joints. 
 
 4. The spongy, purple, easily-bleeding gums. 
 
 A thorough examination should establish the diagnosis in any case. If 
 doubt remains, a few days' treatment will settle the question. On an anti- 
 scorbutic diet improvement should be prompt. 
 
 Treatment. — Briefly, correct the diet. Put the child upon a proper 
 mixture of cow's milk, raw or pasteurized ; when possible, give milk warm 
 from the cow. Administer orange-juice freely, a teaspoonful every two or 
 four hours. Improvement will be almost immediate, and complete recovery 
 not long delayed. 
 
 Stimulants will be required only in cases of extreme exhaustion. If the 
 anaemia is severe, iron is indicated. It is best given in the form of the 
 powder (Quevenne's iron), gr. j to ij, t. i. d. 
 
 As a rule, the dietetic treatment is all that is required. 
 
PART VI. 
 
 DISEASES OF THE DIGESTIVE ORGANS 
 
 DISEASES OF THE MOUTH AND DENTITION. 
 
 By F. FORCHHEIMER, M. D., 
 
 Cincinnati. 
 
 I. DISEASES OF THE MOUTH. 
 
 The mouth of an infant differs in many respects from that of an adult or 
 even a child : up to the third or fourth month of life it is to be looked upon 
 merely as a passage-way for food. Then comes the first outpouring of saliva, 
 and with it the functions of the mouth are increased by that of incipient 
 digestion, which reaches its full development after a period that varies in indi- 
 vidual cases. The lack of saliva produces more or less dryness of the infant's 
 mouth, a coating of the tongue due to epithelial cells, detritus, and food, and a 
 peculiar glistening appearance by reflected light. After saliva is formed the 
 child does not, at first, know what to do with it, so that, even when normal 
 in quantity, the greater part of it is not swallowed. 
 
 For most of the inflammations of the mouth the etiology is still a matter 
 of surmise. While there can be no doubt that lower forms of life must play 
 a very important role in their production, yet as a matter of fact but few 
 forms of stomatitis can be definitely ascribed to this cause. The mouth is a 
 veritable culture-tube for microbes and lower forms of life, but, as a rule, 
 they do not produce disease. General conditions of the patient must seriously 
 be taken into consideration (syphilis, rickets, scurvy) ; possibly these may 
 produce a soil favorable to low conditions of life, resulting in the production 
 of troubles in the mouth. Local conditions within the mouth must always be 
 sought in examining a case — lack of cleanliness, rough attempts at cleansing, 
 sharp or diseased teeth, the introduction of irritants or poisons ; while, on the 
 other hand, causes may be found only in diseased conditions of remote organs. 
 One important fact must always be taken into consideration, that the glands of 
 the mouth are not only secretory, but also excretory, so that substances taken 
 into the circulation, as well as others formed within the body, may leave the 
 body by means of these glands and produce local lesions. 
 
 In the matter of treatment care must always be exercised in removing the 
 cause of the disease ; where this is impossible, purely symptomatic treatment 
 is called for, and this, in the main, is antiseptic in nature. The most potent 
 mouth-antiseptics are potassium chlorate, potassium permanganate, silver nitrate, 
 
DISEASES OF THE MOUTH. 397 
 
 and sodium salicylate. Each one has its own indications, but the first and 
 second are almost universally serviceable. Potassium chlorate, especially, 
 when used internally, requires cautious administration on account of its effects 
 upon the blood and the kidneys. It is safe to say, however, that the 
 danger has been largely over-estimated by some, and in comparison with the 
 frequency with which the drug is used the number of cases of poisoning is 
 exceedingly small. 
 
 The examination of the mouth should be thoroughly conducted, without 
 force, but in such a way that all parts can be seen to advantage. It is 
 necessary to insist upon this part of clinical examination, since, simple though 
 it be, it is frequently neglected, so that very valuable aids to diagnosis in many 
 diseases are overlooked. 
 
 The classification which follows is one which is principally based upon clin- 
 ical data ; it is completely satisfactory as a working formula up to the present, 
 but will undoubtedly require revision in the future. The term "stomatitis" 
 is retained for many reasons, not the least important being that it has been used 
 quite universally. The following are the forms of stomatitis: I. Stomatitis 
 catarrhalis ; II. Stomatitis aphthosa ; III. Stomatitis mycosa ; IV. Stoma- 
 titis ulcerosa ; V. Stomatitis gangrenosa ; VI. Stomatitis crouposa ; Stoma- 
 titis diphtheritica ; VII. Stomatitis syphilitica. 
 
 I. Stomatitis Catarrhalis. 
 
 Also called simple stomatitis, of which there are two kinds — local and 
 general. 
 
 Etiology. — Two things must be taken into consideration — an irritant and 
 the mucous membrane. In healthy children the mucous membrane resists to a 
 greater extent than in children sick with any disease whatsoever. The most 
 favorable conditions for the production of stomatitis catarrhalis are to be found 
 in children with acute febrile disease and in bottle-fed babies. The irritants 
 are either mechanical, thermal, chemical, or to be traced to some lower form 
 of life acting mechanically or chemically. In healthy children teething does 
 not produce stomatitis, and it is denied by many that this process is even a 
 predisposing cause. Lack of cleanliness, over-cleanliness, and food introduced 
 at too high a temperature are common causes for this trouble. Many of the 
 acute infectious diseases produce stomatitis catarrhalis, which then precedes the 
 appearance of the characteristic lesions within the mouth. Nearly all other 
 forms of stomatitis are preceded by this form — most especially is this the case 
 with stomatitis mycosa ; and all other forms are associated with more or less 
 catarrhal inflammation. In all probability, substances excreted by the glands 
 of the mouth, as the result of faulty digestive processes in the intestines or of 
 incomplete elimination, will be found to be of vast importance in the etiology. 
 This will be the most rational way of explaining the frequent concurrent 
 appearance of diseased processes within the mouth and the intestinal tract. 
 For the localized form, it is a local irritation — a sharp tooth, a discharging 
 abscess, or the rubbing of the gums to facilitate teething. 
 
 Symptoms. — We may recognize two varieties, the erythematous and the 
 true catarrhal. In the erythematous form the whole mucous membrane of 
 the mouth is of a deep-red color, produced by hyperasmia. The blood-vessels 
 are sometimes subjected to such great pressure that rhexis occurs, or red cor- 
 puscles may be forced into the submucous tissues, and the haemoglobin may 
 there be changed to hsematoidin, with a resulting distinct yellow discoloration. 
 This condition is frequently found in the mouth of the new-born ; erythema 
 
398 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of the mouth may be looked upon as normal during this period of life, requir- 
 ing no treatment except gentleness, and is of no special importance. 
 
 In pertussis and the acute exanthemata there is produced a peculiar form 
 of erythematous change. In pertussis and measles it consists of a blue tint 
 given to the tongue and the buccal cavity ; in scarlatina the whole mouth is 
 more or less reddened, and in all the acute exanthemata the eruption appears in 
 well-defined places in the characteristic form seen upon the skin. 
 
 In general stomatitis catarrhalis we have all the symptoms of an inflam- 
 mation — swelling, pain, heat, redness. The whole lining of the mouth is 
 hypenemic ; there is more or less puffiness, especially where there is pressure, 
 and here the mucous membrane is somewhat paler. The lips frequently 
 become more tense, and the mucous membrane is covered with small, round 
 prominences due to swelling of the muciparous follicles. When the ducts of 
 the latter become tightly closed the glands dilate, and there are produced 
 cysts, the contents of which are clear, viscid mucus. We also find slight 
 epithelial abrasions, sometimes leading to the production of a deeper process — 
 at all events, important in that they may become the seat of infection. 
 
 The tongue is coated, at first dry and white, then yellowish or grayish, and, 
 as secretion increases, whole flakes of this coating are washed off, leaving red 
 spaces partially uncovered. The tongue never looks like the scarlet-fever 
 tongue, since the catarrhal process seems to affect only the superficial layer 
 of epithelium, sparing the fungiform and even the bases of the filiform papillae. 
 When this process in the mouth is the result of long-continued fevers, the 
 appearance changes; nutrition to all epidermal structures being less active, the 
 tongue and the mouth suffer comparatively more than when the process is 
 purely catarrhal. 
 
 In nearly all the inflammations of the mouth the lymphatics become in- 
 volved, and the intensity of the stomatitis can be measured, as a rule, by the 
 degree of involvement of the glands. Increased temperature is observed (in 
 rare instances as high as 104° F. in the rectum), the prominent symptoms, 
 however, being local. Of these the most important is pain, producing restless- 
 ness, fretfulness, and more or less difficulty in nursing. With this, when the 
 child is old enough, there is increased flow of saliva, producing, sometimes, 
 irritation of the skin upon the lower lip or eczema of the face. 
 
 Prognosis. — As this is usually an acute process of moderate intensity, the 
 prognosis is good. Indirectly, there may be produced loss in weight, dyspepsia, 
 catarrhal conditions of the intestine, continued enlargement of the glands, 
 possibly tuberculosis, and, therefore, a vulnerability of the mucous mem- 
 brane, so that the smallest local irritant will be followed by a return of the 
 stomatitis. . 
 
 Treatment. — In the majority of instances the disease runs its course 
 without any special treatment. The cause must be removed when possible. 
 Next, relief must be given to symptoms ; cold water, applied by means of 
 cotton, either wrapped around a stick or the finger of the nurse, or small 
 pieces of ice wrapped in a handkerchief. All food must be given cold ; usually 
 this causes least pain ; sometimes the opposite will be found necessary. Much 
 comfort will be given by frequent and gentle washing of the mouth with ice- 
 cold sterilized water, to which there has been added boric acid (1-3 per cent.), 
 sodium biborate (2-3 per cent.), zinc sulphate (J-l per cent.), sodium salicylate 
 (1 per cent.), etc. The addition of any of these is not imperative; chlorate 
 of potassium is unnecessary and without value in this form of stomatitis. 
 Silver nitrate (J-l per cent.) is the most reliable of all remedies; if the 
 stomatitis does not disappear in four or five days, the mouth must first be 
 
DISEASES OF THE MOUTH. 399 
 
 thoroughly cleaned, and then pencilled with this weak solution once a day. 
 Where there is loss of epithelium the spot should be touched with the mitigated 
 stick, which can be accurately applied by first melting and then dipping a 
 silver probe into it. Cysts should be duly opened, and their walls should be 
 cauterized when necessary. 
 
 II. Stomatitis Aphthosa. 
 
 Aphtha (from acpda, an eruption or ulceration) is a subepithelial vesicle 
 of different color from the mucous membrane upon which it occurs, and is 
 surrounded by an areola which changes in a peculiar way during its existence. 
 It has nothing to do with the muciparous follicles, appearing in places where 
 there are none; it is therefore not follicular. 
 
 Etiology. — No uniform local cause has ever been found. Micro-organisms, 
 usually pus-producers, have been observed, but no connection could be discov- 
 ered between them and the disease. Aphthae have been produced artificially 
 (caustics, the end of a burning match), but no one has ever succeeded in pro- 
 ducing the whole series of symptoms associated with this form of stomatitis. 
 It is said that the disease is most common between, the tenth and thirteenth 
 months of life (Bohn), and therefore teething has something to do with the 
 eruption. However this may be, we find stomatitis aphthosa associated with a 
 great number of diseases — pneumonia, ague, gastro-intestinal catarrhs, the 
 acute exanthemata, etc. We must therefore look for the cause in a general, 
 not a local, disturbance, and as the disturbance is the same as herpes, the 
 same etiology will be found to hold good for aphthae as for herpes. The dis- 
 ease is not contagious, but the same cause may not infrequently produce it in 
 several members of the same family, and usually those are selected whose diges- 
 tive tracts are either temporarily or permanently weak. 
 
 The foot-and-mouth disease in cattle can be definitely accepted as causative, 
 but as this disease is very rare in this country, it can be almost absolutely 
 excluded as an etiological factor. In a recent epidemic near Berlin studied by 
 Siegel, an ovoid bacillus 0.5// long was found in all cases; only those con- 
 nected with the animals had local lesions, but were protected in a measure, 
 infection taking place from man to man. 
 
 The conclusions arrived at by the author in regard to the etiology of this 
 disease are as follows : It is a disease produced by some form of deleterious 
 material in the circulation, which may have its origin in various processes, bac- 
 terial or otherwise. It may, therefore, be of various kinds. This material acts 
 upon a nerve or nerves, or upon a nerve centre or nerve-centres, and produces 
 an herpetic eruption which is the aphthous process. 
 
 Symptoms. — On the part of the general system there is a great diversity, 
 depending largely upon the patient affected. We may have, for two or three 
 days preceding the eruption, manifestations pointing to the inception of almost 
 any disease common to children — vomiting, constipation, high fever, pain in 
 the throat or mouth, enlargement of lymphatics, a slight cough, depending 
 upon the localization of the disease, and even nervous symptoms, so that it 
 will be almost impossible to foretell what is coming. On the other hand, some 
 patients are very little affected beyond a slight rise of temperature, fretfulness, 
 and loss of appetite. An examination of the mouth made at this period usually 
 reveals stomatitis catarrhalis, sometimes a whitish spot upon the tonsil. Then, 
 possibly the next day, the characteristic eruption appears with lightning rapidity. 
 This consists of white or yellowish-white subepithelial spots, single or in groups, 
 surrounded by an areola, and developing anywhere within the mouth, not uni- 
 
400 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 lateral, and sometimes extending into the pharynx, and possibly also into the 
 larynx. After from twelve to thirty-six hours the epithelial coating is soaked 
 off, and there is left the so-called aphthous ulcer. After a few days more the 
 floor of the ulcer is clean or the exudate is lifted up between regenerating 
 epithelial cells ; it is lifted beyond the level of the mucous membrane, and 
 finally disappears. Some aphthae are absorbed without going through this 
 normal course. They appear in successive crops, and it is not unusual to have 
 the course of the disease extend to from ten to fourteen days. The exudate is 
 made up of fibres, indifferent cells, and various lower forms of life. No cic- 
 atrix is left where these spots have been, showing that the submucous tissue 
 has not been affected. 
 
 The local symptoms are those of stomatitis catarrhalis ; where denudation 
 takes place there is more pain. The most common complication which occurs 
 is stomatitis ulcerosa, and unless this is present the saliva in stomatitis aphthosa 
 is never fetid — a matter of great diagnostic importance. In some instances 
 the aphthae are so numerous that the mouth looks as if it were covered by a 
 diphtheritic membrane. A day of waiting will clear away any doubts on the 
 subject, as by this time the characteristic denudation will have appeared. 
 
 Prognosis. — The prognosis is absolutely good. The disease is self-limited, 
 doing no harm except to interrupt the general thriving of the child. Infection 
 with other poisons has been known to take place, but this, fortunately, is very 
 rare. Relapses are very rare, and the small ulcers, as a rule, heal without 
 difficulty. 
 
 Treatment. — This is the same as that used for catarrhal ulcers — viz. the 
 nitrate of silver. Permanganate of potassium may be used locally to great advan- 
 tage (gr. iij to f Ij), but must not be looked upon as a specific. General treat- 
 ment, as a rule, is not required, and when it is necessary it is purely sympto- 
 matic. Laxatives, usually given early, seem to have no influence upon the 
 process ; calomel does not abort it, and must be used according to the indica- 
 tions which govern its administration in other conditions. The poison has 
 done its work before we are able to attempt to counteract its bad effects ; it is 
 probably eliminated by the time we see the patient, and therefore all causal 
 therapy is futile. 
 
 Bednars Aphthce are found only in the new-born. They are shallow 
 ulcers covered by a gray or yellowish coating, and found upon the soft palate, 
 the posterior part of the hard palate, the palatine suture, always near the velum 
 palati. They may be mistaken for the ulcers produced by the breaking down 
 of milia or retention-cysts, or for that condition described by Epstein in which 
 there are congenital defects in the mucous membrane filled up with epithelial 
 detritus. 
 
 These aphthae are always produced by violence in cleansing the mouth ; 
 this explains their position and their course. They are rarely found in private 
 practice except where the midwife still holds absolute sway. Their course is 
 benign, they require no treatment, and are only dangerous when they become 
 infected. With the modern rubber nipples, when badly shaped, they some- 
 times develop far forward upon the hard palate ; changing the shape of the 
 nipple always results in their cure. 
 
 m Stomatitis Mycosa. 
 
 This condition, commonly termed Thrush, is a disease produced by a pecu- 
 liar fungus, first discovered by Berg of Stockholm, and called oidium albicans 
 by Robin. Rees and Grawitz were the first to show that the fungus is not an 
 
DISEASES OF THE MOUTH. 401 
 
 oidiuin, but a saccharomyces. All later investigations agree in showing that it 
 is not oidiuin, but all do not agree that it is saccharomyces albicans. For the 
 present, however, until the exact position of the fungus is determined, it seems 
 wise to adhere to the last name, saccharomyces albicans. 
 
 Etiology. — The fungus is the only cause, but it must be deposited upon 
 favorable soil to produce the disease. The saccharomyces albicans may be 
 found upon every mucous membrane in the body, the alimentary, the respi- 
 ratory, and genito-urinary : it has been found in the parenchyma of organs, as 
 the brain and lungs, and in blood-vessels. It is usually carried to children by 
 the nipple or by the nursing-bottle. The fact that weak and unhealthy chil- 
 dren are most predisposed to thrush has been emphasized entirely too much : 
 perfectly healthy children have thrush. It has also been stated that flat epi- 
 thelium is necessary for the development of thrush ; this, however, can no 
 longer be maintained, as we see the fungus on a great many surfaces lined by 
 cylindrical epithelium. It is admitted on all hands, however, that catarrhal 
 stomatitis exists either before or with the appearance of thrush. It is more 
 than probable that this is the predisposing cause, and that it works mechani- 
 cally — viz. by a dislocation of the swollen cells, preventing perfect protection 
 to the mucous membrane, and allowing the spores of the fungus to find a place 
 for development. Anything producing this mechanical injury to the mem- 
 brane of the mouth, such as badly-formed or hard nipples, will act in the same 
 way. The younger the child or the w T eaker, the more successful will be the 
 implantation of the saccharomyces, because the function of motion of the 
 tongue and jaw will be least developed. The disease is therefore found 
 especially in infants reduced by illness, and in older children in connection 
 with diseases that are followed by great loss of strength, such as long-continued 
 fevers, wasting diseases, or those in which motion is very much impaired. 
 
 The fungus is found in two forms, depending largely upon the culture- 
 material — the yeast form and the globulo-filamentous form (frequently called 
 mycelium). There is no ascospore ; therefore, according to Roux and Linois- 
 sier, the fungus is not a saccharomyces. The chlamydospore has, however, 
 not been satisfactorily worked out. Propagation goes on in three ways — by 
 filaments produced from conidia, by isolated conidia, and by spores. 
 
 Pathology. — The first lodgement comes between the epithelial cells of the 
 mouth, and from this the growth works its way toward the free surface and 
 toward the mucous membrane proper. In the direction of the free surface the 
 growth is not so luxuriant, but in both directions it is principally in the myce- 
 lium form. In mucous membranes lined by flat or squamous epithelium the 
 growth of the saccharomyces is facilitated by the relation of the cells to each 
 other ; in membranes lined by cylindrical epithelium growth takes place, but 
 not so readily, because there is but one layer of cells. After the first develop- 
 ment growth goes on very rapidly : after having found a nidus, the cells are 
 pushed aside, surrounded by mycelium, the whole forming the characteristic 
 thrush-spot. Pus is rarely produced ; when this does occur the affection is of 
 a complex nature. The growth begins in small spots, sometimes one, some- 
 times more ; from these infection spreads, and at times the whole mucous mem- 
 brane is covered with a rich growth of the saccharomyces. 
 
 Symptoms. — Preceded or accompanied by stomatitis catarrhalis, the local 
 symptoms vary with the intensity of this process. Frequently no symptoms 
 are present, and the existence of the small spots is the first indication of the 
 presence of thrush. These vary in size, seem a part of the mucous mem- 
 brane, are usually of a grayish-white, creamy color, and may or may not be 
 elevated above the surface of the mucous membrane. They appear first upon 
 
 26 
 
402 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the tongue and cheeks, then frequently upon the lips and soft palate, and may 
 be found upon the tonsils, the pharynx, or the oesophagus. With only mode- 
 rate care of the mouth they seem to last indefinitely ; without care they spread 
 rapidly, and instead of the spots we may see membranes, in the case of the 
 oesophagus whole casts being formed, which fill its lumen and often prevent 
 swallowing. In hospital practice thrush has proved a formidable disease ; in 
 private practice it amounts to nothing more than a local disturbance, unless 
 neglected. In the latter class of patients there is always associated some 
 gastro-intestinal disturbance, which may prove serious if not fatal. In debili- 
 tated subjects — and thrush, from the mechanical reasons pointed out before, is 
 more common in such — these gastro-intestinal troubles may be the affection 
 which terminates the child's life. When the membrane drops off there is left a 
 slight abrasion which may become the focus of infection by any other morbific 
 agent. 
 
 But it must not be inferred that thrush occurs only in debilitated or sick 
 children. It may occur in children that seem perfectly healthy, although care- 
 ful investigation will always reveal some lesion in the mouth which has pre- 
 ceded the thrush. Again, not every child with stomatitis mycosa has gastro- 
 intestinal symptoms : the food carrying saccharomyces frequently carries other 
 lower forms of life capable of producing diarrhoea, but in properly-treated 
 cases these symptoms are wanting, and when taken early enough thrush is 
 local, and local only. 
 
 The thrush-spots develop within the epithelium, and examination by 
 reflected light will show this ; the spot is often surrounded by a narrow ring 
 of injected blood-vessels. Removal from the mucous membrane requires 
 considerable violence. The next step in development is a pushing up beyond 
 the level of the mucous membrane, and after this more extensive infection of 
 the mouth may be expected unless counteracted by treatment. At times the 
 whole mass may drop off and leave an ulcer, sometimes very intractable, or 
 the many spots may coalesce to form a membrane. The differential diagnosis 
 is not difficult if all the above be taken into consideration, and a positive 
 diagnosis can be made under all circumstances with the microscope. 
 
 Treatment. — Prophylaxis is very important. In young children all 
 abrasions and all slight forms of stomatitis ought to be looked after. Every- 
 thing coming in contact with the mouth of the infant should be kept aseptic— 
 the nipples, the feeding-bottle, the food. 
 
 The treatment is simple enough if properly carried out. A solution of 
 sodium bicarbonate (1 drachm to a tumbler of water) is to be applied with a 
 brush between the times of nursing or feeding and immediately after feeding or 
 nursing. Ulcers should be treated as has been described under Stomatitis 
 Catarrhalis. (Esophageal thrush, when the diagnosis is possible, should be 
 treated by the introduction of a soft-rubber tube (catheter) into the stomach. 
 The intestinal troubles are best treated by small doses of calomel or corrosive 
 sublimate, combined with careful diet. 
 
 IV. Stomatitis Ulcerosa. 
 
 This is a peculiar process, characterized by destruction of tissue, beginning 
 on the gums around the teeth, never extending beyond the mouth, infecting 
 healthy parts of the mouth, and never occurring where there are no teeth. 
 
 Etiology.— A clinical picture resembling the disease is produced by the 
 internal administration of certain remedies — mercury, copper, and iodine. 
 Mercurial stomatitis is almost identical with stomatitis ulcerosa, and in these 
 
DISEASES OF THE MOVTH. 403 
 
 cases we find that a local irritation caused by bad teeth or uncleanliness of the 
 mouth is a decided factor in the production of this affection. But, in addition, 
 the remedies are excreted by the mouth, and in this fact there is to be found a 
 possible clue as to the etiology of stomatitis ulcerosa. Whether, in addition, 
 there are lower forms of life or chemical substances, or both, which cause this 
 peculiar form of inflammation, it is for the present impossible to decide. 
 
 The disease usually develops in connection with bad hygienic surroundings, 
 or following certain diseases, especially measles and scarlatina, and frequently 
 malaria, pertussis, typhoid fever, or pneumonia. It is said to be endemic in the 
 wards of certain hospitals or in certain barracks ; and damp, poorly-ventilated 
 houses, with or without insufficient nourishment, certainly favor its develop- 
 ment. The disease is usually held to be non-contagious, but experiments 
 with inoculation have proven to me that, with proper precautions, the disease 
 can be propagated. It is not infrequent with soldiers, especially when confined 
 in barracks, and the likelihood of a scorbutic affection being the predisposing 
 factor cannot be disposed of at present. It is rarely observed before the age 
 of five years, most frequently between the ages of five and ten, but it does 
 occur at any time of life, provided teeth be present. 
 
 Pathology. — The process is one of necrobiosis. There is cellular death, 
 but at the same time there results softening of the tissues, and not death 
 en masse. The peculiarity of this form of necrosis is that it does not respect 
 any form of tissue, but may extend to the periosteum, finally producing 
 necrosis of bone. It is not unusual to find sequestra of large size ready to 
 be removed. The process may, at the same time, produce caries of the bone, 
 although this is certainly exceptional. The disease always begins at the free, 
 border of the gums, from which it extends in all directions, frequently 
 infecting healthy mucous membrane, but never extending beyond that of the 
 mouth. 
 
 Symptoms. — We first find swelling of the mucous membrane only at 
 the lower part of each tooth (most commonly the lower incisors), and this 
 gradually increases until the curved outline of the gum is converted into a 
 more or less straight line. This swelling may become so great as to produce 
 eversion of the part affected ; at the same time there is great injection, almost 
 lividity, accompanied by more or less bleeding upon the slightest provocation. 
 The anterior aspect of the gum is first affected, but in severe cases the posterior 
 portion also takes part in the process. Soon the gums can be detached from 
 the teeth, and there is exposed a cavity or sac filled with a muco-purulent 
 secretion. These characteristic local symptoms are further distinguished by 
 the appearance upon the swollen gum of a yellowish seam, which may become 
 a broad band. This represents the ulceration, and is due to cellular necrosis. 
 With this there is a constant flow of fetid saliva from the mouth, but the 
 odor comes from the diseased gums, except in very bad cases, when it may 
 in part occur from diseased bone. In older children subjective symptoms 
 are slight ; in younger ones the principal evidence is pain, fretfulness, change 
 in disposition, crying, and wakefulness. 
 
 The outpouring of large quantities of saliva commonly produces eczema of 
 the lips, which may persist long after the cause has been removed. The lym- 
 phatic glands are always involved ; they are soft, and remain enlarged fre- 
 quently for a long time ; as a rule, they do not suppurate, although this may 
 occur some time after the disease in the mouth has run its course. 
 
 At this stage the disease is very amenable to treatment ; if left to itself, it 
 goes on indefinitely and develops. The yellowish seam increases, and when 
 removed there is exposed an ulcerated surface. There is greater formation of 
 
404 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 pus; the gums become more detached from the teeth, which are loosened. 
 Ulcers may now form upon other parts of the mouth, the lips, the cheeks, the 
 tongue. In very bad cases the whole of the mucous membrane covering the 
 body of the lower gum has ulcerated away, and we look in upon a cavity filled 
 with offensive pus, bleeding, and possibly showing a piece of denuded bone at 
 the bottom. In these cases salivation has reached its maximum development, 
 and the whole room may become tainted with a peculiar foul odor. Sometimes 
 ulcers form upon the mucous membrane joining the lower lip to the gum; 
 wherever they may be, however, it is always the characteristic sequence : first, 
 necrobiosis, the seam surrounded by injected tissue, then ulceration below. 
 
 Nature rarely cures these cases without assistance : when cure takes place 
 the symptoms disappear slowly, but in every case the disappearance of the 
 fetid saliva is the first symptom of improvement. Sometimes the disease 
 becomes chronic ; it then runs an exceedingly mild course when deep tissues 
 are not involved. It always takes some time for this to take place, so that if 
 a patient has had stomatitis ulcerosa for several months without involvement 
 of deep structures, it is more than probable that we are dealing with the 
 chronic form. This is characterized by its resistance to ordinary methods of 
 treatment and by the frequency of relapses. 
 
 Prognosis depends upon three factors : the disease upon which stomatitis 
 ulcerosa is engrafted, the stage of the disease, and the treatment. The worst 
 form is found in scorbutus. Where bone-changes are present the disease 
 assumes the aspect of a disease of bone, but the prognosis is not bad when the 
 condition is recognized. The important fact that stomatitis gangrenosa some- 
 times develops must never be forgotten : every case of stomatitis ulcerosa, 
 therefore, requires most careful watching. 
 
 Treatment is prophylactic and curative. Improve the hygienic condi- 
 tions of the patient and prevent extension of the disease to others. Chlorate 
 of potassium can be looked upon as almost a specific in this affection. It is to 
 be administered, with all precautions, in a 3 per cent, solution, of which \ to 1 
 teaspoonful is given every two hours. At first its administration is accom- 
 panied by pain, sometimes very intense, but this no longer occurs in from 
 thirty-six to forty-eight hours after treatment has begun. It takes about 
 twenty-four hours for the remedy to produce any appreciable effect, and this is 
 evidenced by a diminution of salivation. Soon this hypersecretion disappears 
 entirely, and with it the fetid odor from the mouth ; in the course of a week, 
 usually, all symptoms will have disappeared. If ulceration has not disappeared 
 at this time, careful search must be made for the cause. Carious teeth must 
 either be removed, filled, or otherwise treated by antiseptics ; if this does not 
 remove the ulceration, recourse must be had to cauterization, either by nitrate 
 of silver or the galvano-cautery. Dead bone must always be removed. Where 
 the cause of a continuance of the process cannot be found, frequent applica- 
 tions of permanganate of potassium yield good results. As a last resort, the 
 teeth around which the ulcerative process is best developed must be extracted 
 and the cavity frequently washed, when the process will soon be found to come 
 to an end. As potassium chlorate is a remedy almost specific in its properties, 
 any other medicaments will hardly ever become necessary. 
 
 In chronic cases potassium chlorate does not act so universally ; here, how- 
 ever, its use is also indicated, combined with local treatment in the form of 
 applications of silver nitrate three times a week. 
 
DISEASES OF THE MOUTH. 405 
 
 V. Stomatitis Gangrenosa. 
 
 This disease, termed also cancrum oris, gangrene of the mouth, or noma, 
 is comparatively rare, most common in hospital practice, and in private prac- 
 tice depends for its frequency principally upon the surroundings. It is a 
 gangrenous process, beginning upon the gums or inner surface of the cheek, 
 spreading with great rapidity, and destroying every kind of tissue upon which 
 it develops. 
 
 Etiology. — There can be no doubt that the disease may become infectious 
 in its nature ; several cases occurring in the same family or a number breaking 
 out in one ward of a hospital can be offered in evidence. On the other hand, 
 a great many cases are observed in which it seems to be impossible to take into 
 consideration anything like contagiousness ; a case occurring in a patient miles 
 out in the country where no other case of noma has ever been observed in 
 that neighborhood. 
 
 Noma occurs only in children sick with other diseases, never in healthy 
 children. Furthermore, it follows in the wake of such diseases as produce 
 great debility and least cellular resistance. The diseases most commonly 
 followed by noma are — the acute exanthemata (especially measles and typhus), 
 whooping-cough, syphilis, scorbutus, chronic intestinal catarrhs, and malaria. 
 The excessive use of mercurials has been frequently considered the cause of 
 this disease ; no doubt such consequences have followed the heroic doses of 
 former days, but are certainly exceptional now. Stomatitis ulcerosa is fre- 
 quently a forerunner of noma, being the result of identical predisposing 
 causes, but in all probability the resemblance of the two processes ceases 
 there. 
 
 A great many lower forms of life have been found, but the testimony as to 
 their causative relation is, as yet, inconclusive. Short rods, as in pulmonary 
 gangrene, and streptococci (Cornil and Babes), streptococci resembling those 
 found by Koch in progressive tissue-necrosis of white mice (Ranke), and bacilli 
 in thread-like growth (Lingard), have been looked upon as the immediate cause ; 
 but the predisposing cause, after all, is the most important, and the probability 
 is that sooner or later any number of different kinds of organisms, both patho- 
 genic and otherwise, are developed in every case of noma. 
 
 Pathology. — We find all the evidences of a phlegmonous gangrene. Sur- 
 rounding destroyed tissue there is an infiltrated zone. The latter is a true 
 necrobiotic process, all evidences of cellular tissue being destroyed, only a 
 homogeneous substance in which are found micrococci being left. Around 
 this is found increased connective tissue, the connective-tissue corpuscles in 
 active cell-division, while the blood-vessels are closed by thrombi and lower 
 forms of life. Outside of this we find healthy tissue. In every case of noma 
 these four zones can be distinguished. 
 
 Symptoms. — The first and most characteristic symptom noticed is the odor 
 of gangrene. Upon examination an ulcer will be found upon the gums or the 
 inner surface of the cheek ; this spreads very rapidly. Very soon the whole 
 cheek begins to swell ; it becomes oedematous, the skin is waxy, and within 
 twenty-four hours the whole side of the face may become involved. Some- 
 times the swelling is painful, but frequently children will not complain of any 
 local symptoms. The ulcer in the mouth has now become deeper, and is evi- 
 dently eating its way through the cheek, producing symptoms almost pathog- 
 nomonic as it comes nearer the skin. The latter becomes discolored, red, 
 blue, purple, black. Sometimes a bulla filled with ichorous fluid is formed 
 upon the cheek ; then the epithelial covering breaks down, and with it the gan- 
 
406 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 grenous process goes on from without inward. Where no bulla is formed the 
 gangrene goes on from the mucous membrane to the skin. Perforation of the 
 
 Fig. 1. 
 
 Cancrum oris in a child five years old. 
 
 cheek takes place under all circumstances and in a very short time — from twenty- 
 four hours to three or four days. As a rule, the process continues, involving the 
 whole of the cheek, the neck, the eyelids, destroying the eye, but rarely becoming 
 bilateral. The bones are denuded, the teeth become loose, the tongue, hard and 
 soft palate, even the tonsils, may become infected, and there is left a discolored, 
 fetid, soft mass. The whole terminates in producing probably the most repul- 
 sive appearance the physician has opportunity to see. The odor is frightful, 
 filling the whole house ; the flow of saliva is very much increased, and death 
 usually results from the depressed general condition. Spontaneous recovery is 
 rare : a line of demarcation then forms around the gangrenous spot, the surface 
 is covered by granulations, and finally cicatrization follows, leaving most 
 horrible scars. Relapses sometimes occur, but they are rare. The whole du- 
 ration of the disease is from one to three weeks, sometimes longer, depending 
 upon the vitality of the patient. The general symptoms are usually those of 
 the disease upon which noma is engrafted. Sometimes children with noma are 
 found playing in bed, picking out loose teeth, and apparently little concerned 
 about the intense fatal process going on upon their cheek. This is, however, 
 not the rule, and when it does occur it is followed in a short time by general 
 symptoms showing the severity of the local process. The temperature is some- 
 times very high, becoming hectic in type, but not infrequently it becomes sub- 
 normal before death. The pulse is small, easily compressed, weak, and rapid. 
 The appetite is diminished, and diarrhoea is the rule, most intractable in its 
 nature and probably due to infection from the process in the mouth. Catar- 
 rhal pneumonia, due to inhalation of septic material, is common, and diphtheria 
 
DISEASES OF THE MOUTH. 407 
 
 has been observed in several cases. Exhaustion comes on, and then the child 
 becomes apathetic, refuses food, and dies in collapse. Haemorrhages are rare, 
 because the blood-vessels are filled with thrombi. 
 
 Prognosis. — This is very bad, the mortality ranging from 70 to 90 per cent, 
 of all cases affected. Complications make the prognosis absolutely fatal. 
 
 Treatment. — Of the general treatment, always of great importance, little 
 new can be said, as the physician has already done all in his power to avert a 
 gangrenous process by keeping up the strength of the patient. When noma 
 sets in stimulants should be used methodically and systematically ; food should 
 be given in as condensed a form as possible. If feasible, rectal alimentation 
 may be tried, but this, as a rule, is not very satisfactory for children. 
 
 The local treatment is of prime importance, and, as the mortality is so great, 
 even the most heroic treatment can be adopted with complacency. The prin- 
 ciple of local treatment is to destroy the infiltrated zone and the healthy tissue 
 surrounding it for some distance, so as to make an artificial line of demarca- 
 tion. Nitrate of silver in stick, dilute muriatic or other acids, chloride of zinc, 
 and many other remedies have been recommended for this purpose. To the 
 author it seems that the best and most active method of destroying this tissue 
 is to be found in the use of the thermo-cautery of Paquelin or the galvano- 
 cautery ; and lately several cases have been reported in which success has 
 followed these applications, although it is far too early to draw positive con- 
 clusions. As soon as the gangrenous nature of the disease has been established 
 the operation must be performed. A loss of time, even of hours, means con- 
 siderable loss of tissue. Again, delay may make the operation one of great 
 magnitude, in that blood-vessels may have to be tied which before the exten- 
 sion of the process could be safely cut with the galvano-caustic knife. Under 
 anaesthesia, when possible, necrotic tissue should be removed, and then every- 
 thing that seems gangrenous should be destroyed. After this a certain amount 
 of healthy tissue should be cauterized. Tf gangrenous spots appear the next 
 day, the operation should be repeated, and so on ; applications can be made 
 daily. The wound is to be treated according to surgical rules, and plastic 
 operations should be put off as long as possible, because, in the first place, 
 they do not offer much chance of success when done early, and, in the second 
 place, noma sometimes recurs as the result of these operations. 
 
 In conclusion, it must be stated that, whatever has been done and will be 
 done, the results must be bad, because the process is one developed in a 
 patient very much reduced, in whom the least complication is likely to prove 
 fatal. 
 
 VI. Stomatitis Crouposa; Stomatitis Diphtheritica. 
 
 Croupous stomatitis may be produced by a variety of causes, both chemical 
 and bacterial. Primary croupous stomatitis is certainly a very rare affection, 
 although it may occur. As a rule, the croupous membrane develops contem- 
 poraneously with a membrane upon the tonsils. In very severe cases the 
 membrane has been found upon the cheeks, the tongue, and even upon the lips. 
 The lymphatic glands are not much involved, and as the mouth-process is 
 commonly only part of another of more importance, little more will be said 
 in this connection. The important thing to establish is the absence of the 
 Loeffler-Klebs bacillus ; this will make the diagnosis absolute. At the present 
 time the whole subject is being investigated, but enough has already been 
 done to show that all false membranes are not diphtheritic. 
 
 Diphtheritic stomatitis does occur as a primary affection, although it is 
 
408 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 not very common. When primary in the mouth, the membrane usually 
 develops upon the lips, and may extend thence to any part of the mouth. As 
 a rule, the tonsil is the primary seat, and thence the membrane spreads to 
 the soft palate, the tongue, the cheeks, the lips, and the gums. There is but 
 one positive method of making the diagnosis of diphtheria, and that is by 
 proving the presence of the Loeffler-Klebs bacillus by cultures, and then 
 making inoculative experiments upon lower animals. In primary diphtheritic 
 stomatitis this would become imperative ; in the secondary form there are, 
 fortunatelv, still left for the clinician combinations of certain symptoms that 
 make it possible to diagnosticate the disease without consulting the bacteri- 
 ologist. 
 
 Salivation usually occurs, and the odor from the mouth is fetid. Some- 
 times diphtheria of the mouth, when primary, runs it course most insidiously, 
 and is overlooked or not recognized until further complications develop. The 
 membrane lasts from three to six days, sometimes longer, and then either drops 
 off or ulcerates away ; in either instance there is left a denuded place. Haemor- 
 rhages are common, either slight or otherwise ; when not due to mechanical 
 irritation they are matters of anxiety. In some instances haemorrhage has 
 been so great as to cause death ; in others only a slight loss of blood seems 
 sufficient to produce a fatal termination. The prognosis depends largely upon 
 the form, whether primary or secondary ; it is very much worse in the latter 
 than in the former, but even in the primary form may become very grave 
 by extension. The author has seen two cases in which a primary diphtheritic 
 stomatitis has become a laryngeal one. 
 
 Treatment is that of diphtheria. When possible, the membrane must 
 be removed if this proceeding be not accompanied by violence, so that infec- 
 tion of healthy membrane be produced. Constitutional treatment is of the 
 utmost importance, in order to counteract the tox-albumins produced by the 
 bacillus. For this purpose corrosive sublimate, administered internally in full 
 doses frequently repeated, seems to be the favorite. In the septic cases much 
 good can be done by frequent local applications without violence. 
 
 VH. Stomatitis Syphilitica. 
 
 Syphilis produces stomatitis only in an indirect manner, either by causing a 
 specific deposit, which, in its turn, produces the disease, or by rendering the 
 mouth in such patients more sensitive to agents which produce stomatitis. 
 
 The three stages of syphilis are developed in the mouth. Primary lesions 
 are very rare, but infection does take place from syphilitic wet-nurses, and 
 when this occurs the lesion in the mouth of the child does not differ from the 
 same lesion in the adult. The secondary manifestations are most common, and 
 any part of the mucous membrane may be their seat. Upon the lips we find 
 the following forms : syphilitic fissures, papules, plaques, and erosions. The 
 fissures (rhagades) are most common, and are generally found at the corners of 
 the mouth or upon the upper and lower lips. They are syphilitic infiltrations 
 which have been split near their middle, so that at the corner of the mouth one 
 part of the infiltration lies nearer the upper lip, the other nearer the lower, and 
 the split seems a continuation of the commissure. Upon the lip rhagades 
 usually end in the mucous membrane. Sometimes these fissures are present 
 in such great numbers that they disfigure the mouth, and by the pain which 
 they produce cause great annoyance to the patient. When they heal they leave 
 cicatrices which, in their turn, may permanently disfigure the mouth. The 
 characteristics of these fissures are the infiltration, the split, and the lack 
 
DENTITION. 409 
 
 of tendency to spontaneous healing. Papules are most common at the 
 commissure and the free border of the lips ; they may also be split, and then 
 resemble the former variety. As a rule they look like condylomata lata in 
 similar positions ; they are elevated, their surface is moist, the centre has a 
 tendency to break down, and unless they involve the mucous membrane they 
 do not cause pain. The remaining forms may be found upon any part of the 
 mucous membrane ; they cover more space, are not characterized by the same 
 amount of infiltration, but usually produce more pain and more salivation. 
 
 Upon the tongue we most commonly find plaques muqueuses and syphilitic 
 ulcers. Their localization depends largely upon irritation, either from a sharp 
 tooth or other cause. The healed ulcers leave cicatrices, but the characteristic 
 appearance of the tongue, as it is found in the adult after syphilis has run its 
 course, is exceedingly rare in children. In the early stages of syphilis we find 
 a decided enlargement of the circumvallate papillae, and a loss of the filiform 
 papillae, so that the tongue looks "shaven." The so-called geographical 
 tongue (wandering rash, ringworm, lichenoid condition) has nothing in com- 
 mon with syphilis and bears no relation to it. 
 
 Treatment. — As in all forms of syphilis, so with stomatitis syphilitica — gen- 
 eral treatment is of most importance. When deformity or danger to life is threat- 
 ened, that method must be used which produces the quickest effects. The manifes- 
 tations in the mouth, as a rule, yield rapidly to constitutional treatment, but 
 local prophylaxis and treatment must not be lost sight of, as being accessory 
 and highly important. Cleanliness is absolutely necessary to prevent saliva- 
 tion as well as to aid in recovery. All sources of irritation must be removed 
 and the teeth must be kept in good condition. Frequent applications of silver 
 nitrate are best for ulcers, erosions, or losses of substance. Corrosive sublimate 
 is preferable when there is considerable infiltration, either in weak solution as 
 a mouth-wash, or in stronger solution applied with a brush, in which case it is 
 apt to produce pain. The weak solutions should be applied two to four times 
 daily ; the strong ones (as high as 12 per cent.) are caustic and should be used 
 with great caution. When children are old enough an application of emplas- 
 trum hydrargyri with lanolin (1 part of lanolin to 2 parts of the emplastrum) 
 upon chamois gives better results than either of the former remedies in rhagades 
 at the corners of the mouth. In cases of stomatitis mercurialis, potassium 
 chlorate or any remedy containing tannic acid, such as tannin itself or tincture 
 of rhatany or catechu, is very serviceable. 
 
 E. DENTITION. 
 
 Nearly all diseases of childhood have been ascribed to teething ; even at 
 the present time authors will be found who do not hesitate to work out the 
 most improbable relations of teething to disease. But, be this as it may, there 
 is no one who does not admit that some children may have teeth without any 
 great amount of disturbance, or, indeed, that teething may go on without pro- 
 ducing any symptoms at all. This latter form of teething would be called 
 normal ; the abnormal form has been called dentitio dJfficilis. It is proper to 
 state that medical authorities are much divided as to the importance of teeth- 
 ing as an etiological factor of disease, and that they can be divided into three 
 classes : those claiming that almost any disease can be produced by teething. 
 
410 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 those claiming that no disease is produced by teething, and, lastly, those who 
 state that some few diseases may follow the eruption of teeth. The first class 
 states that normal teething occurs in only 20 per cent, of all children. 
 Although teething in healthy and teething in unhealthy children is a better 
 division from a clinical standpoint, we will, for the present, follow the division 
 as given above. 
 
 The greater part of teething is accomplished before the child is born. At 
 about the seventh week of foetal life the epithelium within the mouth is thick- 
 ened, forms a ridge, and at the same time dips into the embryonic tissue about 
 to form the jaw. This epithelial process is called the enamel-germ ; it grows 
 so as to surround a flask-shaped cavity, which it lines ; partitions develop into 
 this, forming ten cavities for each jaw. A papilla is now developed, which, 
 pushing up toward the embryonic tooth, forms a complete mould for the enamel- 
 germ to rest upon, and this is called the dentine-germ. We now have the 
 beginnings of the ten temporary teeth in the form of the partitions, the enamel- 
 and dentine-germ, and the papillae. The connective tissue around these primi- 
 tive teeth has at the same time been forming into the dental sac, an investing 
 membrane for each tooth. In the partitions, as well as in the rest of the jaw, 
 bony tissue is being formed ; the teeth become farther separated from each 
 other, and by this deposit of bone the alveolus is formed, lined by the dental 
 sac coherent with the gum along the border of the jaw. This process of devel- 
 opment has taken the whole period of foetal life, so that the child comes into 
 the world with all its temporary teeth fully formed within the jaw. The per- 
 manent teeth are formed, in so far that the enamel-germ is developed from the 
 enamel-germ of the temporary tooth as a small sac, from which subsequently 
 the development goes on, as already described for the temporary teeth. The 
 topographical relations of the teeth at birth are as follows : above, the tooth-sac, 
 the submucous connective tissue, and the mucous membrane itself; on either 
 side, the tooth-sac and bony tissue. There is no bony tissue to impede the 
 tooth on its way to the oral cavity ; all that it needs to overcome is the sub- 
 mucous coat, the mucous membrane, and the dental sac, which is very thin. 
 Not enough stress can be laid upon the fact that the opening of the alveolus is 
 wider than necessary to allow the tooth to pass through. 
 
 Calcification of the fangs begins, and as the tooth becomes elongated by 
 means of this, it is slowly forced in the direction of least resistance, the mouth. 
 Pressure is directed toward the mouth ; the papilla cannot be pressed upon, 
 for the simple reason that where, during growth, blood-vessels come in contact 
 with bony substances, absorption of the latter is produced, the blood-vessels 
 not being affected. It is possible that, as Kassowitz has pointed out, the 
 growth of the blood-vessels causes the alveolus to be moved constantly, and 
 that this growth acts as another cause for the coming through of the teeth. 
 Calcification of the fangs usually begins in the lower incisor teeth at birth, 
 beginning in those teeth first which are first to make their appearance in the 
 mouth. 
 
 The order of teething can be described as occurring in three ways. Unfor- 
 tunately, there is as yet no unanimity among authors as to the most common 
 method. The first is the appearance of the teeth in pairs, principally in rela- 
 tion to the incisors. The second is the appearance of the first two incisors, 
 then all the other incisors, and then the molars. The third, which we believe 
 to be the most common order, is the appearance of the first two lower incisors, 
 then the four upper incisors, then the first molars, and with them the remain- 
 ing two lower incisors, as follows : 
 
DENTITION. 411 
 
 I. Two lower central incisors 5-7 months. 
 
 II. Four upper incisors 8-10 " 
 
 III. Four first molars and two lower lateral incisors . 12-14 " 
 
 TV. Four canines 18-20 " 
 
 Y. Four second molars 28-34 " 
 
 It will be borne in mind that this table represents average times, and that 
 the time for eruption depends upon a great many different causes. The nation- 
 ality, heredity, climate, and general development of the child may either 
 retard or accelerate the appearance of teeth. Certain diseases, especially 
 rickets, have a well-marked retarding influence, but because a child is late in 
 teething it must by no means be taken as positive evidence that he has rickets. 
 
 The time of eruption depends, first, upon the distance the tooth has to 
 travel from the dental sac to the mouth ; secondly, the amount of calcification 
 in the fangs ; and, lastly, the condition of the rudimentary organs. Increased 
 calcareous deposit would compensate for length of distance, and possibly for 
 deficiencies in the rudimentary organs ; but frequently no compensation can 
 take place, and the teeth are left permanently deformed as well as late in 
 appearing. 
 
 Premature teeth may occur from several causes : some change in the 
 embryonic structure may result in the production of teeth without fangs, which 
 are attached only by mucous membrane ; or the deposit of calcareous material 
 may be too early or too great; or, finally, more than twenty primitive teeth 
 may have been formed, one or more of which project into the cavity of the 
 mouth. Premature ossification of the bones of the skull is said to be accom- 
 panied by premature teeth, and in this case Jacobi claims that the upper 
 incisors then appear first. The latter view, however, still requires verification. 
 Premature teeth must not be interfered with unless there is a special indication 
 for their removal, because it may be possible that no second tooth shall appear 
 until the permanent one comes through ; and, furthermore, their removal is 
 not unattended by danger (haemorrhage). The most urgent indication for 
 removal is to be found in their being in the way of nursing ; they may 
 produce fissure of the nipples or may make nursing so painful to the mother 
 that serious consequences follow. 
 
 The teeth are retarded by the constitutional diseases, rickets and syphilis — 
 these forms of general disturbance of nutrition resulting in cachexia and in 
 long-continued fevers or chronic diarrhoea. Acute febrile disturbances, such 
 as the exanthemata, may not have any effect upon the temporary teeth, and 
 yet show distinct tracings upon the permanent teeth ; or the group coming 
 through at the time of fever may not be delayed at all, and yet the next 
 one will be delayed some time. 
 
 A food-supply defective in calcareous material has been frequently accused 
 of delaying teething. This is, theoretically, correct ; but, as a matter of fact, 
 when the salt material of the food is diminished to such an extent as not to be 
 able to supply the small amount demanded for teething, life can no longer be 
 sustained by such food. Our own experience has been that none of the 
 proximate principles of which teeth are composed, when administered inter- 
 nally, have any effect upon the appearance of the teeth. There is but one 
 remedy which seems to hasten teething, and that one affects rachitic children 
 principally, though not exclusively ; we refer to the internal administration of 
 phosphorus. 
 
 The permanent teeth appear in about the following order and times : 
 
412 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 First Molars. Incisors. Bicuspids. Canines. Second Molars. Third Molars. 
 
 6 years. 7-8 years. 9-10 years. 12-14 years. 12-15 years. 17-25 years. 
 
 In regard to the symptoms produced by teething, it can be definitely stated 
 that in a healthy child teething goes on without producing symptoms of any 
 sort. In children reduced by malnutrition, affected by hereditary syphilis or 
 rickets, and in those extremely nervous either as a result of hereditary or other 
 causes, there are symptoms which can be divided into two groups : first, local ; 
 secondly, remote. The local symptoms are pain, heat, irritation, not infre- 
 quently stomatitis catarrhalis. All these may occur in healthy children, but 
 are manifestly of little importance, as they produce little if any general 
 reaction, and are certainly very rare. At times children may become a little 
 fretful or cross, and in the evening have a slight rise of temperature. As a 
 rule, however, the teeth which have long been expected by the anxious 
 watchers make their appearance without premonitory signs, so that the wise 
 physician will hesitate before he prophesies when a tooth is to appear. 
 Salivation cannot be looked upon as a symptom of teething, as it usually 
 occurs from two to three months before the first incisors appear, and is 
 physiological. The salivation occurring during teething is due to stomatitis. 
 The pain can only be very slight, and can be judged by analogy with that 
 produced during the appearance of the second teeth. In an unhealthy or 
 over-sensitive child this, however, may be sufficient to produce restlessness or 
 peevishness. That the pain cannot be very great must be accepted also from 
 anatomical facts : the nerve-filaments covering the tooth have either been 
 absorbed or rendered insensitive by continuous pressure upon them. The 
 papilla cannot be taken into consideration at all, as it has been shown that 
 the teeth could not in any way press upon it. 
 
 The symptoms in remote parts have to be analyzed carefully, and much 
 cool judgment may be required to find their cause. The tendency at the pres- 
 ent time is to accept fewer and fewer symptoms as due to teething ; but for 
 convenience we have grouped them under the following headings : symptoms 
 on the part of the nervous system, the digestive apparatus, the skin, the respi- 
 ratory apparatus, the genito-urinary system, and the organs of special sense. 
 
 The principal symptom on the part of the nervous system, still adhered to 
 by many, is convulsions. It is claimed that they are of a reflex kind, the 
 tooth being the irritant producing an abnormal afferent impulse to the medulla. 
 Theoretically, this can be taken into consideration, but in practice convulsions 
 are not produced by teething, least of all as the result of a reflex mechanism. 
 Tonic contractions of muscles of a local nature may easily be produced by an 
 increased afferent impulse, but the most painful lesions involving the fifth pair of 
 nerves in the reflex arc are not followed by generalized muscular contractions. 
 In the alimentary canal we find the bowels participating in the general hyper- 
 sensibility of the child. There is no evidence to show that bowel lesions are 
 produced by teething, either as the result of swallowing an imaginary excess 
 of saliva or otherwise. The most pernicious doctrine that exists is the one 
 that intestinal disease is due to teeth. An over-fed or badly-fed child — and at 
 the time of the eruption of the canines it is most liable to be both — if suffer- 
 ing, generally has an irritable intestine; and very likely substances which 
 should not enter the circulation may pass into it from the intestine, and the 
 result will be stools changed as to quantity and quality. This, in the lat- 
 ter instance, is a curative act, and disappears as soon as the diet is corrected. 
 There is nothing characteristic about this form of diarrhoea ; it rarely becomes 
 pathological, and may be helped along by the administration of a laxative. 
 Any diarrhoea, however, occurring at any time during infancy should be 
 
DENTITION. 413 
 
 watched, whether the child is supposed to be teething or not, and, the cause 
 being removed, the bowels should be "checked." It is important to disre- 
 gard teething entirely in long-continued diarrhoea, and to look to the food or 
 other known agencies for the cause. 
 
 On the part of other organs the symptoms which occur must be looked 
 upon as concomitant with teething and not caused by it. 
 
 Some have claimed that teething does not, per se, make children sick, but 
 that it predisposes them to illness. Predisposition to disease undoubtedly exists, 
 both temporary and permanent, but it is a difficult thing to establish, and, from 
 what we know at present, such a theory must be denied absolutely as far as 
 teething is concerned. 
 
 There is no treatment for teething, as it requires none. The healthy child 
 has no symptoms to manifest any diseased condition, because there is no dis- 
 ease. The unimportant symptoms that may occur are to be treated purely 
 symptomatically. The restlessness, where necessary, will be relieved by bro- 
 mides. The various forms of stomatitis are to be treated by the appropriate 
 remedies referred to in another place. Bowel troubles require rigid diet, always 
 a proper precautionary measure in all forms of intestinal disturbances. Beyond 
 this nothing is required. 
 
 Gum-lancing or gum-scarifying is looked upon by many as the specific 
 method of treatment for teething ailments. The indication for the operation 
 is to relieve pressure. The tooth has been supposed to press in any or all 
 directions, and by means of this pressure to produce the baneful results referred 
 to. Some authors claim that the pressure is exerted upon the mucous mem- 
 brane ; others, upon the dental sac ; others, upon the alveolus ; and finally 
 others, upon the "sensitive" papilla. Accordingly, each one has a peculiar 
 method to recommend for the operation. From a practical standpoint any of 
 these methods can do good in only one of two ways — either as a method of blood- 
 letting or as a suggestive remedy ; but either indication can be met by simpler 
 means. From a theoretical standpoint everything is against any such method 
 of ' operation. It has already been shown that the papilla cannot be pressed 
 upon, and that the opposite condition exists : the papilla is forcing the tooth. 
 All this in the growing tooth is done so gradually, however, that very little 
 pressure is exerted in any direction. The mucous membrane cannot be accused 
 of suffering, for, as we have seen, movement of the teeth toward the oral 
 cavity practically begins at birth. Given any mucous membrane which has 
 been pressed upon by a rigid substance for from five to seven months, and 
 atrophy will undoubtedly follow — atrophy of the membrane and all its com- 
 ponent parts, including the nerves. For the same reason pressure upon 
 the dental sac would be impossible. Pressure upon the bony walls is out of 
 the question, because there is ample room in all directions for the tooth, the 
 opening of the alveolus being especially large, so that the crown of the tooth 
 can pass without difficulty. 
 
 It cannot be denied that indiscriminate gum-lancing does harm. Hemor- 
 rhage is its greatest danger : we have collected twelve fatal cases, and it is not 
 overstating the matter when we say that many more have occurred that have 
 not been recorded. Behrend, Churchill, Barthez and Rilliet, and Finlayson 
 refer to the danger to children arising from anaemia as a result of this 
 operation — a danger that cannot be expressed statistically. Under normal 
 circumstances the pushing through of a tooth does not leave a wound of any 
 sort: there are no lymphatics, no blood-vessels opened, these having been 
 closed by the process referred to before. Every time a gum is lanced an open 
 wound is produced — fortunately, one which, under ordinary circumstances, heals 
 
414 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 quite rapidly. But with the mouth as a playground for many pathogenic 
 microbes the danger of infection must not be under-estimated. 
 
 In conclusion, I wish to emphasize the following points : I. Gum-lancing is 
 useless, a, as far as giving relief to symptoms ; b, as far as facilitating or hasten- 
 ing teething. II. It is useful only as bloodletting or as a suggestion, and ought 
 not to be used as such. III. It is harmful, a, in producing local trouble ; b, in 
 producing great disturbance on account of haemorrhage ; c, in having estab- 
 lished a method which is too general for specific good and too specific for uni- 
 versal use. IV. It is to be used only as a surgical procedure to give relief foi 
 surgical accidents. 1 
 
 1 The author certainly presents in a very forcible manner one side of the disputed question 
 of the advisability of gum-lancing. That too many aberrations from health are laid to the 
 score of teething, and that lancing is often performed heedlessly, unnecessarily, and even inju- 
 riously, cannot be questioned, yet there are many well-informed physicians and clinicians who 
 use the lance in appropriate cases, because experience — the crucial test — has demonstrated its 
 utility. In this class the Editor must be included. — L. S. 
 
DISEASES OF THE PHARYNX AND 
 NASOPHARYNX. 
 
 By W. E. CASSELBEKRY, M. D., 
 
 Chicago. 
 
 I. Acute Pharyngitis and Nasopharyngitis. 
 
 The posterior wall, the vault, and the lateral angles of the pharynx, the 
 pillars of the fauces, the velum palati, and the tonsils may be, each alone or all 
 together, the seat of an acute inflammation of the mucous membrane, which for 
 convenience is commonly designated simply as "pharyngitis." 
 
 Predominant inflammatory diseases of the tonsils, however, are considered 
 apart under appropriate titles, although tonsillitis of a superficial type is often a 
 detail only of diffuse simple pharyngitis, and may then be included in the 
 latter term. The forms of symptomatic pharyngitis which are incidental to the 
 exanthemata are excluded from consideration at this point. 
 
 Etiology. — The predisposing conditions are chronic hypertrophy of the 
 faucial and naso-pharyngeal tonsils, acute or chronic rhinitis, previously exist- 
 ing chronic pharyngitis, and digestive disturbance. Climatic inequalities, with 
 exposure to chilling influences, furnish adequate exciting causes. 
 
 Pathology and Symptoms. — Hyperemia may be so pronounced and so 
 diffuse as to lend a bright reddish hue to the entire oro-pharynx, or, on the 
 other hand, only limited spots of congestion may be noticeable. Often the 
 pillars of the fauces alone are implicated. 
 
 The posterior surface of the velum palati is a frequent point of attack, and, 
 indeed, the disease not infrequently embraces the rest of the naso-pharynx, 
 and occasions an amount of pain and discomfort located high up which is far 
 in excess of that which can be explained by inspection of the fauces only. 
 More explicitly speaking, naso-pharyngitis may be conjoined with pharyngitis. 
 
 After the first twenty-four hours thickening and relaxation of the mucosa, 
 with swelling and cedema, especially of the velum and uvula, is associated with 
 the hyperemia, and the disease culminates at times in chronic relaxation of the 
 velum and elongation of the uvula. The secretion is at first diminished, the 
 patient complaining of " dryness," but later there is an excess of viscid 
 mucus. 
 
 In childhood the acute folliculous variety of pharyngitis is very common ; 
 that is, the isolated muco-lymphoid glands which are scattered over the pos- 
 terior wall of the pharynx are especially the centres of inflammatory action. 
 
 The patient complains of a constant sense of discomfort, which necessitates 
 frequent acts of deglutition, which are positively painful, although actual 
 swallowing of food is rarely painful except in severe forms of the disease. 
 There is but little systemic derangement in uncomplicated cases. 
 
 Diagnosis. — Critical inspection of the pharynx by means of a good light, 
 preferably light reflected from a concave mirror, will establish the diagnosis by 
 
 415 
 
416 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 correspondence with the signs above described. In the first twenty-four hours 
 it may be difficult to distinguish simple pharyngitis from the symptomatic 
 pharyngitis of scarlatina, the preliminary pharyngitis of diphtheria, the first 
 stage of acute infectious phlegmon of the pharynx, and pharyngeal erysipelas. 
 The presence of high temperature, perhaps following a distinct chill and accom- 
 panied by pronounced systemic derangement, should cause one to anticipate 
 future developments. 
 
 Prognosis. — Recovery is hastened by treatment, but in uncomplicated 
 cases it would naturally ensue within ten days. It is supposed that simple 
 pharyngitis may predispose a child to infection by the bacillus diphtheriae and 
 other pathogenic micro-organisms. 
 
 Treatment. — In mild cases a simple gargle of potassium chlorate, ten grains 
 to the ounce, every two hours, is sufficient. This may be made more effective 
 when greater astringency is desired by the addition of tannic acid two grains 
 to the ounce. A variety of other astringents are also available. 
 
 In severer cases, especially those which are conjoined with nasopharyn- 
 gitis and rhinitis, it is important first to cleanse the entire area by spraying or 
 gargling with an antiseptic alkaline solution : 
 
 1^. Sodii boratis 
 
 Sodii bicarbonatis aa gr. xx. 
 
 01. eucalypti TflJ. 
 
 Thymol gr. j . 
 
 Menthol gr. ss. 
 
 01. gaultheriae Itlj. 
 
 Glycerini f^ss. 
 
 Alcoholis fsj. 
 
 Aquae q. s. ad fgj. — M. 
 
 Sig. Dilute, adding one or two fluidrachms to one fluidounce of water, 
 for use as a spray or gargle. 
 
 Young children cannot gargle, and are often terrified by spraying, in which 
 case one may project, through each nostril into the throat, a half-drachm of 
 this diluted mixture by means of an ordinary glass medicine-dropper. After 
 thus cleansing the parts the same astringent gargle may be used ; or with larger 
 children and in the hands of the physician, an astringent spray, preferably of 
 the sulphate of iron and ammonium, three to five grains to the ounce, may be 
 applied to the pharynx, and, if need be, by an upward spray-tip to the naso- 
 pharynx. The astringents should never be projected through the nose. In 
 painful cases much comfort and some benefit follow spraying by a 1 per cent, 
 solution of cocaine hydrochlorate, and with especially irritable throats its pre- 
 liminary use will permit subsequent topical applications to be made with greater 
 ease. 
 
 When necessary, minute quantities of cocaine may be used in the form of 
 a lozenge, as in the following formula, recommended by Bosworth : 
 
 1^. Cocainae muriatis gr. v. 
 
 Ext. krameriae gr. ij . 
 
 Sodii bicarbonatis gr. xv. 
 
 Ext. glycyrrhizae 3iiss. — M. 
 
 Ft. massa in trochisci No. xxx div. 
 
 In office practice as a final spray, or for self-medication, even alone or 
 
DISEASES OF THE PHARYNX AND NASO-PHARYNX. 417 
 
 is ... . 
 
 .... m v. 
 
 
 . . . . m y. 
 
 
 . . . . m ij. 
 
 
 
 . . . . gr. ss. 
 
 
 .... gr.j. 
 
 
 
 . q. s. adf^j.— M 
 
 following an astringent gargle, we find the following emollient very soothing 
 to highly inflamed mucous surfaces : 
 
 3$$. 01. pini Canadens 
 01. eucalypti 
 01. gaultherise 
 Thymol . . 
 Menthol . . 
 " Vaselin oil " 
 Sig. Use with a double-bulb atomizer. 
 
 A laxative is usually indicated, even though the bowels may be stated to 
 be regular. Apart from this, little constitutional treatment is required, other 
 than may seem appropriate for any associated conditions. 
 
 II. Simple Chronic Pharyngitis; Elongation of the Uvula. 
 
 Simple chronic pharyngitis occurs but rarely in childhood, and is then 
 dependent upon diseases of the nose, tonsils, or digestive organs, and the most 
 rational line of treatment, and the only one likely to result successfully, is that 
 indicated by the primary affection. The same is true in part of elongation of 
 the uvula, but only in part, since radical treatment directed to this organ will 
 occasionally be required. 
 
 Relaxation of the velum palati and paresis of its muscles are usually asso- 
 ciated with lengthening of the uvula, and the disability is due to chronic or 
 recurrent acute inflammation of the nose, naso-pharynx, or pharynx. Frequent 
 necessity to dislodge mucus by "hawking" is somewhat instrumental in its 
 production. 
 
 Symptoms. — The chief symptom is a harassing cough, which is found 
 especially annoying on retiring and rising and at times of acute inflammation 
 of the throat. It often causes the child to be 
 treated indefinitely for bronchitis or other in- 
 visible disorders, when a critical inspection of 
 the pharynx in a state of quietude would dis- 
 close the palate lying on the base of the tongue. 
 Extreme elongation has even served to excite 
 attacks of laryngismus stridulus. Rarely the 
 uvula is bifid, a congenital defect which pre- 
 disposes it to elongation. 
 
 Treatment. — Concerning the treatment, 
 palliation may be secured, even cure in recent 
 cases, by an astringent spray or gargle. More 
 often this will fail to produce wholly satisfac- 
 tory results, and then attention must be given 
 to whatever abnormality underlies the elonga- 
 tion of the uvula ; if the tonsils be hypertro- 
 phied, they should be abscised; if there be 
 naso-pharyngeal adenoid hypertrophy, it should 
 be removed, etc. If the difficulty then con- 
 tinue, one should not hesitate to abscise the 
 surplus portion of the uvula, leaving it of nor- 
 mal length. It is most quickly done by a 
 
 uvulatome fashioned on the principle of a tonsillotome, but can readily be 
 accomplished by forceps and scissors. (Fig. 1.) 
 
 27 
 
 Fig. 1. 
 
 Abscission of the Uvula. 
 
418 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 TTT Chronic Folliculous Pharyngitis. 
 
 Although, as previously stated, simple chronic pharyngitis occurs but rarely 
 in childhood, chronic folliculous pharyngitis is not uncommon. It is character- 
 ized by enlargement of the isolated muco-lymphoid follicles which are scattered 
 over the posterior wall of the pharynx and arranged in a chain in each lateral 
 angle of the throat behind the posterior pillar. These are single follicles of 
 the same histological structure as the tonsils, which are compound glands. It 
 is natural, therefore, that they should become hypertrophied in response to the 
 same underlying dyscrasia — lymphatism — which predisposes patients_to hyper- 
 trophy of the tonsils and of the nasopharyngeal adenoid tissue. Indeed, in 
 children the disease is usually conjoined with the latter pathological states. 
 Symptoms are manifest only in pronounced cases, and then, usually, at times of 
 an acute exacerbation. A constant tendency to "hawk," a sense of discomfort, 
 and, in rare instances, a sense of a foreign body in the throat, are the most 
 important. On inspection one observes small round eminences dotted irreg- 
 ularly over the posterior wall of the pharynx, and ridges of reddish hue in the 
 lateral angles. The latter aspect of the disease, when especially marked, has 
 been designated, in recent works, pharyngitis lateralis. 
 
 Treatment. — The enlarged follicles should be destroyed by touching each 
 one with the galvano-cautery point-electrode. Three or four may be cauter- 
 ized at each sitting, and several sittings will be required. The result is very 
 satisfactory. When tonsillar and naso-pharyngeal adenoid hypertrophy is also 
 present, this condition should first be removed, in which case further treatment 
 often becomes unnecessary. 
 
 IV. Acute Folliculous Tonsillitis. 
 
 The infectious nature of most cases of folliculous tonsillitis is now defin- 
 itely established; yet other cases are, seemingly, of simple catarrhal origin, 
 devoid of pathogenic germ infection ; it is therefore evident that one can 
 distinguish, and should describe, at least two forms of this disease : infectious 
 pseudo-membranous tonsillitis and simple folliculous tonsillitis. 
 
 Infectious Pseudo-membranous Tonsillitis 
 
 is also termed "croupous tonsillitis," "tonsillitis lacunaris," "diphtheritic sore 
 throat," and "pseudo-diphtheria," although the latter term has been indis- 
 criminately applied also to scarlatinous diphtheria and to all forms of mem- 
 branous pharyngitis not caused by the Klebs-Loeffler bacillus. 
 
 Etiology. — The infectious nature of certain forms of acute folliculous ton- 
 sillitis has long been suspected, yet the fact has not been generally credited, 
 for the reason that when the clinical evidence of infectiousness was conclusively 
 present the disease would be attributed to diphtheritic origin or the subject 
 be dismissed as a mere coincidence. We now know that the true bacillus 
 diphtheria? is not present in this disease, but that the form described under 
 the name of infectious pseudo-membranous tonsillitis, or croupous tonsillitis, 
 is caused by local infection by any one of several species of pathogenic micro- 
 organisms ; e. g. streptococcus erysipelatosus, streptococcus pyogenes, staphy- 
 lococcus pyogenes aureus, staphylococcus albus, etc. 
 
 Symptoms. — Infectious pseudo-membranous tonsillitis is characterized by 
 deep congestion, but often only by moderate swelling of the tonsils and by a 
 punctated exudate of pseudo-membrane, the spots of which are in size from 
 2 to 4 mm. in diameter, and are attached around the follicular openings, pre- 
 
DISEASES OF THE PHARYNX AND NASO-PHABYNX. 419 
 
 senting the appearance as if the crypts were also lined by the same material ; 
 unlike the cheesy pellet, the exudate in its typical form is thin, translucent, and 
 intimately connected with the underlying mucosa. Two or more puncta may 
 join at their borders and form larger spots, but after cleansing away all muco- 
 purulent matter this punctated conformation of even the larger areas may be 
 readily discovered (Fig. 2). In addition to the tonsils, any or all of the muco- 
 lymphoid glands in the pharynx may be likewise affected, especially the chain 
 of glands located just behind the tonsil and separated from it by the posterior 
 pillar ; but the pseudo-membranous exudate is limited absolutely to the glandular 
 structures of the pharynx, although careful cleansing and critical inspection will 
 be required to demonstrate this fact. 
 
 The attack is ushered in by chilly sensations, perhaps preceded, for a day 
 or so, by malaise, and followed by a temperature of 102° to 105° F., with con- 
 sequent febrile symptoms. After one 
 
 to three days the temperature falls Fig. 2. 
 
 materially ; the pain, which has been 
 quite severe, gradually ameliorates, 
 and within one week convalescence 
 is established. The cervical lymph- 
 atic glands are often secondarily in- 
 fected, as evidenced by swelling and 
 tenderness, which last for two or 
 three weeks. Suppurative cervical 
 adenitis and cellulitis may follow in 
 rare instances. Transient albumin- 
 uria is an occasional complication. 
 
 Diagnosis. — The opinion of bac- 
 teriologists that in these affections 
 diphtheria can only be excluded posi- 
 tively by the absence of the Klebs- 
 Loeffler bacillus, as determined micro- 
 scopically, is doubtless correct as applied to rare border-line cases ; but com- 
 monly a differential diagnosis can also be made with greater promptness and with 
 reasonable certainty from the macroscopic signs and clinical symptoms. 
 
 True diphtheritic exudation may commence at the orifices of the crypts of 
 the tonsil, but does not long remain limited to the tonsils and muco-lymphoid 
 glands of the pharynx, as does the exudate of tonsillitis. The diphtheritic 
 membranes will extend within twenty-four hours to the pillars, velum, or 
 pharyngeal wall. The exudate of tonsillitis is thin, and not materially raised 
 above the surface; it is white, translucent, and presents a living, clean aspect 
 devoid of necrotic change ; while the exudate of diphtheria is thickish or pro- 
 truding from the surface, opaque, and dirty-yellow or rapidly becoming so — 
 appearances indicative of necrotic change. 
 
 The exudate of tonsillitis is punctated, the spots corresponding to the 
 follicular openings, and, while two or more puncta may join at their borders 
 and form larger areas, after careful cleansing, critical inspection, under thorough 
 illumination, will disclose this punctated conformation, which distinctly differs 
 from the diffuse plaque of diphtheria, even when, for the time being, the diph- 
 theritic exudate occupies the tonsil alone. 
 
 Acute Infectious Pseudo-membranous Tonsillitis 
 (follicular). The two whitish points on the pos- 
 terior wall represent exudate formed on isolated 
 muco-lymphoid follicles. 
 
 Simple Folliculous Tonsillitis. 
 With the simple form there may or may not have been previous chronic 
 
420 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 hypertrophy or inflammation : it is conditioned, if not caused, by " taking 
 cold," i. e. by refrigeration of some part of the body surface, which determines 
 vascular engorgement of the tonsils, exactly as in another individual it may 
 occasion vascular engorgement of the nasal turbinated bodies. The tonsil 
 swells, the follicular openings are obliterated and the pent-up secretion acts as 
 a further irritant ; it becomes inspissated and mixed with epithelial de'bris ; it 
 is soon forced out to the surface of the gland in the form of " cheesy " pellets, 
 which are altogether different from a pseudo-membrane, and which protrude 
 from the narrowed follicular openings. Finally, when the tonsils are free of 
 this accumulated debris, or at times earlier if the globules are forcibly dis- 
 lodged and removed, the tonsillitis rapidly subsides. It is not usually pre- 
 ceded by a distinct chill, and not accompanied by much fever or systemic 
 depression. It is without evidence of primary parasitic infection as a cause, 
 and therefore not contagious ; it is capable, however, of being transposed into a 
 conglomerate variety of tonsillitis by secondary infection with pathogenic 
 micro-organisms, thus becoming contagious. 
 
 In fact, between these two types of tonsillitis are observed numerous cases 
 of mixed variety which present all degrees of approximation to one or the 
 other type. 
 
 G-eneral Treatment. — The rheumatic diathesis is frequently associated 
 directly or indirectly with tonsillitis, in which case salicylate of sodium or 
 salol should be administered internally. Otherwise, the tincture of the chloride 
 of iron, 1 part to 10 parts of glycerin, may be administered every hour with- 
 out further dilution in the dose proportionate to the age of the child, both for 
 its local effect, as it is diffused over the fauces in swallowing, and for its sys- 
 temic influence. 
 
 For the high febrile action of the first day or two we have been accustomed 
 to give minute doses of tincture of aconite, conjoined with potassium bromide, 
 disguised in solution by a few minims of spirit of peppermint, and to which 
 may be added very small quantities of morphine if it is needed to control pain. 
 
 Of late years, antipyrine or phenacetin has been often substituted advan- 
 tageously for the aconite and bromide mixture. A saline laxative is nearly 
 always needed. 
 
 Local sprays by a hand-atomizer are of the greatest benefit when the child 
 is old enough to tolerate them. An alkaline and antiseptic lotion (See Acute 
 Pharyngitis) is to be preferred. This should be sprayed every three hours 
 through the mouth, and also through the nose, into the naso-pharynx, thus 
 cleansing that cavity, as well as the fauces, of the viscid muco-purulent matter 
 which accumulates and conduces to much discomfort. 
 
 Hydrogen peroxide, diluted to the point of freedom from production of 
 smarting sensation, is also an excellent local spray, especially if used alter- 
 nately with the one above mentioned ; and either or both of these may be used 
 following a preliminary spray of 1 per cent, solution of cocaine hydrochlorate, 
 which serves to control pain and super-irritability of the fauces. 
 
 Generally speaking, it is best to avoid the use of cotton swabs and brushes. 
 Gargles may be substituted for sprays when necessary, or made to supplement 
 spraying, and for use as a gargle the formula for spray above referred to should 
 be diluted doubly as much as for use in a spray. 
 
 T\ ith very young children the naso-pharynx and fauces can be readily 
 cleansed by the same solution freely diluted, warmed, and injected gently in 
 small quantities by a small syringe or an ordinary medicine-dropper through 
 the nares. 
 
DISEASES OE THE PHARYNX AND NASO-PHABYNX. 421 
 
 V- Peritonsillar Abscess, or Suppurative Tonsillitis. 
 
 This condition is also termed acute parenchymatous tonsillitis, phlegmonous 
 tonsillitis, quinsy, etc., but of these terms the best is peritonsillar abscess, 
 because it is descriptive, since the suppuration does not occur in the tonsil 
 itself, but in the cellular tissue around it or above, behind, in front, or to the 
 outer side of the gland. The disease is comparatively rare in early childhood, 
 but about 3 per cent, of all cases occur under ten years, and about 6 per cent, 
 under fifteen years, of age. 
 
 Etiology. — The direct cause of suppuration here, as elsewhere, is infection 
 by specific pathogenic micro-organisms from some source, either from within or 
 without the body. 
 
 The predisposing causes are exposure, the rheumatic diathesis, chronic ton- 
 sillitis, and acute folliculous tonsillitis. 
 
 Symptoms. — A chill or chilly sensation is followed by a temperature of 
 102° to 105° F., and consequent febrile symptoms. About the same time a 
 sense of soreness and fulness is perceived in one side of the throat, followed by 
 lancinating pains which dart through to the ear, and, later, by a deep-seated 
 throbbing pain as suppuration ensues. On inspection the swelling is seen to 
 extend to the median line of the throat, and even far beyond, in severe cases 
 projecting upward into the naso-pharynx and downward along the side of the 
 pharynx, sometimes leaving only the smallest chink available for respiration 
 and deglutition. The latter function is painful, and the diet must be confined 
 to liquids, for the reason, also, that the lower jaw is "set" so that the mouth 
 can be opened only about half an inch. 
 
 Viscid mucus accumulates in the partially occluded pharynx and in the naso- 
 pharynx, causing suffocative attacks and necessitating painful efforts to clear 
 the throat. Indeed, for a night or two the patient cannot assume a recumbent 
 position or sleep uninterruptedly, as voluntary efforts are required to maintain 
 patency of the throat. The uvula becomes oedematous, and the opposite tonsil 
 is usually somewhat swollen, often suppurating later, although simultaneous 
 suppuration of the two sides is rare. 
 
 Diagnosis. — During the first twenty-four hours the disease cannot be dis- 
 tinguished with certainty from folliculous tonsillitis, which, indeed, often pre- 
 cedes the peritonsillar abscess. Later, the diagnosis is established by the 
 characteristic distortion of the throat, as represented in Fig. 3, in which it 
 is seen that the tonsil itself is not the chief seat of swelling, but that this 
 gland is projected inward by tumefaction in the cellular tissue of the velum 
 palati. 
 
 Prognosis. — This is favorable, except in cases of rare complications, such 
 as oedema of the larynx, extensive burrowing of pus, or haemorrhage. 
 
 Treatment. — During the first twenty-four or thirty-six hours an effort 
 should be made to abort the disease, and to this end the internal and local 
 medicinal treatment is much the same as that described for folliculous tonsil- 
 litis — a saline laxative, the immediate administration of salicylate of sodium in 
 full doses because of the common dependence of the disease on the uric-acid 
 diathesis, and tincture of aconite with potassium bromide as an adjuvant. The 
 same alkaline and antiseptic spray which is recommended for folliculous ton- 
 sillitis should be used every hour or half-hour, and in the same manner, spray- 
 ing through the mouth, and to a less extent through the nose. In the early 
 stage of the affection the application of cold externally by means of Leiter's 
 coil would assist in aborting the suppurative inflammation were it as feasible 
 with restless children as with adults. As soon as it becomes evident that sup- 
 
422 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 puration must occur, a hot poultice, applied externally over the corresponding 
 part of the neck, will both ease the pain and hasten the formation of pus. 
 
 At the earliest moment that pus is indicated with reasonable certainty by 
 fluctuation or an effort at "pointing " the abscess should be punctured, prefer- 
 ably by a loner, slightly curved, double-edged bistoury devised for the purpose, 
 or in the absence of this instrument, by an ordinary sharp-pointed bistoury. 
 The puncture should not be made into or through the tonsil itself, but some- 
 what* above and to the outer side of the gland into the anterior surface of the 
 velum, where the pus actually is located, in the cellular tissue of the velum 
 palati and palato-glossal fold (Fig. 3). 
 
 Fig. 3. 
 
 Peritonsillar Abscess : a, point for puncture. 
 
 VI. Hypertrophy op the Tonsils. 
 
 The exact function and size of normal tonsils are questions of interest 
 which are answerable only in a general way. Histologically, they possess the 
 structure of both a lymphatic and a mucous gland, and, anatomically, they are 
 in close connection by lymph-channels with the cervical lymphatic glands. 
 The inference is that they are lymphatic glands, possessing the function of 
 similar glands elsewhere located, which by virtue of their position in the fauces 
 have been endowed also with mucous elements for lubricating purposes. The 
 natural size approximates that of an almond-kernel. 
 
 Etiology and Pathology. — The predisposing cause of enlargement of the 
 tonsils is a peculiar diathesis now termed "lymphatism," the local manifestations 
 of which include also enlargement of the naso-pharyngeal tonsil, or "adenoids," 
 and of the muco-lymphoid glands of the pharynx and base of the tongue. This 
 diathesis is certainly not identical with scrofula, even in the limited sense to 
 which that term is now restricted, for lymphatism frequently manifests itself 
 in children who are otherwise robust, yet the condition seems allied to, and 
 often conjoined with, scrofula. Climatic inequalities furnish adequate exciting 
 causes. 
 
 In the usual form of the disease, that of mere hypertrophy, there is simply 
 an overgrowth, both in size and number, of all the natural elements of the 
 gland — the lymphoid bodies, crypts and follicles, mucous glands, and connec- 
 tive tissue. 
 
 Another variety of hypertrophy of the tonsils, named by Bosworth the 
 hyperplastic form, which is rare in children, but common in adults, results from 
 repeated attacks of acute inflammation and consists chiefly of hyperplasia of 
 
DISEASES OF THE PHARYNX AXD XASO-PHARYNX. 423 
 
 the fibrous connective-tissue element, with a less degree of enlargement and 
 multiplication of the lymphoid bodies. Such tonsils are dense and fibrous, 
 while .those of the first type are soft and friable. Between these two types, 
 exist all degrees of variation, both in contour and texture. 
 
 Symptoms. — Moderate enlargement only will occasion a tendency to recur- 
 rent attacks of acute tonsillitis, and any degree of hypertrophy unquestionably 
 predisposes the child to diphtheritic infection and increases the gravity of the 
 latter disease when it occurs. 
 
 The effects of mechanical obstruction to respiration occasioned by enlarged 
 tonsils, either alone or especially in conjunction with enlargement of the naso- 
 pharyngeal tonsil, will be described in the article on Naso-pharyngeal Adenoid 
 Hypertrophy, and I need only mention here the more prominent features. 
 
 Mouth-breathing can be caused even by enlarged faucial tonsils alone — by 
 their projection backward and upward into the pharynx in such a way as to 
 interfere with the passage of air inspired through the nose. Mouth-breathing 
 in turn causes deformed development of the facial bones and muscles and an 
 idiotic expression of countenance and mental stupidity ; also, deformed develop- 
 ment of the chest and thoracic weakness. The recumbent position and absence 
 of voluntary muscular control to keep the throat open aggravate the obstruc- 
 tion to both nasal and oral respiration at night, so that the patient is frequently 
 awakened or thrown into a nightmare by a sense of dyspnoea. Deglutition 
 and mastication are impaired in proportion to the extent of the disease, although 
 it is probable that deficient oxygenation of the blood arid disturbed rest at 
 night, together with subsequent thoracic deformity, are the chief factors in 
 seriously stunting the development of the child. 
 
 Treatment. — Abscission is the only satisfactory method of treatment when 
 the enlargement is sufficient to occasion the symptoms of mechanical obstruc- 
 tion. 
 
 It is probable that the syrup of iodide of iron so far tends to correct the 
 underlying constitutional dyscrasia as to prevent recurrence after operation, 
 and even to cause partial reabsorption of very slight and recent overgrowths; 
 but we have never been able to discern therefrom any permanent reduction of 
 tonsils which were greatly or even moderately enlarged. Local astringents are 
 wholly inadequate. Ignipuncture or galvano-cautery puncture affords only 
 palliation for the milder cases. We have repeatedly found it necessary to 
 abscise tonsils after months had been spent with this somewhat painful and 
 ineffective mode of treatment. 
 
 The wire snare is an excellent means of abscission when the child is anaesth- 
 etized, as when combining this operation with that for " adenoids; " but other- 
 wise it is slow and painful, and, like the galvano-cautery snare, it requires more 
 time and quietude for adjustment than are available with young children when 
 not anaesthetized. An anaesthetic is not usually necessary when the faucial ton- 
 sils alone are to be abscised, although it is decidedly best to administer ether 
 when the combined operation for removal of the faucial tonsils and naso-pharyn- 
 geal " adenoids" is to be made. Also, with unusually excitable or obstreperous 
 children ether may be administered. 
 
 The tonsillotome is still the best implement for children who are not anaes- 
 thetized, because of the rapidity, precision, and comparative ease with which 
 this method can be practised. With older children it is best to use a prelim- 
 inary spray of 5 per cent, cocaine solution. Younger children are apt to be 
 terrified by spraying, and it is best to omit it. The pain is not really great. 
 
 The Mathieu tonsillotome is well adapted to the purpose, especially for 
 children, and it is the one now in general use. The mechanism is very 
 
424 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 ingenious, being fitted with a fork attachment which is designed to transfix 
 the tonsil, and withdraw it from its bed by the same motion of the operator's 
 fingers which draws the ring-knife home. The much-vaunted Mackenzie ton- 
 sillotome is an unnecessarily cumbersome instrument. 
 
 The author has described elsewhere a simplified instrument which he has 
 
 Fig. 4. 
 
 Mathieu's Tonsillotome. 
 
 used for years with the utmost satisfaction. It is the Mathieu guillotine, so 
 constructed as to do away with the fork attachment (Fig. 5). 
 
 In place of the fork he uses, held in the other hand, a specially con- 
 structed vulsellum (Fig. 5), by which the tonsil can be grasped, drawn 
 out of its bed, and abscised at the point desired with much greater accu- 
 racy than by the fork attachment (Fig. 6). He has found the action of the 
 fork to be largely accidental, dependent on the size and shape of the tonsil 
 and the amount of gagging by the patient — that now it determines too deep an 
 
 Fig. 5. 
 
 wszsmamm 
 
 The Author's Tonsillotome and Tonsil Vulsellum. 
 
 abscission, and, again, misses the tonsil entirely, especially if this happens to 
 be rather small or flat. In other words, the new instrument, assisted by the 
 vulsellum, will abscise many tonsils that could not be satisfactorily grasped by 
 the old mechanism, and it will abscise all tonsils with a reasonable degree of 
 accuracy at the proper line. 
 
 One can also by this instrument more easily avoid wounding the anterior 
 and posterior pillars, which eliminates one of the sources of persistent haemor- 
 rhage. The instrument therefore conduces to safety by virtue of greater pos- 
 sible precision in operating. It is less formidable in appearance and is easy to 
 use. No tongue-depressor is necessary, the body of the tonsillotome answering 
 this purpose, at the same time that the vulsellum prongs grasp the tonsil to 
 draw it from its bed into the ring of the tonsillotome. 
 
 The proper line or point for abscission I believe to be close to the base of 
 the gland, but not so close as to constitute a total extirpation. A stump 
 should be left, but one not much larger than the normal gland, and not of suf- 
 
DISEASES OF THE PHARYNX AND NASO-PHAPYNX. 425 
 
 ficient size to protrude from or widely separate the pillars of the fauces. A 
 total extirpation would seem unnecessarily hazardous on account of difficulty of 
 access to bleeding vessels should haemorrhage occur, and I cannot think that 
 haemorrhage is any less prone to occur after total extirpation, as recently stated, 
 than after abscission. 
 
 On the other hand, when a considerable portion of the gland is left, only 
 the cortical layer being removed, redevelopment of the growth is common. 
 
 Very large and densely fibrous tonsils in older children are best removed 
 
 Fig. 6. 
 
 The Author's Method of Tonsillotomy. 
 
 by the galvano-cautery snare, since they are especially apt to bleed if cut, 
 and are difficult to abscise by a cold wire. In rare instances haemorrhage 
 even then occurs, either primarily when the wire is overheated, or second- 
 arily on the separation of the slough. The chief objection to the method 
 for general use is the intense inflammation of the fauces which is liable to 
 follow it. This can be, in part, but not wholly, obviated if one is careful 
 not to singe the pillars, which, however, are not so easily avoided in the use 
 of the cautery snare. To this end, Dr. Jonathan Wright has adapted the 
 frame of the Mackenzie tonsillotome to galvano-cautery purposes by substi- 
 tuting for the steel blade a wire mounted on compressed paper and to be con- 
 nected with a battery. 
 
 Consideration of this subject would not be complete without reference to 
 the views of Dr. Harrison Allen of Philadelphia, as advanced in a recent essay 
 before the American Laryngological Association. He believes " that abscis- 
 sion should be restricted to the removal of the superficial or cortical part of 
 the tonsil, and in preference to the treatment by amputation of the whole mass; 
 that after removal of such cortex, should the crypts be closed, he would search 
 
426 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 for hidden canals, and when found pass a probe or director through them and 
 freely divide the overlying tissues, incising thus the tonsil in any direction and 
 to any required depth. After this is done the separate coarse lobules can be 
 severally taken up by forceps and removed, care being taken to avoid touching 
 enveloping folds of mucous membrane." It is evident that this would be an 
 impossible method with most young children, because of tediousness, but it may 
 be advantageously utilized with older patients. 
 
 The only serious objection to abscission of the tonsils is the rare possibility 
 of troublesome haemorrhage, which has seemed to a few extreme conservatives 
 to justify avoidance of the operation; but a greater risk is assumed in every 
 phase of life, in travel, and in pursuit of business and pleasure. It is stated 
 that Elsberg made the operation eleven thousand times with but two cases of 
 even alarming haemorrhage, and Morell Mackenzie, whose experience must 
 have been enormous, only once met with a case in which the bleeding appeared 
 actually to endanger life. Only one authentic case of death of a child from 
 haemorrhage after tonsillotomy is recorded in modern literature, and it is prob- 
 able that this case need not have ended fatally but for a deception of the ope- 
 rator relative to the seriousness of the haemorrhage, by reason of the blood being 
 swallowed by the young child and not expectorated ; which caused the adoption 
 of a less vigorous treatment than otherwise would have been used. 
 
 When one considers the number of cases, beyond computation, of tonsil- 
 lotomy in children, and the few reported cases of haemorrhage, one must regard 
 it as among the safest of even minor operations. 
 
 The treatment of severe haemorrhage may consist, first, of a trial of the 
 astringents and styptics. The most popular of these is Mackenzie's mixture 
 of tannic and gallic acids: 
 
 ty,. Acidi tannici £vj. 
 
 Acidi gallici 3ij. 
 
 Aquae f|j. — M. 
 
 Sig. Sip and swallow half-teaspoonful quantities at short intervals. 
 
 If this fail, it is probable that any simple astringent or vaso-contractor will 
 fail. 
 
 Ice, held in the mouth and swallowed, is also an efficient remedy. 
 
 Pressure may be successfully applied by grasping the tonsil firmly between 
 the thumb, held within the mouth and enveloped in three or four layers of linen, 
 and the fingers held over the corresponding part of the neck. It must be main- 
 tained sometimes for an hour or more. 
 
 When the simpler expedients fail, then the bleeding points and surfaces 
 should be accurately located and thoroughly seared by the actual cautery, or 
 the galvano-cautery if at hand. For this purpose one needs several small 
 sponges mounted on long sponge-holders, which, if not at hand, may be sub- 
 stituted by wooden sticks (sponges are much more effective than absorbent 
 cotton) ; also, a small surgical retractor, like a tracheotomy retractor, in the 
 absence of which a palate hook, or even a bent probe, will serve. An assist- 
 ant is desirable to hand and clean the sponges. 
 
 Under the illumination of a head reflector, the throat should first be well 
 sprayed with a 5 per cent, solution of cocaine, and sponged clear of clotted blood; 
 the bleeding surface can then be exposed to view by holding aside the anterior 
 pillar by means of the retractor, when by rapid sponging the bleeding points 
 can be discerned and then cauterized. 
 
 As a substitute for the galvano-cautery one may use a thick wire heated 
 
DISEASES OF THE PHARYNX AND NASO-PHABYNX. 427 
 
 to redness over a gas-flame. We have used this means successfully with adults, 
 but have never had occasion to apply it with children. If necessary, however, 
 we would endeavor to do so with young children by first administering chloro- 
 form and inserting a Whitehead gag, as in operation for cleft palate, placing 
 the patient with the shoulders elevated and the head pendent, so that blood 
 could not gravitate into the trachea. 
 
 When the haemorrhage is comparatively slight exact cauterization of the 
 bleeding points by solid nitrate of silver is effective. Torsion is applicable 
 only when a spurting artery can be seen. 
 
 As a last resort, may be mentioned ligation of the external carotid artery, 
 as advised by Delavan, in preference to ligation of the common carotid, which 
 latter might permit haemorrhage to continue by collateral circulation through 
 the circle of Willis. 
 
 VII. Retropharyngeal Abscess (Retropharyngeal Lymph- 
 adenitis). 
 
 It is now well established that retro-pharyngeal abscess arises ordinarily 
 not in caries of the cervical vertebrae, but in suppurative inflammation of the 
 lymphatic glands which are imbedded in the posterior pharyngeal wall. In 
 harmony with accepted views of the origin of pus elsewhere, the source of this 
 inflammation must be infection, either from within or without the body, by 
 some one or more of the pathogenic micro-organisms which produce sup- 
 puration. 
 
 Children are especially prone to inflammations of the lymphatic system. 
 Cervical lymphadenitis is common among them. Frequently it is tuberculous, 
 but often it is not, and usually the acute suppurative variety results from infec- 
 tion by a previously existing tonsillitis. So also with retro-pharyngeal abscess: 
 it is most reasonable to regard it as a secondary infection of the pharyngeal 
 lymphatics from inflammation of exposed and associated muco-lymphoid glands, 
 like the faucial and naso-pharyngeal tonsils. But, whatever the source of 
 infection, whether primary or secondary, the initial stage of retro-pharyngeal 
 abscess is retro-pharyngeal lymphadenitis. Moreover, the lymphadenitis may 
 be of a non-suppurative type, or the disease become arrested in this stage, 
 undergoing resolution without the formation of an abscess. 
 
 Bokai reports a case of retro-pharyngeal lymphadenitis in a child eight 
 months old, in which tracheotomy was necessitated by the supervention of 
 alarming symptoms of suffocation. The posterior Avail of the pharynx showed 
 diffuse hard swelling without fluctuation, and a deep incision into the mass had 
 yielded no pus. After the tracheotomy resolution was quickly established. 
 This simple lymphadenitis has been but rarely observed in this country, but 
 Bokai, in addition to 400 cases of abscess, mentions 112 cases of simple retro- 
 pharyngeal lymphadenitis as having passed under his observation in the Pester 
 Kinderspital. (See note at end of this chapter.) 
 
 In rare instances the source of infection may be rhinitis, communicated 
 through the nasal lymph-channels, or, still more rarely, a suppurative otitis ; 
 but, as previously intimated, folliculous and suppurative forms of tonsillitis, as 
 well as those forms of tonsillitis and pharyngitis which are symptomatic of the 
 exanthemata, may reasonably be regarded as the most frequent causes of retro- 
 pharyngeal lymphadenitis, which in turn may proceed to the formation of an 
 abscess. Cases which originate in any of these ways are grouped by Bokai 
 under the term "idiopathic ;" and of 204 cases analyzed, he placed 189 in this 
 class, in contradistinction to only 7 cases secondary to caries of the vertebra?, 
 
428 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 7 cases from burrowing of pus from abscess in the neck, and 1 case of trau- 
 matic origin. 
 
 Symptoms. — The disease may commence quite insidiously or it may cul- 
 minate rapidly. Attention is directed to the throat by a deep-seated pain, 
 dysphagia, and, later, by dyspnoea. When located low down in the laryngo- 
 pharynx, a comparatively small abscess may speedily occasion suffocative symp- 
 toms. Critical inspection or palpation of the throat will disclose a swelling 
 of the posterior pharyngeal wall, which may be either in the median line or 
 somewhat to one side. 
 
 Diagnosis. — The disease is distinguished from oedema of the glottis by 
 inspection, which reveals pharyngeal instead of laryngeal swelling, and from 
 both diphtheritic and spasmodic laryngitis in the same manner ; moreover, in 
 both forms of croup the voice is impaired, which is not the case in retro- 
 pharyngeal abscess. 
 
 Prognosis. — The affection usually terminates in recovery in from five to 
 fifteen days, the abscess discharging spontaneously in many instances. In a 
 considerable proportion of cases, however, prompt recognition of the disease 
 and evacuation of the pus is necessary to avert a rapidly-fatal issue by suffo- 
 cation, or, in rarer cases, to prevent burrowing of the pus into the oesophagus, 
 larynx, mediastinum, or pleural cavity. 
 
 Treatment. — As soon as pus has formed it should be evacuated by making 
 an incision as near the median line as possible, and then the head of the child 
 should be inclined well forward to prevent the pus from running into the larynx. 
 An ordinary bistoury will suffice for the incision. An exploratory puncture 
 may be made at any time to determine the presence of pus. In Bokai's expe- 
 rience tracheotomy has been but rarely necessary, but it should be promptly 
 performed if puncture of the swelling does not relieve the suffocative symptoms 
 by evacuation of pus. 
 
 The syrup of iodide of iron and nutritive tonics are indicated. 
 
 "VlLL. Nasopharyngeal Adenoid Hypertrophy. 
 
 This disease, which is variously known as "adenoid hypertrophy in the 
 naso-pharynx," "adenoid vegetations," and "third tonsil," in multiplicity of 
 cases and gravity of consequences will bear comparison with any other affec- 
 tion of the upper respiratory tract. In the normal state isolated and aggre- 
 gated muco-lymphoid follicles of the same adenoid structure as those in the 
 pharynx are imbedded throughout in the mucous and submucous tissues of the 
 naso-pharynx. Histologically, each in its simplest form consists of a depression 
 of the mucous membrane lined with its epithelium and enveloped in a stratum 
 of reticular connective tissue, entangled in which are numerous lymphoid 
 cells, lymphoid bodies (closed follicles), and lymphatic and other vessels. 
 Morphologically, they are closely related to the faucial tonsils, which are com- 
 pound aggregations of the same. At the vault of the pharynx a number of 
 these follicles are grouped together, forming a compound gland analogous to 
 the tonsils, and known as the third tonsil, the pharyngeal tonsil, or the tonsil 
 of Luschka. In the normal state this is not of sufficient size to deserve such 
 appellation, but when hypertrophied, as it frequently is, it bears some resem- 
 blance to the faucial tonsil in a state of enlargement. Several sorts of aggre- 
 gation are distinguishable clinically by rhinoscopic inspection. Of these the 
 more common are : (1) the fimbriated variety, in which the growth is composed 
 of several cock's-comb-like masses closely packed together ; (2) the stalactitic 
 form, in which multiple pear-shaped bodies are pendent, like stalactites, from 
 
DISEASES OF THE PHARYNX AND NASO-PHARYNX. 429 
 
 Fig. 7. 
 
 the vault of the pharynx, and to which the name " adenoid vegetations" is most 
 truly applicable; (3) the individuate variety, in which the mass is made up, in 
 large part, of but a single neoplasm, of firmer consistency, smoother surface, 
 and more or less irregular contour according to size and degree of impaction. 
 
 Regarding consistency, this is found to vary in accordance with the amount 
 of fibrous tissue in its composition. In the fimbriated and stalactitic forms the 
 adenoid element predominates, rendering them friable and soft to the touch, 
 while the individuate variety often contains much fibrous tissue, which gives it 
 greater density and tenacity. Between these forms are encountered all degrees 
 of variation both in contour and texture. 
 
 Etiology. — Children of syphilitic and tuberculous parents and those other- 
 wise the victims of scrofulosis are predisposed to it, but children in other 
 respects robust are also affected. 
 
 The term " lymphatism " has been introduced as a recognition of an under- 
 lying dyscrasia which is characterized by hyperplasia of this and other muco- 
 lymphoid structures, including the faucial tonsils. Climatic inequalities fur- 
 nish adequate exciting causes. 
 
 Symptoms. — The space of the naso-pharynx is designed to serve as a 
 common area of air-communication between the five openings which enter it. 
 The Eustachian tubes open into it, one on each lateral wall posterior to the 
 nasal choanae, and upon perfect patency of these openings, together with free 
 nasal respiration, the power of hearing is dependent ; for ventilation, with nor- 
 mal air-pressure in the cavity of the middle ear, is essential to correct auditory 
 sense. The adenoid excrescences, when large, are forcibly compressed between 
 the lateral walls of the naso-pharynx or they overlap the tuber of the Eustach- 
 ian orifice from above, acting in either case 
 as a stopper to one or both openings ; or 
 else the vegetations which are crowded in 
 above and behind the Eustachian tubes de- 
 form and close the orifice by forcing its 
 upper projecting lip downward to meet the 
 lower border of the rim. Fig. 7, accurately 
 drawn from nature, is a typical representa- 
 tion of an average case, in which the naso- 
 pharynx is seen to be occupied by a fim- 
 briated adenoid mass which occludes, in 
 large part, the posterior nasal choanae, and 
 so presses downward the upper lip of the 
 tuber of the left Eustachian orifice as to practically close the channel to the 
 middle ear. 
 
 Again, even with lesser hypertrophy, the accompanying catarrhal state is 
 prone to extend by continuity of surface along the Eustachian tube, and to 
 excite exudation or suppurative inflammation of the middle ear. Deafness, 
 therefore, is frequently a deplorable symptom, and one which is liable to 
 become permanent unless speedy relief be afforded. 
 
 Into this space open also the posterior nares, the natural respiratory pas- 
 sage being via the nose and naso-pharynx. Adenoid hypertrophy, therefore, 
 serves as a plug to the posterior nasal openings, and obstructs nasal respiration 
 completely or in part according to the degree of glandular enlargement. From 
 this point we find it a matter of exceeding interest to trace the origin and 
 development of each successive step in the series of deformities consequent upon 
 this condition. The plugging up of the posterior nares necessitates oral breath- 
 ing, and the constantly open mouth interferes with the normal adaptation of 
 
 Nasopharyngeal Obstruction by Adenoids. 
 
430 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 certain facial muscles, which in turn effects radical changes in the contour of 
 the soft and developing bones of the face, the whole resulting in a physiognomy 
 characterized by a vacant, stupid, almost idiotic expression of countenance, which 
 can be better illustrated by a photograph from nature than described (Fig. 8). 
 Fig. 8. The hanging lower jaw causes the face 
 
 to appear elongated. The nose is pinched 
 or its alse distended, while the angles of 
 the mouth and eyes have a drawn appear- 
 ance. 
 
 Moreover, the air-cavities in commu- 
 nication with the nose, as the frontal, 
 maxillary, sphenoidal, and ethmoidal sin- 
 uses, which are essential to the proper ex- 
 pansion of their respective bones, cease 
 to develop when the circulation of air 
 through the nose is interfered with, thus 
 altering nature's intent regarding the 
 dimensions of the face and head, and still 
 further deforming the physiognomy. Aug- 
 mentation of atmospheric pressure upon 
 the buccal surface of the palate process, 
 and the impact of air-currents to and fro 
 during mouth-breathing, together with the 
 diminution of intra-nasal air-pressure inci- 
 dent to nasal obstruction, gradually force 
 upward the centre of the hard palate, and 
 change thus the obtusely rounded Romanesque arch into one of Gothic shape 
 — thepointedor high-arched palate commonly existing in association with long- 
 
 Fio. 9. 
 
 Characteristic Physiognomy of Adenoid Vege 
 tations (from a photograph by the author). 
 
 High-arched Palate. 
 
DISEASES OF THE PHABYXX AND NASO-PHARYNX. 431 
 
 continued and excessive adenoid development during childhood (Fig. 9). Ele- 
 vation of the palatal arch lessens the traverse diameter of the jaw, and causes 
 it to grow pointed in front — the so-called V-shaped indenture ; and with the 
 resulting contraction of the alveolar process, the teeth, especially those near the 
 point, are crowded into various grotesque aggregations or are rotated on their 
 axes — a condition depicted in Fig. 9, drawn from a typical case, in which the 
 two central incisors overlap, and the two lateral incisors undergo a quarter rota- 
 tion and stand at right angles to the alveolar process. 
 
 It is proper to state that this relation of mouth-breathing to deformed 
 indentures is questioned by some dental authorities, who attribute the elevation 
 of the palatal arch solely to a perverted production of the permanent teeth. 
 The association between the adenoid hypertrophy as a cause of mouth-breath- 
 ing and the high-arched palate is, however, so constant that an etiological 
 relationship is most probable. 
 
 Next, elevation of the palatal arch must produce contortion within the nose, 
 for the septum, composed of the vomer, the perpendicular plate of the ethmoid 
 bone, and its cartilaginous portion, is unequal in power of resisting compression 
 to the bones by which it is incased. Designed by nature to fill vertically the 
 
 Fig. 10. 
 
 Fig. 11. 
 
 natural space between the roof of the nose and its floor, the abbreviation of 
 this space by elevation of the palatal arch through the instrumentality of naso- 
 pharyngeal adenoid hypertrophy cannot result otherwise than in forcing the 
 septum to provide for itself by bending and curving 
 laterally in various directions — a condition which is dia- 
 grammatically represented in Fig. 10. 
 
 The septal deflection acts as an additional impedi- 
 ment to nasal respiration and drainage, and becomes 
 a potent factor in the evolution of hypertrophic 
 rhinitis or that form of nasal catarrh characterized 
 by enlargement of the turbinated bodies (Fig. 11). 
 
 Headache is also complained of, although a sense 
 of mental obtundity and heaviness is more usual than 
 absolute pain in the head. 
 
 Finally, not only, as before said, do these un- 
 fortunates look stupid, but they really are stupid, and 
 exhibit abundant evidence of mental hebetude, with 
 inability to fix the attention, to learn, to memorize, or 
 to reason. 
 
 Three varieties of thoracic deformity are observed to accompany obstruc- 
 
432 AMEBIC AN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tive nasopharyngeal adenoid hypertrophy, the association of one or other form, 
 in advanced cases, being so constant that a direct causal relationship, although 
 difficult of absolute demonstration, can reasonably be assumed. 
 
 For the induction, however, of two of these forms, the "pigeon-breast" 
 deformity and the " barrel -shaped" chest, the intermediation of still another 
 symptom, bronchitis, seems essential ; but adenoid hypertrophy is an etiological 
 factor in the production of chronic bronchitis. Especially in neurasthenic 
 individuals it is exquisitely sensitive to reflex-producing impressions, and its 
 irritation may result, reflexly, in spasm of the glottis, cough, asthma, and pare- 
 tic vaso-motor bronchitis. 
 
 The third variety of thoracic deformity, the "flat chest," is due directly 
 to obstruction by the adenoid growth itself, and is an indrawing of the chest- 
 walls, especially a shortening of the antero-posterior diameter, which results 
 from an insufficient air-supply to the lungs. The chest becomes flat and thin 
 (Fig. 12), has a sunken appearance over the lower part of the sternum, perhaps 
 a deep concavity at the ensiform cartilage, with depressed intercostal spaces. 
 
 Fig. 12. 
 
 Flat-chest Deformity (Hooper). 
 
 Rachitis, so often associated with depraved nutrition, is doubtless the pre- 
 disposing condition to all of these forms of chest deformity. 
 
 Treatment. — For pronounced hypertrophy the only satisfactory method 
 of treatment is removal by surgical means. Many methods by cautery, snare, 
 curette, and forceps, without general anaesthesia, have been described. With 
 older children it makes little difference which of these methods is employed, so 
 that the object is thoroughly accomplished. With young children, however, 
 who will not hold still, most of them are inapplicable, and others border on 
 the barbarous. The young child should be completely anaesthetized by ether, 
 and then placed in the sitting position on the lap of an assistant, with its head 
 against the left shoulder. The mouth is kept open by a gag similar to those 
 furnished with sets of intubation instruments. Three or four pairs of forceps, 
 either the author's (Fig. 13) or other modification of Lowenberg's instrument, 
 being in readiness, the left index finger is passed behind the velum, followed 
 by forceps held in the other hand ; a portion of growth is located, grasped, and 
 
DISEASES OF THE PHABYNX AND NASO-PHARYNX. 433 
 
 Fig. 13. 
 
 Author's Forceps. 
 
 removed, when, without withdrawing the guiding finger, quickly a second? 
 third, and even fourth pair of forceps are used, and thus several pieces 
 extracted before active haemorrhage ensues. Instantly, then, the patient is 
 tilted well forward with the head pendent to permit the blood, while flowing 
 actively, to escape by the nose and mouth. In a few seconds the gush is 
 over, the patient can be raised, the remaining blood cotton-swabbed from 
 the pharynx, and the procedure repeated, and still again repeated, until the 
 naso-pharynx is completely cleared. As a final stage remaining shreds are 
 thoroughly scraped by the finger-nail. 
 
 Little fear need be entertained of blood running down the trachea. 
 That which trickles slowly will course along the oesophagus into the stomach, 
 and at times of rapid flow this danger will be obviated by the method of 
 tilting the child well forward to permit of escape through the nose. Other- 
 wise the blood is liable to gush into the trachea rather than to be swallowed, 
 assertions to the contrary notwithstanding ; for the function of deglutition 
 during profound anaesthesia is suspended. Rapid and persistent cotton- 
 swabbing may suffice, but is not so completely effective, and it prevents the 
 reapplication of the anaesthetic during the bleeding interval, so prolonging 
 the operation. The patient should be kept in bed until the following day, 
 and during healing the parts should be cleansed by syringing through the 
 anterior nares with an antiseptic alkaline solution. 
 
 When the adenoids are small and soft, sufficient palliation perhaps, but not 
 an absolute cure, can be effected by thorough and rapid scraping with the 
 cleansed finger-nail, used as a curette, without the administration of ether. 
 Gottstein's knife and Hartmann's curette, when deftly plied, can also be made 
 effective without anaesthesia, but are apt to terrorize both the child and its 
 parents. 
 
 Syrup of iodide of iron, internally, tends to correct the underlying dyscrasia 
 — lymphatism. 
 
 IX. Cleft Palate. 
 
 True cleft palate is a congenital fissure in the roof of the mouth, of variable 
 extent. The so-called acquired cases differ therefrom in presenting an unequal, 
 ragged, or incomplete cleft, such as would be produced by the destructive ulcer- 
 ations of syphilis. The extent of congenital cleft may vary from the slightest 
 manifestation, that of a bifid uvula, to the grossest form of conjoined cleft 
 palate and hare-lip, in which the fissure involves not only the velum palati and 
 hard palate, but penetrates one or both sides of the alveolar arch and upper 
 lip, with the presence of a separate intermaxillary structure. This article, 
 
 28 
 
434 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 however, will not embrace the subject of hare-lip except incidentally (Figs. 
 14, 15, 16). 
 
 Fig. 16. 
 Fig. 15. 
 Fig. 14. 
 
 Bifid Uvula. 
 
 Cleft Palate 
 
 Cleft Palate and Hare-lip con- 
 joined. 
 
 Etiology and Pathology. — Nature fails to complete her design as origin- 
 ally intended, and the defect doubtless dates from an early period of intra-uterine 
 life. It is assumed that the same causes which produce rickets in children are 
 prone to effect cleft palate. A deficient supp'ly of phosphates in the diet of the 
 mother, or failure on her part to thoroughly assimilate the phosphatic elements, 
 may be regarded as an exciting cause. 
 
 Vander Veer states that " several years ago the lions in the Zoological Gar- 
 dens of London were fed upon flesh containing too large bones for them to 
 break and swallow, as is their custom. The young born while this method of 
 feeding was pursued were observed to have cleft palates, and lived but a 
 short time. The lions were then fed upon small animals, whose bones they 
 could break easily, and the young born afterward had perfectly-formed 
 palates." 
 
 Intermarriage and unfortunate " maternal impressions " are also stated to 
 be exciting causes. Whatever may have been the causes of the original in- 
 ception of the malformation in previous generations, there can be no doubt that 
 heredity now serves as a potent predisposing cause. In my own cases I have 
 nearly always been able to elicit histories of other cases in other branches of 
 the family. Vander Veer, Lawson Tait, and Gurdon Buck emphasize this fact. 
 It will often reappear after skipping one or more generations, or it will diverge 
 into collateral branches. 
 
 Symptoms. — The symptoms consist of an inability to nurse or to swallow 
 perfectly, and, later, to talk properly — disabilities, of course, which vary in 
 accordance with the extent of the cleft. A peculiar nasal intonation of the voice 
 is occasioned, which, if the cleft be an extended one, will first attract attention 
 to the defect in the crying of the infant, and later in life will characterize the 
 speech. In swallowing, fluids regurgitate through the nose. 
 
 On inspection in marked cases the parts appear as if there were no soft 
 palate, the side flaps being retracted by muscular tension, leaving a wide, 
 inverted V-shaped opening, through which are visible the posterior and supe- 
 rior walls of the naso-pharynx with their covering of adenoid glandular 
 tissue. 
 
 Treatment. — This may be considered in three divisions : prophylaxis, pal- 
 liative measures, and operative treatment. 
 
DISEASES OF THE PHARYNX AND NASO-PHABYNX. 435 
 
 Prophylaxis. — Whenever any hereditary tendency to cleft palate, however 
 remote, can be established, it would be a rational precaution to provide in 
 abundance for the mother those articles of diet which are rich in phosphates — 
 e. g. oatmeal — and to administer precipitated phosphate of calcium in powder, 
 five to ten grains twice daily. It should be given, however, without the know- 
 ledge of the mother concerning the end in view, in order not to excite in her 
 a " mental impression " toward cleft palate. For the same reason, in order to 
 avoid directing the mother's thoughts into this channel, she should not person- 
 ally be questioned relative to heredity, or the subject be given prominence in 
 any way in conversation with her during the period of gestation. 
 
 Palliative Measures. — If the cleft be large, some provision will be neces- 
 sary to facilitate nursing. A large rubber nipple or one which is large and 
 flat, so as to serve at the same time, while nursing, as a temporary obturator to 
 close the cleft and permit of suction, is generally the best device. Such a 
 nipple can be attached to the glass shield of an ordinary artificial nipple, com- 
 monly used to protect the mother's nipple when nursing is painful, thus ena- 
 bling the child to nurse indirectly from the breast, or it can be used with a 
 nursing-bottle. In this latter case the bottle can be supplied with mother's 
 milk, at least for a time, by the preliminary use of a breast-pump. In extreme 
 cases, especially those which are conjoined with the worst forms of hare-lip, it 
 becomes necessary to feed the child by a spoon or feeding-cup, which is a 
 laborious undertaking, but one likely to result successfully if it be properly 
 carried out. Vander Veer mentions two cases, "son and daughter in one family, 
 where the mother, for nearly two years in each instance, was obliged to give 
 nearly her entire time to their care as regards feeding before they could help 
 themselves." 
 
 Later in life, if for any reason the operative treatment be not adopted or if 
 operations should fail, much may be done to lessen the disability by the skil- 
 ful adaptation of an obturator — a dental plate so constructed as to cover as 
 much as possible of the cleft. A skilful dentist will fashion one to fit accu- 
 rately and to extend quite far posteriorly, made of firm material, such as hard 
 rubber or gold, furnishing thus a substitute for the hard palate and to a slight 
 degree for the velum palati. But an obturator at best is but a poor substitute 
 for a natural palate ; it mitigates, but does not remedy, the defect ; and to 
 adopt permanently the use of one in lieu of a radical surgical operation is but 
 to condemn the patient for life to the employment of a more or less trouble- 
 some and incomplete appliance. 
 
 A radical surgical operation, if it be skilfully managed, will be ultimately 
 successful in a large majority of cases, and its dangers are slight in comparison 
 with the disadvantage of a perpetuation of cleft palate for a lifetime. 
 
 Operative Treatment. — On account of the difficulty in phonation the 
 operation for closure of the cleft should always, when possible, be performed 
 early, before the child has learned to talk in an imperfect manner ; otherwise, 
 even though the cleft be closed later, much difficulty is experienced in teach- 
 ing correct articulation. It should therefore be performed between the ages of 
 one and a half and three years. 
 
 The operation is known as staphylorraphy when the cleft involves the soft 
 palate only or extends but little into the hard palate ; and osteoplasty when the 
 palate process of the superior maxilla is so deficient as to necessitate the Fer- 
 gusson procedure of drilling off edges of bone to bring together in the centre. 
 
 It is not my purpose to speak of this operation in detail. It is one which 
 has interested the greatest surgeons of the day, and which will be found 
 described at length in all text-books of surgery. But there are certain points 
 
436 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 essential to obtain a good result — that is, perfect primary union of the two 
 sides — and these salient features of the operation will be described. 
 
 It is important that the general condition of the patient be good, and that 
 the season of the year be favorable; that is, preferably, not during the heated 
 term of summer. The bowels should be opened freely the day before the 
 operation by the administration of castor oil the night preceding this. Special 
 care should be taken to avoid vomiting, caused by the anaesthetic, by forbidding 
 any breakfast on the morning of the operation. One can readily understand 
 that the whole success of this long and tedious operation will depend upon 
 securing primary union, and that this preliminary treatment is calculated to 
 insure a condition of health favorable to such union. 
 
 For anaesthesia in operations about the mouth chloroform is often preferred 
 to ether, because its administration can be more interrupted ; but children with 
 cleft palate are apt to be generally feeble, so one must consider ether the safer 
 anaesthetic for prolonged use ; but one can commence with chloroform, because 
 of its greater rapidity and pleasantness of action, and continue, as soon as 
 unconsciousness is secured, with ether. 
 
 As with most other operations on the mouth and throat, the patient should 
 be placed in Rose's position ; that is, with the head pendent from the edge of 
 the table, and the shoulders elevated by a small hard pillow, so that blood will 
 gravitate into the naso-pharynx and not into the windpipe. In this position, 
 at times when haemorrhage is freest, the patient can be rolled upon the abdo- 
 men and the blood allowed to flow from the mouth and the nose. 
 
 The most suitable gag is Mussey's modification of the Whitehead gag. It 
 has a tongue-depressor attached, — a matter of importance as it is absolutely 
 necessary that the tongue be held depressed at the same time that the mouth 
 is gagged open. The tongue-depressor of the Whitehead gag is attached by a 
 hinge-and-ratchet joint, which easily gets out of order, and detracts from the 
 value of the mechanism. In the Mussey gag the tongue-depressor is a part 
 of the same piece, but by force it can be bent to a different angle if required. 
 
 Many and complicated needles have been devised for the purpose, among 
 which may be mentioned Prince's needle as ingenious, but rather complicated. 
 All that is necessary is a curved needle mounted in a handle, as illustrated in 
 Fig. 17. This needle is often kept in the shops, but the curve should be much 
 
 Fig. 17. 
 
 Author's Modified Staphylorraphy Needle (half size). 
 
 more acute than is usually supplied, and the eye of the needle as near as possi- 
 ble to its point. These may seem like small details, but the selection of the 
 needle is one of the most important points to insure a successful operation, 
 inasmuch as it is sufficiently difficult to place the sutures with a perfect needle, 
 and with a faulty one it may be impossible. 
 
 The patient being thoroughly under the influence of the anaesthetic, the 
 first, and absolutely necessary, step is the division of certain muscles. This 
 should be the first step of the operation, and not the last, for the reason that 
 firm and accurate coaptation of the edges can be made only after the perfect 
 relaxation of the muscles thereby produced. Having introduced the gag, one 
 will notice the wide aperture in the roof of the mouth, and that it is seemingly 
 impossible to draw together the two sides of the palate. This is by reason of 
 the constant contraction of the palatal muscles. If one were to draw the two 
 
DISEASES OF THE PHARYNX AND NASO-PHABYNX 437 
 
 sides together forcibly by means of stitches under the partial relaxation pro- 
 duced by the anaesthetic, they would only be ripped out again at the first effort 
 of the child in crying or coughing or swallowing. Only perfect relaxation of 
 the velum can assure complete primary union of the parts. The muscles to 
 be divided on each side are the tensor palati, the levator palati, the palato- 
 glossus, and one of the palato-pharyngei. The last-named muscles constitute 
 the anterior and posterior pillar of the fauces respectively. The tensor palati 
 arises on each side at the base of the internal pterygoid process, and, descend- 
 ing, its tendon winds around the hamular process, which can be felt by the 
 tongue just to the inner side of the upper third molar tooth, and then spreads 
 through the body of the velum. The levator palati has its fibres distributed 
 just behind the tensor. A puncture, therefore, through the velum, com- 
 mencing at the point of the hamular process, and following its curve about 
 three millimetres upward, will sever the tendon of the tensor. Then the knife, 
 with its cutting edge directed upward, should have its handle depressed, with- 
 drawn, reintroduced (in the same opening), the cutting edge directed downward 
 and handle elevated, cutting, in this manner, the posterior surface of the velum 
 more widely than the anterior surface, and so severing as many fibres as possible 
 of the levator. Having done this, one will notice how much more easily the 
 two sides can be approximated. 
 
 Next raise the velum on each side and snip with scissors the anterior pillar, 
 and, on one side only, the posterior pillar, in order to guard against atrophy of 
 the palate by leaving the arterial supply intact on the opposite side. 
 
 The haemorrhage which is caused by these punctures is not likely to be 
 dangerously profuse, although a small artery is severed, but the galvano-cau- 
 tery point-electrode subsequently introduced would serve to arrest an excessive 
 bleeding. 
 
 The edges of the cleft should be thoroughly pared, as merely splitting them 
 does not result in the same satisfactory raw surface, and then provision can be 
 made for closing the cleft in the hard palate. If this part of the fissure be not 
 very extensive, the Warner-Langenbeck method is best. Loosen tissue to slide 
 to the median line by making lateral incisions through the mucous membrane 
 and periosteum, and by incision around and behind the anterior end of the cleft, 
 extending to the bone both on the buccal and nasal surface ; then, by means 
 of a periosteal elevator raising the periosteum from the bone from the lateral 
 incisions to the edges of the cleft, which part of the edge must also be well 
 detached from the underlying bone and fascia, and properly freshened wherever 
 it is to join the one of the opposite side (Fig. 18). These two flaps can then 
 be brought together in the median line. 
 
 For extensive bony clefts Fergusson advocated the separation, by boring 
 and chiselling, of sufficient of the bony edges to bring together in the centre 
 to close the cleft. This procedure appears unnecessarily formidable, apart from 
 the fact that with very wide cleft — the cases with which the ordinary flap ope- 
 ration is inadequate — the bony edges are likewise too scanty to afford a reason- 
 able prospect of success. For such wide clefts the soft flap method recently 
 proposed by Davies-Colley, of Guy's Hospital, commends itself. Figs. 19 and 
 20 will convey his idea. 
 
 Next, the introduction of the sutures, by far the most difficult part of the 
 operation. I prefer silk sutures, and consider them much superior to silver wire 
 and shot, as they are softer in the mouth, and seemingly do not produce the 
 same amount of irritation and annoyance to the child. Two colors, white and 
 black, should be used, as all the stitches should be passed before tying, and if 
 these colors alternate confusion of the ends need not occur. The well-curved 
 
438 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 18. 
 
 Warner-Langenbeck Method of Closing Small Bony Clefts, flap prepared on one side only. 
 
 Figs. 19 and 20. 
 
 Method of Closing a Wide Cleft of the Hard Palate (after Davies-Colley). 
 
DISEASES OF THE PHARYNX AND NASO-PHARYNX. 439 
 
 needle, having been threaded, is introduced on one side (the patient being 
 recumbent), from below upward, or what would be, if the patient were upright, 
 from behind forward (Fig. 21). To facilitate passing the needle the flap is held 
 and drawn tense by forceps. The thread is then caught from the eye of the 
 needle by a blunt tenaculum (Fig. 21), one end drawn all the way through, and 
 the needle passed back and drawn off the other end. 
 
 Fig. 21. 
 
 Fig. 22. 
 
 End of suture, a, is next passed through loop, b, 
 which is used only to draw end a through the 
 flap of that side. Ends a and c are subsequently 
 tied. 
 
 Passing a Suture. 
 
 This procedure is easier than if the needle were previously passed in the 
 reverse direction, as is usually recommended. Having passed the suture on 
 one side, one must pass a double thread on the opposite side, drawing up in 
 like manner with a tenaculum the two free ends, which leaves the loop below 
 (Fig. 22); the needle is then drawn back as before and disengaged. Then 
 through the loop is passed the lower end of the single suture, and, by means 
 of the double thread, it is pulled through the opposite side. In passing the 
 stitches great care should be taken to engage sufficient tissue, not getting them 
 too near the edge, and also to have them passed as nearly as possible at points 
 opposite each other. 
 
 Before tying the sutures special care should be observed to see that the edges 
 of the flaps are clean and free from clotted blood. Then, commencing anteriorly, 
 the sutures are tied first by means of a slip-knot pushed down by the finger, 
 the suture well tightened, and again tied by an ordinary knot. As the sutures, 
 one after another, are thus tied, see that the edges are not turned in so as 
 to bring mucous-membrane surfaces together instead of freshened edges. 
 
 Failure to unite by primary union is probably due to incomplete division of 
 the muscles more frequently than to any other one cause ; but the good health of 
 the child, the careful paring of the edges, and placing of the sutures are also 
 essential points. If, however, complete union should not result at the first oper- 
 ation, we certainly should operate a second or a third time. 
 
 It is rare indeed, with ordinary care and skill, that partial union will not be 
 produced at the first trial, and this will encourage both parents and surgeon to 
 persevere to a complete result. 
 
440 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Concerning now the subsequent treatment of the patient : At the completion 
 of the operation, before the patient has revived from the anaesthetic, a hypo- 
 dermic of morphine should be administered. This to prevent, as far as possible, 
 vomiting and excessive crying — in other words, to maintain quietude of the 
 parts. I consider it best, although all authorities will not be in accord with 
 this opinion, to keep the patient partially under the influence of morphine 
 during the first three days, for the same reason. The stitches may be removed 
 from the sixth to the tenth day. Some of them by the sixth day will have 
 ulcerated out on one or both sides, but this matters not when primary union is 
 secured ; and if primary union is not secured, the stitches will not hold the parts 
 together after the third or fourth day. But as a matter of precaution, to give 
 some strength to the newly-formed union, the stitches may be left until the 
 time stated. To facilitate their removal an anaesthetic should be administered. 
 
 [Note. — Since going to press the author has observed an instructive case of retro- 
 pharyngeal lymphadenitis in an infant four months of age. The child was convalescing 
 from infectious pseudo-membranous tonsillitis (folliculous) when dyspnoea commenced, 
 and increased for two weeks, when suffocation was imminent. Voice was unimpaired 
 and inspection of the fauces negative, but palpation disclosed a hard tumor projecting 
 from the posterior pharyngeal wall in the median line, low down and pressing upon the 
 opening of the larynx. Three punctures into this tumor failed to evacuate pus. Trache- 
 otomy was immediately performed. Eesolution was complete ; at the end of two weeks 
 the tube was withdrawn, and the child recovered.] 
 
GASTRIC CATARRH AND GASTRIC ULCER. 
 
 By A. D. BLACKADER, M. D., 
 
 Montreal. 
 
 I. Acute Gastric Catarrh. 
 
 Acute gastric catarrh, otherwise known as acute gastritis, gastro-aden- 
 itis, acute dyspepsia, or gastric fever, is an acute inflammation of the glandular 
 tissue of the stomach interfering with its digestive functions, and generally due 
 to the presence of irritating ingesta. The attack is attended with pain, ano- 
 rexia, and nausea or vomiting; frequently also by general pyrexia. It is 
 occasionally complicated by reflex nervous symptoms of a more or less serious 
 character. Associated disorder in other portions of the alimentary canal may 
 be met with. While occurring at any age, artificially reared infants and deli- 
 cate children are especially prone to this disorder. 
 
 Etiology. — During infancy the stomach appears to be peculiarly liable to 
 disturbance of its functions. It is the period of its most rapid development, 
 and not only does it increase in size, but it has to assume more varied duties. 
 At the same time, the demands upon it, incident to the very rapid growth of 
 the body at this period of life, are proportionately larger than at a more 
 advanced age. Infants fed at the breast generally escape, but not always. 
 Occasionally errors in diet on the part of the mother, violent disturbance of 
 the nervous system, or the appearance of the catamenia, may produce such 
 changes in maternal milk as to render it less digestible, and thus bring about 
 an attack of acute catarrh in the infant. It is, however, among those who 
 have been artificially fed from the early days of infancy that disturbances of 
 this character most frequently occur. The essentials of artificial feeding in in- 
 fancy, — a milk, practically sterile, containing the proper amount of albuminoids, 
 fats, and sugars, fed to the infant in proper amounts, at a proper temperature, 
 and at due intervals, so as to permit perfect digestion with a short period of rest 
 for the stomach, — have not yet been generally attained, even in our more intel- 
 ligent families ; while, among the poorer classes, how often does the infant's food 
 fail in every one of these details ! During infancy, also, appear the reflex nerve- 
 disturbances generally attributed to dentition. Certainly at this period acute 
 disturbances of the stomach are more frequently met with than either before or 
 after. 
 
 By the end of two years the powers of the stomach are more developed ; 
 the demands of the system less exorbitant ; any irritation accompanying denti- 
 tion is past; and, under a careful dietary, attacks of acute catarrh should be 
 infrequent. The rich and varied table diet often injudiciously allowed after 
 this age may, however, conduce to an attack. 
 
 Generalizing, we may say that any excess in the amount of food, too great 
 variety in its character, the use of such stimulating food as highly-spiced dishes, 
 pickles, or sauces, irregularity in the meal hours, or the unregulated and un- 
 limited eating of fruits, cakes, or sweetmeats, especially between meals, may in 
 
 441 
 
442 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 children bring on an attack of acute indigestion. Food or drink, too hot 
 or too cold, quickly taken, may also occasionally be an exciting cause. 
 
 Closely associated with errors in the dietary as an etiological factor is the 
 imperfect mastication so often given to food. Children require to be taught to 
 masticate, and their teeth from the time of their first appearance should claim 
 the careful attention of the attendants. 
 
 There is not, however, in all children an equal susceptibility to disturb- 
 ance. Some appear to have particularly vigorous stomachs which tolerate 
 much abuse, while it is only with the greatest care that attacks can be averted 
 in others. In some a predisposition to weak digestion is distinctly hereditary. 
 Anaemic children are peculiarly prone to attacks. The close association be- 
 tween rickets and disorders of digestion has long been recognized. The 
 scrofulous and rheumatic diatheses are also predisposing factors. Unsanitary 
 conditions of life markedly impair the digestive powers, and thus favor an acute 
 disturbance ; especially is this true of want of exercise in the open air. 
 
 The acute ailments and specific fevers of childhood frequently leave the 
 mucous membrane of the alimentary canal in a weakened condition, from 
 which it takes time and a very careful dietary to thoroughly recover. Of this 
 class of disease Ewald says : " Although the gastric symptoms are relegated to 
 the background by other manifestations, yet in those cases with dyspeptic dis- 
 turbances, in which we are enabled to examine the organ soon after death, we 
 will find the anatomical changes of acute gastritis." 
 
 In some children the sudden checking of the cutaneous circulation, by chill 
 from imprudent exposure, may occasionally interfere with the process of diges- 
 tion and bring about an attack. Eustace Smith thinks this a very frequent 
 cause of trouble. In our more severe climate children are more perfectly 
 clothed in flannel than in England, but in children with weak stomachs I have 
 frequently noticed an attack of gastric catarrh brought on by getting the feet 
 damp. Unless due care be exercised, one attack may predispose to others. 
 
 Pathology. — Our knowledge of the minute changes in the mucous mem- 
 brane in acute gastric catarrh has, until lately, been very limited ; so much so, 
 that some writers have questioned the propriety of admitting this among the list 
 of actual diseases. In his recent work Ewald protests against the use of the 
 word " catarrh " as creating an erroneous conception. " The structure," he says, 
 " of the gastric mucosa, better designated the glandular layer, tunica glandularis, 
 is such that it is out of the question to call it a mucous membrane in the ordi- 
 nary meaning of the term It is simply a peculiar feature of the 
 
 inner layer that the protoplasm of the epithelium of the excretory ducts pos- 
 sesses in a remarkable degree the property of being converted into mucus. . 
 ... Dr. Beaumont's investigations on his patient, St. Martin, showed that 
 every catarrh, even the mildest, was accompanied by a disturbance of the 
 secretion of gastric juice ; consequently by an affection of the glands them- 
 selves. The inflammation is thus not catarrhal, but parenchymatous and inter- 
 stitial. It has nothing in common with a catarrh except the " flow," the secre- 
 tion of a more or less abundant, but always alkaline, transudate into the cavity 
 of the stomach. Misled by the term "catarrh," we are too prone to under- 
 estimate the importance of these processes, particularly when they are chronic, 
 and by thinking, for example, of a chronic pharyngeal catarrh, we lose all 
 proper standards of comparison." 
 
 Macroscopically, the mucous membrane in acute catarrh appears swollen and 
 reddened. In severe cases slight haemorrhages, or even small erosions, may 
 occur ; the submucosa may be ©edematous. Microscopically, there appears an 
 infiltration of the interstitial tissue with leucocytes ; the differentiation between 
 
GASTRIC CATARRH AND GASTRIC ULCER, 443 
 
 the parietal and the principal cells can no longer be made out, while all the cells 
 may alike be seen to have become granular and cloudy, and in part separated 
 from the membrana propria of the glands. The mucous cells are especially 
 abundant in the pyloric region, and extend down deeply into the ducts of the 
 glands. 
 
 Symptoms. — Cases of acute gastric catarrh have been divided into two 
 classes, the febrile and the afebrile, according as they are, or are not, accom- 
 panied by pyrexia. The division is a convenient one. The febrile are much 
 the more severe. The afebrile run a short, mild course, and are as a rule 
 unaccompanied by serious symptoms. 
 
 The onset of an attack is generally sudden. Within an hour or two after 
 the error in diet the child shows signs of being unwell. If an infant, after a 
 short sleep it awakes crying and apparently in pain. Its thighs are flexed on 
 the abdomen. It moves restlessly from side to side, and whines piteously or 
 cries bitterly. The temperature will be found more or less elevated, 102 ° to 
 104°, the pulse and respiration quickened, the tongue furred, the abdomen 
 distended, and pressure on it evidently increases the child's distress. The 
 bowels at this time may, or may not, show signs of disturbed action. Vomiting 
 generally occurs early, with some temporary relief. After this the infant, if 
 allowed, may eagerly take the breast or its food again, only to reject it, curdled 
 and sour-smelling, after a short interval. If the ejecta be carefully examined, 
 there will be found a marked deficiency of hydrochloric acid, and in its place 
 the presence of lactic and butyric acids. Vomiting may recur several times ; 
 at the last, watery, sour-smelling mucus, perhaps more or less bile-stained, 
 being ejected. There is now complete anorexia. The infant is restless and 
 feverish, if not actually crying with pain, and its sleep is much broken and 
 disturbed. Under proper treatment the attack is generally of short duration, 
 and in twenty-four or forty-eight hours a few loose movements carry away any 
 of the oifending material that has escaped into the bowel ; the fever subsides ; 
 the infant again sleeps quietly ; but for a few days it is less eager for its food, 
 which it is inclined to take more slowly and in smaller quantity. 
 
 In older children the attack manifests itself by a feeling of listlessness, 
 with more or less drowsiness. The child will give up its play and prefer to 
 lie down. Uneasy pain in the epigastrium is soon complained of, with a feel- 
 ing of nausea and headache. If the child fall asleep, it is a very disturbed 
 sleep, from which it frequently awakes in a fright, complaining of bad dreams. 
 Dark circles may now be noticed under the eyes ; the face is generally pallid 
 unless the fever runs high. In that case a peculiar pallor about the upper lip 
 and the alae nasi is very distinctive of irritation of the stomach. The tongue 
 is coated heavily toward the base, but the tip and the edges are red ; the skin 
 is dry ; the pulse is quickened ; the temperature may be high — 103° to 104° 
 — but if so it reaches its height early ; the abdomen is distended, pressure over 
 the epigastrium increasing the uneasiness ; and the breath is generally heavy or 
 sour-smelling. The secretion of saliva is increased, so that during sleep it may 
 dribble on the pillow. Vomiting may occur, but not so generally as in infants. 
 When it does, there is usually much retching, and toward the close biliary 
 matters, with watery mucus, are ejected with much straining. The bowels are 
 constipated and the urine scanty and high-colored, with an abundant sediment 
 of lithates. The headache is generally frontal, although sometimes temporal. 
 In some cases an associated pharyngitis may be noticed ; in others a few 
 herpetic vesicles appear on the lips. In mild cases the attack subsides in a day 
 or two, but in the more severe forms the fever may persist for four or five days, 
 leaving the child in an exhausted state, from which, however, under careful 
 
444 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dietary, it generally recovers rapidly. Occasionally an attack of acute gastric 
 catarrh is followed in a few days by catarrhal jaundice. The inflammation 
 has probably extended down the duodenum, blocking the common bile-duct. 
 Such cases are usually of short duration. 
 
 Although, in general, an attack of acute gastric catarrh may give us little 
 anxiety, at times we have associated reflex symptoms of a very alarming char- 
 acter. The convulsive seizures of infancy, dependent so frequently upon 
 gastric or intestinal irritation, are familiar to all and require prompt treat- 
 ment. The danger of cerebral haemorrhage during such an attack should 
 always be borne in mind. 
 
 In older children more alarming, because more unusual, symptoms of reflex 
 irritation are occasionally met with. In some instances localized or diffuse 
 clonic muscular movements have their origin in gastric irritation. Symptoms 
 closely resembling those of meningitis have been reported by Seibert. Fraen- 
 kel relates the case of a child four years old who shortly after eating a large 
 amount of table food lost the power of movement and sensation on the right 
 side. Complete recovery followed on the next day. Henoch records a case of 
 complete aphasia in a child which passed away an hour later after the vomiting 
 of some undigested fruit. Such cases, however, are rare, and should always 
 receive the most careful attention on the part of the physician, lest, instead of 
 being reflex, they arise from a distinct and all-important lesion. 
 
 Diagnosis. — In most instances, with a distinct history of some error in 
 diet, no serious difficulty will be experienced in arriving at a guarded conclu- 
 sion. The sudden onset, the tenderness over the epigastrium, the relief afforded 
 by vomiting, and the rapid subsidence of the symptoms will in a day or two 
 enable us to assure the parents that no more serious trouble need be appre- 
 hended. In cases attended with fever, however, it is always wise to speak 
 more or less guardedly at the first. The onset of scarlet fever should always 
 be excluded. In this disease we have as an early symptom a definite amount 
 of congestion of the fauces, followed frequently by some enlargement of the 
 glands at the angle of the jaw. The irregular erythema, sometimes appearing 
 for a few hours in disorders of the stomach, should be distinguished from the 
 scarlatinal eruption with its more regular development and longer duration. In 
 doubtful cases, for such will arise, isolation for twenty-four or forty-eight hours 
 will solve the problem. Tonsillitis and diphtheria may, with care, be easily 
 excluded. An attack of acute catarrh may closely resemble the onset of pneu- 
 monia. J. Lewis Smith relates a case in which the high temperature and ex- 
 piratory moan simulated a pulmonary inflammation, but was promptly relieved 
 by the expulsion of some orange-pulp. In cases such as these careful attention 
 must be paid to the pulse, the respiration, and the temperature. In typhoid 
 fever the rise is more gradual; we frequently meet with an initial bronchitis, 
 the prodromata are more marked, and some enlargement of the spleen may be 
 made out. In acute gastric catarrh the onset is more sudden, and the disten- 
 tion of the abdomen more marked, than is general in typhoid fever at an early 
 stage, while tenderness is noted in the epigastrium, not in the iliac region, and 
 the temperature falls after a few days. In delicate children the possibility of 
 tuberculosis must always give us anxiety. We have no absolute symptoms by 
 which we can exclude this disease. A slow pulse may occasionally be met with 
 in gastric disorder from irritation of the vagus. The vomiting of meningitis is, 
 in general, indistinguishable in its character from the vomiting of mere gastric 
 irritation, and the condition of the tongue is no certain guide. Under these 
 circumstances a careful watch for localizing symptoms will be required, and a 
 very guarded opinion must be given. 
 
GASTRIC CATARRH AND GASTRIC ULCER. 445 
 
 Prognosis. — The prognosis of acute gastric catarrh must be regarded as 
 very favorable. Only in delicate infants, whose hold on life is extremely frail, 
 will the disturbance of nutrition or the gastric irritation threaten immediate 
 serious results. Such an attack may be the beginning, however, of a gastro- 
 enteritis, which may prove fatal. Convulsive seizures are always serious. 
 Relapses are common in artificially-fed infants and in older children unless 
 due care be exercised. 
 
 Treatment. — In acute gastric catarrh the first important indication for 
 treatment would appear to be the removal of the offending material in the 
 stomach. Nature in many cases effects this spontaneously by the induction of 
 vomiting. Should we see the case early, before vomiting has taken place, we 
 may favor it by the administration of ipecacuanha, either in the form of a 
 powder, or of the wine or syrup. If some hours have elapsed, however, a 
 large portion of the offending stomach-contents may have escaped through the 
 pylorus, and a gentle but prompt purgative is then called for. The following 
 are suitable prescriptions under the circumstances : 
 
 3^. Hydrarg. chloridi mitis gr. ij-iv. 
 
 Sodii bicarbonatis gr. xij. — M. 
 
 In pulv. iv. divid. 
 Sig. One every three hours until a free evacuation of the bowels is 
 secured (for a child of three years). 
 
 Or, ^. Hydrarg. cum creta gr. vj. 
 
 Sodii bicarbonatis gr. viij. 
 
 Pulv. rhei gr. viij. — M. 
 
 In pulv. ii. divid. 
 Sig. One to be given immediately (for a child of three years). 
 
 Or, Ify. Sodii et potassii tartratis gr. xxx. 
 
 Sodii bicarbonatis gr. iij. — M. 
 
 In pulv. vj. divid. 
 Sig. One to be given every hour in a wineglassful of hot water until 
 a free evacuation is secured (for a child of three years). 
 
 In those cases where vomiting is troublesome and persistent minute doses 
 of calomel, or of calomel and soda, may be given dry on the tongue. My own 
 preference is for the triturate of a tenth of a grain, or of the tenth of a grain 
 of calomel with a grain of soda, to be given hourly until eight or ten doses 
 have been taken. This generally checks vomiting and secures a free evacua- 
 tion of the bowels within twelve or twenty-four hours. It probably serves also 
 to check to some extent the development of bacteria in the stomach. Should 
 pain in the epigastrium be complained of, a warm poultice of linseed-meal, 
 
 I either pure or with a proportion of mustard, applied over this region, will be a 
 source of much comfort. After the first acute symptoms have passed off, a 
 mixture containing sodium bicarbonate, with a minute dose of nux vomica, will 
 _ 
 
 I^. Sodii bicarbonatis gr. xlviij. 
 
 Tr. nucis vomicae 1U v j- 
 
 Aquae carui, adf^iij. — M. 
 
 Sig. One dessertspoonful to be given four times daily (for a child of three 
 years). 
 
446 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 As the case progresses and the inflammatory action subsides, the amount 
 of the nux vomica may be increased. 
 
 The dietetic treatment is even more important than the medicinal. After 
 the stomach is emptied it should have complete rest for some hours. Water in 
 small quantities or small pieces of ice should be all that is allowed until the 
 inflammatory action has sufficiently subsided to permit the secretion of gastric 
 juice. Any attempt to give the child food before this will only increase the 
 existing hyperemia. In general, after about twelve hours of abstinence, milk 
 diluted with either Vichy or lime-water, may be allowed in small quantities 
 at a time. Should it disagree, a weak broth with barley- or rice-water may be 
 tried. The recourse to solid food must be gradual. Starchy food, which is 
 principally digested in the small intestine, may first be given, while stronger 
 nitrogenous food is withheld for a few days longer. 
 
 Should nervous symptoms, such as sudden twitchings or startings, make 
 their appearance, great quiet should be maintained in the sick-room, which 
 should be moderately darkened. At the same time an enema, containing 
 bromide of potassium or chloral, or both, in a little starch- or gum-water, may 
 be given to relieve the nervous irritability, and, if possible, to ward off any 
 convulsive seizure. 
 
 As long as the pulse is quickened or the temperature elevated the child 
 should be kept in bed. Afterward over-fatigue should be avoided, as tending 
 to a relapse. 
 
 When the gastric irritation has quite subsided, the tongue become clean, 
 and the appetite has to some extent returned, the administration of some fer- 
 ruginous tonic, with a daily drive in the open air, will generally prove of dis- 
 tinct value. 
 
 II. Chronic Gastric Catarrh. 
 
 This disease, also called chronic glandular gastritis, or chronic vomiting, is 
 a chronic inflammatory condition of the glandular tissue of the stomach, giving 
 rise to a diminution in both the quantity and the quality of the true glandular 
 secretion (hydrochloric acid and pepsinogen), but attended with the secretion, 
 sometimes in large quantities, of an alkaline mucus which possesses no digest- 
 ive powers. As a result of this condition we meet with, in time, an enfeeble- 
 ment of the muscular coat of the stomach leading to the undue retention of 
 food. Chronic gastric catarrh is undoubtedly the condition most frequently 
 encountered in the chronic digestive disorders of childhood. Only very seldom 
 at this period of life can such disorders be referred to a distinct neurosis. 
 
 Etiology. — The causes leading to the condition of chronic gastric catarrh 
 in childhood are closely allied to those already mentioned as inducing an acute 
 catarrh. The continued irritation of the gastric mucous membrane by the 
 ingestion of large, imperfectly masticated and insalivated morsels of food ; by 
 the habitual use of food, indigestible or improperly cooked, such as hot bread 
 or cakes, pastry, and fried dishes ; or by the habit of eating sweetmeats at all 
 hours of the day, may occasion this condition, either directly or indirectly, by 
 producing acrid fermentation in the contents of the stomach. Another source 
 of irritation is the continued contamination of the food by offensive discharges 
 from ulcerations in the nose, throat, or mouth ; from decaying teeth ; and from 
 the muco-purulent discharges, often very considerable in amount, from adenoid 
 growths. Repeated attacks of an acute or subacute form are very liable to 
 lead to this condition, especially in children with lowered vitality living under 
 imperfect sanitary conditions. The presence of anaemia, rachitis, or scrofula 
 
GASTRIC CATABBH AND GASTRIC ULCER, 447 
 
 may be regarded as distinctly predisposing ; also prolonged convalescence from 
 an acute inflammatory or specific fever. 
 
 Anv endorsement f the gastric veins due to valvular heart disease or to 
 chronic inflammatory disorder in the liver and lungs will, of course, distinctly 
 predispose to this condition. 
 
 Pathology. — The conditions in chronic catarrhal gastritis are but an exten- 
 sion of those referred to under the heading of Acute Gastric Catarrh. The 
 whole organ is usually enlarged. The mucous membrane, usually thickened, 
 is of a pale-gray or slate-gray color, with insular deeply injected areas, and is 
 covered with a closely adherent layer of mucus. In places, especially in the 
 vicinity of the pylorus, the hypertrophied mucous membrane may form small 
 papillary projections, the so-called Stat mamelonne. In more advanced stages 
 this condition may give rise to distinct polypoid outgrowths. The minute 
 anatomy, says Dr. Ewald, is that of a parenchymatous and interstitial inflam- 
 mation, most noticeable in the pyloric region. The gland-cells may be found 
 partly destroyed, partly granular, and partly shrivelled up. The differentia- 
 tion between the principal and parietal cells is impossible. In many places 
 the ducts have lost their regular form and show an atypical ramification. 
 There is an abundant small-celled infiltration, most marked near the surface 
 of the mucosa. The superficial layer of the epithelium of the mucosa is loos- 
 ened, and can be separated in adherent shreds. The mucoid transformation 
 of the cells of the tubules is a prominent feature, and may be observed to 
 extend down to the base of the glands. Whether this degeneration may to 
 any extent retrograde, or whether it is permanent, Dr. Ewald has not been able 
 to decide. 
 
 As the disease advances changes in nutrition produce a progressive fatty 
 degeneration of the cells, with finally complete atrophy of the mucous mem- 
 brane. To this condition Dr. Ewald proposes to give the name of anadenia 
 of the stomach. This atrophic process may advance in two ways : (1) by pro- 
 gressive destruction of the glandular parenchyma, so that finally nothing is 
 left but a layer of small round cells, in which appear isolated remnants of the 
 former parenchyma ; (2) by a marked activity of the interstitial connective 
 tissue, leading to hypertrophic proliferation, with much thickening of the walls, 
 but with great contraction, so that the capacity of such a stomach becomes very 
 limited. 
 
 In either form it is a severe irreparable process, which specially involves the 
 glandular layer of the stomach, and which is characterized by a complete dis- 
 appearance of the secretory parenchyma. 
 
 Symptoms. — The symptoms at first are those of impaired digestion. The 
 appetite is lessened, except at occasional intervals, when it may appear in- 
 creased. Ill-defined gastric distress and colicky pains, with distention of the 
 abdomen, indicate the presence of fermentation. Nervous symptoms, such as 
 headache, listlessness, irritable temper, and disturbed sleep, owing in great 
 measure to reflex irritation, become manifest. General nutrition sooner or 
 later begins to show signs of impairment. The child looks pallid, dark circles 
 appear under the eyes, the muscular system is badly nourished, the pulse is 
 wanting in tone, and slight exertion produces signs of fatigue. The indi- 
 cations of digestive disorder now become more prominent : the appetite fails at 
 the regular meal-hours, but during the intervals there may be cravings for 
 unsuitable food. The breath, especially in the early morning, is heavy-smell- 
 ing ; eructations occur during the day ; pain, referred to the epigastrium, is 
 frequently complained of; nausea, recognized by sudden pallor of the coun- 
 tenance, recurs occasionally, but vomiting in older children is infrequent. In 
 
448 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 infants vomiting is often a most pronounced feature; hence the title, " chronic 
 vomiting," often given to the disease. Constipation is generally pronounced, 
 and is very difficult to relieve. The motions consist of hard rounded masses, 
 of offensive smell and variable color, passed with much straining, and generally 
 associated with an increased amount of mucus. Occasionally an evening rise 
 in temperature may be observed, exciting suspicions of typhoid fever or tuber- 
 culosis. In the more severe cases, after the disorder has run a prolonged 
 course, and the failure in general nutrition has become very marked, "the 
 patient either literally pines away like a lamp the oil of which has not been 
 replenished," or falls an easy victim to some intercurrent disease. 
 
 Such may be said to be a general picture of this disease. Its course, 
 always very prolonged, is perhaps more irregular than that of most chronic 
 affections. The stimulus of a season at the seaside, or in bracing mountain-air, 
 may for a time make an improvement in such children, especially in the early 
 stages of the disease, but unless we can secure the necessary watchfulness over 
 the dietary and general hygiene, a fresh exacerbation is easily induced, with 
 renewal of all the unfavorable symptoms. 
 
 In infancy symptoms of indigestion occasionally appear shortly after birth. 
 Frequently the fault in such cases lies in the character of the nutriment sup- 
 plied to the infant ; but sometimes a feeble power of digestion appears to be 
 inherited. Should disturbances of the digestive functions persist, the infant 
 becomes restless, fretful, and colicky. Attacks of vomiting occur frequently ; 
 sometimes shortly after the food is taken, on some slight movement, the greater 
 portion of the meal will be rejected, curdled and sour-smelling. At other times 
 vomiting takes place some hours after the meal, and consists of watery mucus 
 and lumps of hard curd or other undigested food. The appetite is variable ; at 
 times the breast or the bottle may be refused absolutely, and again food may be 
 taken eagerly at first, but is shortly pushed aside with evident signs of distress. 
 The face is pale, and, instead of the normal expression of placid content, it 
 frequently puts on a pained look. The tongue is generally furred, but in infancy 
 this is not so reliable a symptom as in older children. Sleep is fitful, much 
 disturbed, and for short intervals only. Nutrition distinctly fails. Instead of the 
 normal increase of from four to eight or ten ounces per week, the infant may 
 scarcely hold its own or may even lose weight. The skin, along with the other 
 tissues, suffers from lack of nutrition, the subcutaneous fat is absorbed, and 
 the superficial veins show distinctly through its more delicate structure ; the 
 muscles are small and flabby ; the extremities are with difficulty kept warm ; 
 the fontanelles, if open, will be found depressed ; and the coronal suture may 
 be prominent, owing to depression of the frontal bones. Constipation is a 
 frequent symptom, but occasional attacks of diarrhoea occur, with the passage 
 of undigested food and some mucus. Various forms of skin rashes frequently 
 make their appearance, such as erythema, urticaria, and lichen. Vomiting in 
 such infants, especially if there be much failure in general nutrition, is always 
 a symptom requiring much attention. In my own experience it has almost 
 invariably yielded to patient and careful treatment, but it quickly reduces the 
 strength, and hydrocephaloid symptoms may supervene. PaTasitic stomatitis 
 is apt to prove a troublesome and, in a few cases, a serious, complication. If 
 symptoms of indigestion persist and wasting becomes extreme, all our measures 
 seem to fail, and the infant sinks into the condition known as simple atrophy. 
 
 A few of the symptoms met with in older children require more extended 
 notice. Pain and uneasiness, referred to the epigastric region, is a very com- 
 mon complaint. In general, the distress becomes more pronounced shortly 
 after taking food, but occasionally it seems to be more felt when the stomach is 
 
GASTRIC CATARRH AND GASTRIC ULCER. 449 
 
 empty. In all cases distinct tenderness is elicited by pressure on the epigas- 
 trium. The tongue is usually large and flabby, with heavy yellowish fur 
 toward the base. The tip is red, and its papillae reddened and prominent. 
 Occasionally we meet with a comparatively clean tongue, or one marked by 
 crescentic and wandering rashes. Too much importance must not be placed 
 upon its appearance. The appetite is whimsical, variable, or sometimes alto- 
 gether wanting. In some it is satisfied after a few mouthfuls, and afterwards 
 requires much coaxing. Although a feeling of nausea is not an infrequent 
 symptom, vomiting seldom takes place except on the occurrence of an acute 
 exacerbation. 
 
 The sleep of such children is generally much disturbed. They toss about 
 from side to side, dream, and talk in their sleep. Occasionally they may awake 
 suddenly in great terror, and remain for some few minutes screaming wildly 
 under the influence of fright, unable to recognize their attendants. Somnam- 
 bulism in children is generally due to this same cause. 
 
 The amount of interference with nutrition that may take place is variable. 
 Some appear to grow fairly well, though they remain pale; their frame is well 
 developed, but the muscles are deficient in tone. In others nutrition is markedly 
 defective. They are small for their age, their muscular tissue is poorly devel- 
 oped, and their pulse small, weak, and occasionally intermitting. Such chil- 
 dren are liable to suffer from neuroses. Headaches, chiefly frontal, are fre- 
 quently complained of; the temper is uncertain, and generally very irritable. 
 Local muscular twitchings of choreic character are not infrequent. Syncopal 
 attacks, closely resembling those of petit mal, are sometimes met with. Dis- 
 turbances affecting the heart's action, or the respiration, have been reported. 
 
 The nutrition of the skin in such children is always impaired. Their skin 
 is never clear, but is generally sallow in appearance. 
 
 A reflex irritation, referred to the nostrils or the anus, manifested by a 
 constant picking of the nose or scratching at the seat, is very common and is 
 extremely troublesome. A "stomach cough," generally due to an accompany- 
 ing pharyngeal catarrh, is a not infrequent symptom. As a rule, it is most 
 troublesome during the hours of sleep. 
 
 The course of chronic gastric catarrh in children varies much. After it 
 has persisted for some time there is always a marked tendency to distention of 
 the stomach, with impaired muscular action. This, if not checked, may go on to 
 the production of actual dilatation, especially in those cases where the abdom- 
 inal parietes are much relaxed. In some the large secretion of mucus becomes 
 a prominent symptom, the disease extends to the lower portion of the aliment- 
 ary canal, and general nutrition becomes still more rapidly lowered. (See 
 article on "Mucous Disease.") In the severer forms of atrophy of the 
 glandular tissue of the stomach the clinical picture may be that of a pernicious 
 anaemia. 
 
 Diagnosis. — In the diagnosis of chronic gastric catarrh there should rarely 
 be much difficulty. The long history, the epigastric tenderness, the disturbed 
 digestion, and impaired nutrition, after the exclusion of organic trouble in the 
 lungs, heart, or kidneys, will indicate clearly the character of the trouble with 
 which we have to deal. If possible, however, an exact determination should 
 be made by examination of the stomach-contents one hour after a test break- 
 fast, which in older children should consist of bread and milk. The examina- 
 tion may be easily managed in infants by passing a soft rubber stomach-tube 
 and withdrawing some of the contents. In older children this is more difficult, 
 but may sometimes be managed. Advantage may be taken of any ejecta, or 
 artificial means may be used to produce emesis. By this measure three forms 
 
 29 
 
450 AMER T CAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of chronic gastritis may be distinguished: 1. Simple gastritis, in which, after 
 the test breakfast, hydrochloric acid is found in diminished quantity, while 
 lactic and butyric acids are usually present. 2. Mucous gastritis, which differs 
 from simple gastritis chiefly by the presence of a large amount of mucus. 
 3. Atrophic gastritis, in which the secretion of hydrochloric acid and pepsin is 
 almost entirely absent. 
 
 In some cases of impaired digestion in infants it is necessary to exclude 
 the presence of hereditary syphilis and tuberculosis. In the former possi- 
 bility a decision should be arrived at without having recourse to medicines, as 
 in simple gastric disorder a course of antisyphilitic remedies may do harm 
 (Pepper). In older children the presence of pyrexia, with the symptoms of 
 chronic gastric catarrh, should always suggest the possibility of typhoid 
 fever. The same considerations should influence us in forming a diagnosis in 
 the case of chronic, as in that of acute gastric catarrh. 
 
 Popular opinion generally refers many of the symptoms of chronic gastritis 
 to the presence of intestinal worms. In suitable cases it may be desirable to 
 give a few doses of mild vermifuge to exclude their presence. 
 
 Prognosis. — The prognosis of chronic gastric catarrh in childhood, if 
 placed under careful dietetic and hygienic treatment before the atrophic 
 changes have proceeded too far, may be regarded as good. In infancy there 
 is always danger of extension of the trouble to other portions of the aliment- 
 ary canal. This is especially the case during the summer months. The 
 continued interference with nutrition renders children more prone to the 
 development of some intercurrent disease. 
 
 "While the dyspepsias of children are not of themselves often fatal, they 
 are serious on account of the vulnerability of system they induce. They are 
 prone to recur. They are apt to interfere with normal development, and to 
 entail subsequent debility of digestion, of nerve, or of the entire nutrition " 
 (Pepper). 
 
 Treatment. — The treatment of chronic gastric catarrh is in many instances 
 one of the most unsatisfactory that we can undertake. The disease is apt to 
 run a prolonged course and to have many relapses. The families in which we 
 meet our more severe cases are frequently those w T ho can only with much diffi- 
 culty be impressed with the importance of strict attention to the details of 
 treatment, and when we finally succeed in convincing the parents of the 
 necessity of our rules, we find that the children refuse to be controlled. 
 
 Our first step in each case must be to investigate carefully all the factors, 
 exciting and predisposing, tending to impair the functions of the stomach. 
 The character of food taken by the child must receive our most careful atten- 
 tion, and, making due allowance for the idiosyncrasies of digestion so 
 frequently met with among children, a systematically arranged dietary for the 
 week should be drawn up, and rigidly adhered to, in each case. Instructions 
 should be given that the attendant insist on proper mastication of the food. 
 Nervous children especially are very apt to bolt it. Should the teeth be so 
 defective as seriously to interfere with mastication, all food requiring it should 
 be minced before giving it to the child. The amount also should be carefully 
 regulated. I am convinced that many children accustomed to a richly-spread 
 table have a tendency to overfeed themselves. Dinner, the heaviest meal of 
 the day, should be taken about noon. The evening meal should be a light 
 one. The general hygiene of the child will also demand the most careful 
 attention if our efforts are to be successful. The child should live a quiet, 
 regular life ; it should retire early to bed, and its sleeping apartment should 
 be cool and airy. The morning bath should be of a stimulating character. 
 
GASTRIC CATARRH AND GASTRIC ULCER. 451 
 
 For these children I prefer the bath recommended by Wiederhofer. The 
 child on getting out of bed first receives a general rub down with a somewhat 
 rough towel. It then steps into the bath, which contains warm water to the 
 depth of three or four inches. It is afterward sponged down quickly with 
 cool salt water, of which half a gallon or more is to be emptied over the chest 
 and shoulders. When the sponging is finished, the child is then at once 
 wrapped in a large towel and is briskly dried and dressed. 
 
 Children suffering from chronic gastric disorder are easily fatigued, and 
 under the influence of excitement may readily over-tire themselves. This is 
 to be avoided. At the same time, regular moderate exercise in the open air 
 is to be insisted on. 
 
 There are several indications that should be considered in our administra- 
 tion of medicine : 
 
 1. The deficiency of gastric juice, which is generally met with in these chil- 
 dren, may sometimes with advantage be supplied by the administration shortly 
 after meals of hydrochloric acid with pepsin. In those cases where the tongue is 
 coated with a white creamy fur an alkali, such as sodium bicarbonate, given 
 shortly before the meal, appears to act as a sedative to the mucous membrane, 
 while at the same time it stimulates to more active secretion the cells elabo- 
 rating hydrochloric acid. 
 
 2. In almost all cases there is a deficient tone in the muscular coat of the 
 stomach which calls for the administration of one of the vegetable bitters. 
 My own preference is for nux vomica, in smaller or larger doses as the case 
 may require. Columbo, gentian, or quassia may also be employed, either in 
 the form of infusion or tincture. 
 
 3. In many cases, owing to the large amount of mucus, fermentation either 
 in the stomach or small bowel becomes a prominent feature, and the distention 
 thus induced may, if allowed to persist, lead to a more or less paretic condition 
 of their muscular walls. To relieve this aromatics may be added with advan- 
 tage to our remedies, but some reliance may also be placed on antiseptics. 
 Salol under these circumstances has, I think, given me very satisfactory 
 results. 
 
 Should diarrhoea supervene, a combination of bismuth and salol will prove 
 very serviceable. To relieve the colicky pains often complained of by these 
 children some anodyne may occasionally have to be employed. I have also 
 used with much benefit large enemata of warm water, as recommended by 
 Ashby. 
 
 In infants, and sometimes in older children, vomiting becomes occasionally 
 a troublesome feature, persisting in spite of treatment. Absolutely no food, 
 under these circumstances, should be given by the mouth, all extraneous 
 sources of irritation should be removed, and sedative enemata, containing 
 small doses of either opium or bromide with chloral hydrate, may be given twice 
 daily to subdue the nervous erethism. In these cases lavage of the stomach 
 has sometimes proved a successful therapeutic measure. Dr. Booker, after a 
 large experience in the Thomas-Wilson Sanitarium, says : "I believe stomach- 
 washing is of undoubted advantage in the treatment of the digestive disorders 
 of infancy. It has proved with me the quickest and most effective means for 
 the relief of the vomiting, which I found generally relieved after the first 
 washing ; in only one case was it found necessary to stop milk food. The 
 contra-indications to the use of the measure are heart disease and serious bron- 
 chitis or other pulmonary trouble. When the tube continues to excite vomit- 
 ing and strong resistance, it is doubtful if advantage follows its use. A feeble 
 condition of the infant does not necessarily contra-indicate the operation." In 
 
452 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 older children lavage is rendered extremely difficult, owing to their determined 
 resistance. Possibly results less efficient, but somewhat similar, may be obtained 
 by the administration of warm alkaline drinks on an empty stomach. A com- 
 bination of the potassio-tartrate of soda with a small amount of the bicarbon- 
 ate, dissolved in hot water, may be given early every morning, or equal parts 
 of Vichy and hot water may be taken once or twice daily. Sufficient time 
 should be allowed for this to pass out of the stomach before food is taken. 
 
 In cases associated with constipation a determined effort should be made to 
 secure a regular movement of the bowels once a day, with the least possible 
 amount of irritation to the gastric mucous membrane. Some preparation of 
 cascara may be given regularly at bed-time in doses sufficient to secure a daily 
 motion of fair consistence. The action of the medicine should be favored by 
 daily gentle massage of the large bowel, and by regularity in the time of solicit- 
 ing a movement. 
 
 In children suffering from chronic gastric disorder any sudden chill of the 
 surface should be prevented by the habitual use of a flannel binder over the 
 abdomen. The extremities should be efficiently covered ; the feet and ankles 
 especially should be always dry and warm. Although ferruginous tonics, if 
 symptoms of any acute exacerbation are present, may disagree, they may be 
 given to many of these children with advantageous results. 
 
 HI. Gastric Ulcer. 
 
 Gastric ulcer is a lesion affecting the mucous membrane of the stomach, 
 characterized by the formation of an ulcer of varying size and depth, and of 
 uncertain position on the gastric wall. The disease in childhood may be indi- 
 cated by symptoms similar to those met with in the adult — namely, epigastric 
 tenderness, pain increased by the ingestion of food, and h^ematemesis. Occa- 
 sionally the symptoms are very obscure, and a diagnosis is impossible until 
 an autopsy reveals the cause of death. It is an exceedingly rare affection in 
 childhood, and very few cases have been reported. 
 
 Etiology. — Gastric ulcer in children is generally associated with some con- 
 stitutional disorder, such as tuberculosis, struma, and anaemia. Pneumonia and 
 purpura hseinorrhagica are also mentioned as predisposing. Colgan reports 
 a case in a child of two years and a half, due apparently to chronic gastric 
 catarrh. Tuberculous ulcers are often multiple. 
 
 Symptoms. — According to Descroizelles, anorexia develops early and is 
 steadily progressive. Vomiting may come on, but sometimes nausea only is 
 complained of. Eructations and pain are frequently present, and the ingestion 
 of food is generally followed by an exacerbation of the suffering. In some 
 cases the symptoms are by no means distinctive. In one case reported the 
 physical signs simulated those of pericarditis ; in another, those of pneumo- 
 thorax. In the case related by Colgan a well-nourished child had been in 
 fair health up to the morning of the attack, when she complained of feeling 
 unwell. Toward the evening she was seized with convulsions. When seen by 
 Dr. Colgan her temperature was 106 ° ; the pulse 150, rather full and tense ; 
 and the breathing stertorous. The convulsions were general, and there had 
 been involuntary evacuations from both bladder and rectum. The convulsions 
 were temporarily controlled, and consciousness, which had been lost from the 
 beginning of the attack, was beginning to return, when a second attack 
 occurred and terminated fatally. At the autopsy a perforating ulcer was found, 
 with consequent peritonitis. The gastric mucous membrane was in a chronic 
 catarrhal condition. 
 
GASTRIC CATARRH AND GASTRIC ULCER. 453 
 
 Gastric ulcer, dependent upon emboli from thrombosis in the umbilical vein, 
 is said to be a frequent cause of haemorrhage in the new-born. 
 
 Prognosis is very unfavorable. 
 
 Treatment. — The treatment, too, is generally unsatisfactory. If a diag- 
 nosis be made, the child should be confined to bed, and, if possible, it should for 
 some days be fed only by the rectum with artificially digested food. After- 
 wards, a gradual return should be made to milk or bland starchy food, given in 
 small quantities and frequently repeated. Of drugs, nitrate of silver in small 
 repeated doses is probably one of the most satisfactory. Small doses of opium 
 should be given to relieve pain. Gentle, soothing applications may be made 
 over the epigastrium. If vomiting occur, bismuth is indicated. 
 
 Gastro-malacia. 
 
 This term is applied to the softened, and sometimes ulcerated, condition of 
 the stomach occasionally found after death in children. It is dependent upon 
 the action of the gastric juice, which may happen to be present in the stomach 
 at the time of death, upon the walls of the stomach itself, now dead and unpro- 
 tected. Goodhart believes that an action may commence just prior to death, 
 owing to a very defective circulation insufficiently protecting the tissues. Even 
 if such be the case, it is the result of ebbing life, not a disease causing death, 
 and as such it calls for no further remark. 
 
MUCOUS DISEASE. 
 
 By WILLIAM A. EDWARDS, M. D., 
 
 San Diego. 
 
 The fact that many different names and many etiological factors have been 
 advanced to designate the train of symptoms and explain the pathology of 
 the disease under consideration, serves to show that as yet there is not an entire 
 consensus of opinion as to the proper classification of this condition. 
 
 Space forbids a complete recapitulation of the host of synonyms under 
 which this disease appears in medical writings. We cite but a few : Chronic 
 gastro-intestinal catarrh ; Intestinal desquamative catarrh ; Mucous disease ; 
 Chronic muco-colitis ; Chronic croup of the intestines ; Chronic follicular inflam- 
 mation of the intestinal mucous membrane ; Chronic pseudo-membranous gastro- 
 enteritis ; Mucous or Gelatinous diarrhoea ; Mucous casts. 
 
 The term membranous enteritis has recently become somewhat restricted to 
 a particular form of intestinal disorder characterized by irregularly recurring 
 paroxysms of abdominal pain, unaccompanied by fever and relieved by the 
 passage of membranous shreds or tubes, which for the most part are composed 
 of mucin. 
 
 The present chapter will be restricted to a consideration of mucous disease 
 as described by Eustace Smith of London, who defines it as an increased 
 secretion of mucus from the whole internal surface of the alimentary canal : it 
 is a mucous flux which interferes mechanically with digestion and absorption 
 of the food, and by its influence in impeding general nutrition often excites 
 suspicion of the existence of tubercle. This disease, unlike its analogue, 
 membranous enteritis, is a very frequent condition among children, in whom it 
 is most usually met with between the ages of three and twelve years. 
 
 Etiology. — The infectious diseases, particularly measles and scarlatina, but 
 above all pertussis, may be followed by mucous disease — indeed Smith considers 
 that pertussis, of all others, is the one to which this derangement can com- 
 monly be traced. It must not be forgotten that the mucous membrane of the 
 alimentary canal in the child is naturally very active, and that the healthy 
 stool in the young infant contains a large proportion of mucus ; so that we can 
 readily understand that if the child be habitually fed on indigestible food, 
 thus presenting a constant source of intestinal irritation, the normal mucus 
 may appear in abnormal amounts. 
 
 We must also remember that the stool of the healthy infant contains many 
 bacteria and micrococci. Osier says that the most important are the bacterium 
 lactis aerogenes and the bacterium coli commune. 
 
 In diarrhoeal conditions the number is greatly increased. Booker has 
 isolated forty varieties, and his conclusions are, that in the diarrhoea of infants 
 not one specific kind, but many different kinds, of bacteria are concerned, and 
 that their action is manifest more in the alteration of the food and intestinal 
 
 454 
 
* ft 
 
MUCOUS DISEASE. 455 
 
 contents and in the production of injurious products, than in a direct irritation 
 upon the intestinal wall. So that from the authority of this careful observer, 
 together with that of Jeffries and Baginsky, we may conclude that mucous 
 disease is not bacterial in origin and does not arise from the presence of a 
 specific micro-organism. 
 
 We, however, must state that Cornil considers that the peculiarities in all 
 forms of membranous enteritis, mucous disease, and the like are not owing to 
 different anatomical lesions, but to the difference in the nature of the micro- 
 organisms : Jie considers that all forms are due to special micro-organisms intro- 
 duced with the food. 
 
 Heredity does not merit consideration among the etiological factors, nor does 
 climate, as the disease is seen in all countries and in all climes : it is perhaps 
 more frequent in England than elsewhere, although this may be due to the fact 
 that English observers have more carefully recorded their observations. It is 
 usually seen in association with other diseases of the intestinal tract : an ante- 
 cedent dyspepsia or a diarrhoea alternating with constipation is frequently 
 noted before mucous disease becomes firmly established. 
 
 Day agrees with Meigs and Pepper that whether diarrhoea be caused by 
 improper food, summer heat, dentition, or epidemic influences, the complaint, if 
 it becomes chronic, is apt to terminate in mucous disease. It has been observed 
 in children to follow typhoid fever, enteralgia, haemorrhoids, and intestinal 
 tuberculosis. 
 
 We ourselves have always accepted the statement of DaCosta that the 
 disease wa"s a manifestation of disordered nervous supply, which may be either 
 general or local, and that the nerves presiding over nutrition and secretion are 
 primarily at fault. 
 
 Wales is of the opinion that the primary seat of the disorder is in the gan- 
 glionic nerves of the intestines. 
 
 Certain it is that all of our cases presented marked evidences of deranged 
 nervous action, and we agree with Goodhart, who considers the class of diseases 
 that are the subject of this article under the title of "abdominal neuroses," 
 and further states that he "is persuaded that although they may seem to be 
 caused by temporary conditions — such as errors in diet — these varying pains 
 and aches are often but the expression of a constitutional build. They are an 
 evidence of nervous instability, and they are found in nervous children or in 
 nervous families." In this observer's experience the children who are the sub- 
 jects of mucous disease are the offspring of those whose nervous systems are 
 feeble or diseased, or who are closely related to, or have themselves been, the 
 subjects of fits, insanity, hysteria, neuralgia, rheumatism, or gout; or if not, 
 have in themselves given other evidence of unstable nerves in the convulsions 
 of infancy, passionateness, morbid timidity, chorea, or rheumatism. 
 
 Louis Starr, the American editor of Goodhart's book, favors the views of 
 Eustace Smith. 
 
 Symptoms. — In the more chronic cases of mucous disease there is an 
 almost constant sequence of symptoms. A coated, angemic, flabby, and fissured 
 tongue is usually observed, with aphthous ulcers of the mouth and tonsillar 
 derangements. 
 
 Smith considers the appearance of the tongue to be absolutely characteristic : 
 it appears to him as if brushed over with a solution of gum ; this slimy look 
 may be generally limited to a small spot in the centre of the dorsum. In my 
 experience the whole tongue is more apt to be clean, stripped of epithelium, 
 glazed or glossy. See accompanying Plate (XII). 
 
 All the stools do not contain mucus, but its passage may be paroxysmal, or 
 
456 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 there may be an accumulation of mucus, and the discharges for several days 
 may be made up almost entirely of this substance, or a great mass may be 
 passed at a single stool ; constipation may exist or this condition may alternate 
 with diarrhoea. The patient may have only one mucous stool a day, or, as I 
 have seen them, twelve to fifteen in twenty-four hours ; after an attack of this 
 kind the discharges are usually free from mucus for several days, or even for 
 weeks, and the child apparently improves for a time, but only to suffer another 
 exacerbation in a shorter or longer period. A simple enema or a mild aperient 
 usually brings away large quantities of clear mucus or mucus stained by faeces. 
 These children rarely pass a normal faecal evacuation : the faeces are apt to be 
 soft, mushy, light-colored, and mixed with or coated over by mucus. The stools 
 occasionally contain worms. 
 
 Some cases present certain premonitory symptoms before one of these large 
 discharges of mucus occurs, as chilliness, blueness of the nails, tingling or pain 
 at the finger-tips, dyspeptic symptoms, and a sense of uneasiness usually referred 
 to the umbilical region. Smith has also observed that a most frequent seat of 
 pain is over the left hypochondrium, and explains this by calling attention to 
 the fact that at this point the colon makes a very abrupt turn, and the angle 
 thus formed presents a site for the accumulation of flatus. 
 
 During an acute attack the former sense of uneasiness may become true 
 pain ; in some instances it is most severe ; tenderness may extend over the 
 entire abdomen, or it may be localized and developed only by firm pressure. 
 Nausea or vomiting, in my experience, does not often occur, although it is 
 mentioned by some writers. 
 
 The breath is usually most unpleasant, heavy and fetid ; the tonsils are apt 
 to be diseased, and no doubt contribute their share to this unpleasant odor. 
 
 The temperature is rarely above normal except perhaps at the height of a 
 painful paroxysm ; indeed an abnormal temperature would lead one to suspect 
 some other and more serious condition, as phthisis. The surface temperature to 
 the touch seems to be below normal, although the thermometer will probably 
 not so record it. 
 
 The nervous system is early affected, and presents many evidences of 
 derangement ; hysteria in some of its many forms may exist, and night-terror 
 with its peculiar concomitants, nocturnal incontinence of urine, somnambulism 
 or the insomnia of gastro-intestinal origin, irregular muscular tremors, paresis, 
 hysterical tetanus, neuralgia, hyperaesthesia, anaesthesia, convulsions, syncope, 
 and stammering, have all been observed. Tinnitus aurium, transient defects 
 in vision, as squinting, a disordered sense of taste, haemorrhoids, prolapse of 
 the rectum, and anal fissure have also been noted. The child's nature seems 
 to have undergone a radical change: he is irritable and exacting; he suffers 
 from mental depression, faulty memory, and hypochondriasis. In the older 
 child melancholia may be noted. 
 
 Furuncles or carbuncles may arise, and sore mouth or herpes of the genitals 
 are not unusual. 
 
 The appetite is at first increased, then becomes capricious, and finally almost 
 complete anorexia exists ; food produces distress by flatulent distention of 
 the bowels, and it is only by the exercise of good tact that the little patient can 
 be induced to eat at all. This, however, is not true of all cases : some children 
 maintain their appetite throughout the disease, but, notwithstanding the enor- 
 mous quantity of food consumed, the emaciation is extreme. The skin may 
 have the characteristic hue of anaemia or the sallow tint of jaundice; it may be 
 harsh, rough, and scaly. The urine is apt to be acid and to contain an excess 
 of urates. I have not observed that the lymphatic glands in the neck are pecu- 
 
3IUC0US DISEASE, 457 
 
 liarly liable to become enlarged on the slightest irritation, as stated by Smith, 
 who also adds that they do not, however, necessarily suppurate or remain per- 
 manently swollen; the enlargement, after persisting for a variable time, may 
 disappear completely. 
 
 It must be remembered that the little patient who is the subject of mucous 
 disease does not present a regular sequence of symptoms, so that it is a diffi- 
 cult matter to present a didactic picture of the derangement ; the symptoms 
 are as erratic as the child itself. As Goodhart aptly remarks, such children 
 are essentially angular in their moral nature and are an "odd lot." In this 
 connection attention may be called to a paper by Ayres {Med. News, vol. lix., 
 No. 1, 1891, p. 1) on chronic gastro-intestinal catarrh in relation to the etiology 
 of some cases of insanity. 
 
 Microscopic Appearance of Matters Passed. — They are very similar 
 to the masses passed in cases of membranous enteritis, and are made up of 
 opaque white solid masses, moulded or flattened, and small flocculent pieces of 
 semi-translucent membrane. The tubes, branching membranes, casts, and fine 
 network membranes are not seen in mucous disease. The description I have 
 elsewhere given of membranous enteritis (in Keating's Cyclopaedia, vol. iii. 
 p. 166) also applies to the mucous masses voided in chronic gastro-intestinal 
 catarrh. 
 
 Under a low-power objective the masses are seen to be due to the formation 
 of mucous and epithelial matter (the cells having undergone fatty degeneration), 
 and granular debris. H. B. Hare states that these matters are similar in 
 chemical reaction to pharyngeal mucus, that they may possibly contain a trace 
 of albumin, but no fibrin. Their surface may be seen to be composed of opaque 
 and translucent parts ; the former appear as rounded ridges marking off the 
 latter into regularly arranged hexagonal or polygonal crypts. 
 
 Clark has observed that the product of diseased action on mucous mem- 
 branes occurs in three varieties : first, clear, jellylike, and imperfectly mem- 
 branous ; second, yellowish, semi-opaque, flaky, and usually membranous ; 
 third, yellowish-white, dense, opaque, distinctly membranous, tough, and rather 
 adherent to the subjacent surface. 
 
 Morbid Anatomy. — The morbid anatomy of the disease seems to be a 
 thickening of the intestinal mucous membrane ; there may be evidences of 
 ulceration or enlargement of the glandular follicles of the colon or small intes- 
 tine, the sigmoid flexure, and the descending colon, together with the lower part 
 of the ileum. 
 
 Diagnosis. — As I have elsewhere remarked, if mistakes arise in the diag- 
 nosis of the affection, they are in all probability due to the carelessness of the 
 observer rather than to any obscurity in the manifestations of the usual clinical 
 phenonema of the disease. 
 
 The mucous masses may resemble and have been mistaken for ascaris lum- 
 bricoides; indeed, the parasite may be present in the discharges, as it finds in the 
 mucus-loaded intestine a peculiarly acceptable habitat. The white, shining, 
 detached pieces have been mistaken for segments of the various tape-worms, 
 taenia mediocanellata, taenia solium, and bothriocephalus latus. 
 
 The lienteric discharges of dysentery have also been erroneously considered 
 as illustrations of this disease; in scarlatina and tubercular disease mucous 
 deposits are sometimes passed per anum. 
 
 The disease, however, of all others, with which we are apt to confound 
 mucous disease is general or pulmonary tuberculosis : here it is that a carefully 
 recorded series of temperature records is invaluable. In tuberculosis we find 
 a continued elevation of temperature, while in mucous disease the temperature is 
 
458 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 usually normal ; at all events, it is only elevated during the height of a paroxysm, 
 remaining high for two or three days and returning quickly to the normal. 
 
 Smith makes the statement that in some cases the temperature rises and 
 remains elevated, perhaps permanently, although the symptoms in other respects 
 correspond to those of mucous disease. I have never met such cases. He con- 
 siders that these subjects are peculiarly prone to pneumonia, and that the deposit, 
 only partially absorbed, undergoes cheesy transformation and forms the so-called 
 pneumonic phthisis. Under these conditions I must confess that the differen- 
 tial diagnosis between mucous disease, pneumonic phthisis, and tuberculosis 
 would indeed be a difficult problem to solve. 
 
 Prognosis. — Most cases run a prolonged and tedious course, with many 
 recurrent attacks and exacerbations, extending sometimes into adult life. Abso- 
 lute recovery rarely occurs. 
 
 Treatment. — The child that is the subject of mucous disease must submit 
 to a constant supervision of its daily life. Its diet, regimen, and personal 
 hygiene are of vital importance. The little patient must have a daily bath, 
 first with castile soap and warm water, then a general sponging with alcohol, 
 followed by an inunction of olive oil. In this way the peculiarly harsh, dry, 
 and scaly skin can be restored to its normal function as one of the excreting 
 organs of the body. 
 
 The diet always merits the most painstaking care ; indeed, without a correct 
 and suitable diet all other methods of treatment will inevitably fail. All sources 
 of irritation are to be removed; easily-digested or even pre-digested food should 
 be supplied, and the medical attendant should satisfy himself that undigested 
 particles of food are not irritating the alimentary canal. 
 
 The following diet-table is taken from Eustace Smith (fifth edition, 1888), 
 and is applicable to a child of seven years of age and upward : 
 
 Breakfast, 8 A. M. Three-quarters of a pint of fresh milk alkalinized by 
 twenty drops of the saccharated solution of lime; a thin slice of well-toasted 
 bread; fresh butter; a fresh egg lightly boiled or poached. 
 
 Dinner, noon. A mutton chop without fat, broiled ; well-boiled cauliflower 
 or French beans, according to season ; a thin slice of well-toasted bread ; half 
 to one wineglassful of sound sherry, diluted with twice its bulk of water. 
 
 Tea, J/, P. M. Same as breakfast. 
 
 Sniper, 7 P.M. A breakfast-cupful of beef-tea (a pound to the pint); 
 a thin slice of dry toast. 
 
 Or we can adopt a diet-table that I suggested in a lecture before the Univer- 
 sity Training-School for Nurses, which is that of the North-eastern Hospital 
 for Children, London: 
 
 Breakfast, 
 
 Dinner, 12 M. 
 
 Tea, 3.30 p. m. 
 
 Supper, 6 p. m. 
 
 Milk Diet. 
 
 Milk, y, pint ; bread, 
 ounces, with butter. 
 
 Fish Diet. 
 
 Full Diet. 
 
 2'Milk or cocoa, y pint; Milk or cocoa, y pint; bread, 
 j bread, 2y ounces, with 2y ounces, with" butter.- 
 butter. 
 Milk, y pint; rice or other Fish, boiled, 2% ounces ; Roast, boiled, or minced mut- 
 
 milk pudding. 
 
 Milk, y pint; bread, 2 
 ounces, with butter. 
 
 Biscuit (cracker) or slice 
 of bread and butter. 
 
 I potatoes, mashed, 3 ton, or roast or minced beef, 
 ounces; bread, 1 ounce;; 2 l y ounces; mashed potatoes, 
 milk pudding. I 4 ounces, to alternate with 
 
 green vegetables; bread, 1 
 ounce; milk pudding. 
 Bread, 2% ounces, with butter, 
 treacle, or dripping; milk, y 
 pint. 
 Bread, 2 ounces, with butter, or 
 cracker. 
 
 Milk, 
 
 pint ; bread, 2% 
 
 ounces, with treacle or 
 butter. 
 Bread, 2 ounces, with but- 
 ter, or cracker. 
 
 In the more serious forms Jacobi adheres to a very strict diet. He says : " No 
 
3IUC0US DISEASE. 459 
 
 raw milk, no boiled milk, no milk at all in any mixture, in bad cases." In 
 the very worst cases total abstinence is recommended by this writer for from 
 one to six hours ; afterward the following combination is allowed : Five ounces 
 of barley-water, one to two drachms of brandy or whiskey, the white of one 
 egg, salt, and cane-sugar ; a teaspoonful every five or fifteen minutes, accord- 
 ing to age or case. 
 
 Jacobi in his terse way remarks: "That never are the common sense and 
 tact of the intelligent practitioner more thoroughly taxed; no printed rule ever 
 supplies or substitutes brains." 
 
 If the appetite be capricious, these strict dietetic rules cannot of course be 
 adhered to ; we must then endeavor to supply such a variety as will tempt the 
 appetite and check the tissue waste. If the stools show a mass of milk curds, 
 milk must be diluted, predigested, or altogether prohibited. 
 
 The various preparations of predigested food may now be resorted to : milk, 
 milk-gruel, milk-punch, effervescing milk-punch, beef-tea, and oysters may all 
 be prepared in this manner. Raw beef-juice, beef-tea, consomme, chicken, 
 mutton, or veal broth are preparations upon which we may often place absolute 
 dependence. Farinacea as a rule must be excluded, although we occasionally 
 have to allow a little rice pudding, tapioca, or flour-ball by way of a variety. 
 It is somewhat odd to note in this connection that Burnet in his valuable little 
 book on Foods and Dietaries recommends the farinaceous substances as a suit- 
 able diet in mucous diarrhoea. 
 
 Alcohol is not by any means contraindicated, and may be administered as 
 wine-whey or a combination of milk, egg and brandy. English writers advise 
 well-diluted light sherry or light claret. 
 
 Among medicinal agents many and varied plans of treatment have been 
 suggested. Recently much attention has been paid to intestinal antisepsis, but 
 it is interesting to note that so recent and reliable a writer as Osier, in his 
 Practice of Medicine, considers that " we are still without a reliable intes- 
 tinal antiseptic. Neither naphthaline, salol, resorcin, salicylates, nor mercury 
 meets the indications." 
 
 This has not been our clinical experience, nor indeed has it been that of the 
 general practitioner. 
 
 Dujardin-Beaumetz recommends the following formula as a satisfactory 
 intestinal antiseptic : 
 
 ty. Salol 
 
 Bismuthi salicylatis 
 
 Sodii bicarbonatis da gr. cl. 
 
 Sig. Divide in capsul. No. xxx. One capsule before breakfast and before 
 dinner. 
 
 Droixhe considers salol as a remedy easily administered and without toxic 
 action, and ranks it among the approved intestinal antiseptics. 
 Carreras suggests resorcin in the following formula : 
 
 Jfy. Resorcin gr. ij-vij. 
 
 Syr. aurantii f^j. 
 
 Aq. citronellae q. s. ad fsiv. — M. 
 
 Sig. Three teaspoonfuls every three hours. 
 
 The same author suggests that when the child is fed exclusively upon 
 
460 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 milk the dejecta may be very acid ; in this case some such mixture should be 
 given as — 
 
 1^. Bismuth, phosphat. aut subnitrat gr. xxx. 
 
 Sodii bicarbonat gr. xv. 
 
 Pepsinse gr. vij. 
 
 Pulv. ipecac, comp gr. j-iv. — M. 
 
 Divide in chart. No. iij. 
 Sig. One every hour or two. 
 
 Creolin has been recommended in the following combination : 
 
 fy, Creolin Hlviij- 
 
 Sacchari gr. lxxv. — M. 
 
 Divide in chart. No. x. 
 Sig. One every two or three hours. 
 
 0r > 
 
 1^. Creolin gtt. i-ij. 
 
 Syrupi Oj- 
 
 Aq. menthse piperit f^ij. — M. 
 
 Sig. Teaspoonful every two hours. 
 
 Schwinz also endorses creolin. 
 
 Naphthaline may be given to young children in doses of ten centigrammes 
 every two hours. Pure naphthaline never causes accidents even when used in 
 large doses. It may be given per rectum in a mucilaginous mixture which 
 will hold it in suspension but not dissolve it. Bouchard thinks naphthol is 
 superior in its action to naphthaline. 
 
 Constipation may exist sometimes to a stubborn degree : mild saline laxa- 
 tives may be exhibited, or a simple enema may occasionally be administered, 
 and will usually cause the expulsion of large masses of mucus. 
 
 Irrigation of the stomach is generally agreed upon by all writers to be a 
 most efficacious method of dealing with the more chronic examples of the 
 disease. Osier speaks of it in the warmest terms in cases of the most obstinate 
 gastro-intestinal catarrh in children. This method must be combined with the 
 irrigation of the large bowel. The last-quoted authority states that a pint will 
 thoroughly irrigate the colon of a child aged six months, and a quart that of a 
 child of two years. When the temperature is high, ice-cold water may be used 
 for this purpose. 
 
 Booker has had a large experience in stomach-washing. His apparatus is 
 the one proposed by Epstein. A soft Nekton's catheter, No. 8, 9, or 10, is 
 attached by a short glass tube to a common rubber tube two feet long, with a 
 2 ounce (62 grammes) glass funnel fitted into the distal end ; a pitcher contain- 
 ing a half-gallon (2 litres) of tepid water is placed in a convenient position. 
 
 It is only within a short time that the plan of washing out the stomach, 
 which was inaugurated by Kussmaul for diseases of that organ in adults, has 
 been applied to children. The difficulties connected with its application are 
 few, and the dangers, even for the youngest and weakest infants, easily avoided. 
 Kussmaul's apparatus for irrigating the stomach consists merely of a'Ne'laton's 
 catheter, a long rubber tube, and a funnel, and this simple apparatus will 
 accomplish all that is necessary. Escherich's apparatus has greater advantages, 
 however, and is preferred. The time required for irrigation of the stomach is 
 
MUCOUS DISEASE. 461 
 
 usually four or five minutes, from half a litre to a litre and a half of water being 
 usually required before the return flow is clear. If there is gastric or intes- 
 tinal catarrh, a few drops of a 6 per cent, solution of benzoate of sodium and 
 a few drops of tincture of opium may be given hourly after each irrigation. 
 Irrigation is contraindicated only in very feeble children and when collapse is 
 impending. The same apparatus is also used for intestinal irrigation, except- 
 ing that a larger and stiffer catheter, with much larger lateral opening, is 
 employed. It may be introduced, if necessary, to a distance of 27 centi- 
 metres, and the entire large intestine washed out. 
 
 Ehring's experience in this method of treatment in 850 cases has been 
 rapid cure in 68.7 per cent, of cases, moderate success in 14.58, failure or 
 death in 16.73. This writer further considers that the indications for this 
 treatment exist in all cases of intestinal catarrh. Riemschneider reports the 
 results obtained in 140 cases by this method, and is favorably impressed with 
 the results obtained by washing out the stomach with Escherich's apparatus; he 
 follows the irrigation of plain water by an irrigation of a 3 per cent, solution 
 of benzoate of sodium. Of these cases a quickly favorable result was obtained 
 in 89, a slowly favorable one in 31 ; in 20 the result was fatal. 
 
 Seibert in treating 1404 cases of gastro-intestinal catarrh used stomach- 
 washing in 521 cases, and states that the results were most gratifying both in 
 stomach- and bowel-washing. 1 
 
 Von Ziemssen recommends cutaneous electrization of the stomach with very 
 large electrodes, for half an hour before meals. This treatment is supple- 
 mented by faradizing for a short time with the wire brush the skin of the 
 abdomen, cheek, and back. Massage of the stomach and intestines is also of 
 value, although of less importance than electricity. 
 
 Electrization of the intestines is accomplished with large electrodes, one 
 occupying the entire abdominal surface, the other the entire dorsal surface ; and 
 the electricity must be of increased intensity, owing to the great size of the 
 electrodes. The subjective results of this treatment are increased appetite 
 and loss of abnormal abdominal sensations. 
 
 When the excretion of mucus is excessive the alkalies will assist materially 
 in arresting its secretion : we usually select the bicarbonate of sodium ; this may 
 be combined with twenty-drop doses of tincture of myrrh, as suggested by 
 Smith, or the powdered myrrh which Maxson speaks so highly of, given in 
 divided doses of from 9 to 12 grains a day, either in capsules or with mucil- 
 age of acacia, glycerin, and liquorice. Podophyllin and aloes are much lauded 
 
 1 Dr. W. Soltau Fenwick cites the dangers of washing out the stomach : 1. Convulsions and 
 tetany. Probably because, in a case predisposed to convulsive seizures by the chronic absorption 
 of certain morbid products from the dilated stomach, the irritation of a gastric tube may con- 
 stitute an efficient exciting cause. 2. Syncope and sudden death. Any sudden alteration in the 
 gastric pressure can, in certain cases, bring about a reflex condition of shock. 3. Perforation. 
 The using of a gastric catheter for the purpose of investigating the chemical contents of the 
 stomach in cases of acute gastric ulcer is a useless and mischievous procedure. 4. Haemorrhage. 
 Danger may arise from a too rapid evacuation of the contents of a dilated stomach. 5. Injury 
 to the oesophagus or to the walls of the stomach. 6. Poisoning. From the use of antiseptics 
 through the tube. Cases are cited illustrating each division. He concludes that the stomach 
 is washed out for all sorts of symptoms, some of which are manifestly not to be benefited by 
 this procedure. And in cases in which it fails to do good it is likely to be productive of harm 
 in removing products of digestion whose manufacture has caused the stomach a considerable 
 amount of labor. The indiscriminate use of this method in every case of disordered digestion 
 will prove to be a curse rather than a benefit, and will eventually throw discredit upon the 
 whole method of treatment. 
 
 Booker says stomach-washing is contraindicated in children affected with heart disease, 
 serious bronchitis, or pulmonary trouble. If the tube continues to excite vomiting and strong 
 resistance, it is doubtful if advantage follows its use. 
 
462 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 by the English writers ; our preference has been for some of the milder laxatives. 
 We have obtained good results from the following combination : 
 
 Iji. Pulv. rhei 3j. 
 
 Magnesii carb 3iij. 
 
 Pulv. zingiber 3ss. 
 
 Elixir simp q. s. ad f^viij. — M. 
 
 S. Teaspoonful night and morning for child of five years. 
 
 Some cases do well upon the acids, nitric, hydrochloric, or nitro-muriatic. 
 Strychnine, ipecacuanha, and gentian in pill is sometimes a happy com- 
 bination. 
 
 Belladonna, Dover's powder, quinine, subnitrate and subcarbonate of 
 bismuth have all been suggested. Quinine may be given in two-grain sup- 
 positories combined with a sixth of a grain of opium, as suggested by J. C. 
 Wilson. 
 
 When the gastro-intestinal tract is in condition to receive it, iron becomes 
 a valuable adjunct: we select either the tincture of the chloride combined with 
 nux vomica and dilute phosphoric acid, or the dried sulphate of iron with aro- 
 matic syrup of rhubarb. Arsenic, copaiba, bromide of potassium, turpentine, 
 cod-liver oil, oxide or nitrate of silver by mouth or by high injection into the 
 bowel, chloride of ammonium, sulphate of zinc, bichloride of mercury, chlorate 
 of potassium, oxide of zinc, blisters, nux vomica, ergot, are among the drugs 
 recommended by various writers. Gold has been suggested as follows : 
 
 3^. Auri 20 grammes. 
 
 Mellis 125 grammes. — M. 
 
 Sig. One coffeespoonful in the morning and two in the afternoon. 
 
 Antiquedad states that hydrotherapy, sulphate of quinine, chlorate of 
 potassium, and revulsion are the means which will be found -most efficient in 
 the treatment of intestinal catarrh in children. 
 
 It is quite useless to order cod-liver oil while the alimentary canal is covered 
 with mucus ; when we have modified the mucous discharges, oil then becomes 
 a valuable drug. These children, however, cannot assimilate large doses. 
 
 Much is to be gained by a residence in a suitable climate. We can for- 
 mulate no rules, however, as to the locality to be chosen ; each case is a rule unto 
 itself. My practice has been to leave the matter of selection of a climate to 
 a great extent to the patients themselves, with, however, a promise that the local- 
 ity must be such as to permit of an almost constant out-door life, the greatest 
 number of clear sunny days, and the least variability of thermometric range. 
 It must also be understood that the patient will spend several years at the 
 place of selection. 
 
DIARRHEAL DISEASES. 
 
 By VICTOR C. VAUGHAN, M. D., 
 
 Ann Arbok. 
 
 There are many difficulties in the way of a satisfactory classification of the 
 diarrhceal affections of infancy. The gravest symptoms in the most speedily 
 fatal cases are often accompanied by the most superficial lesions ; while, on the 
 other hand, symptoms so mild that no anxiety is awakened may result from 
 marked and extensive pathological changes. Cases which are apparently iden- 
 tical clinically often reveal diverse lesions. It is therefore apparent that the 
 pathological alterations do not form a suitable basis of classification. The 
 variations from the normal condition found after death are dependent more 
 upon the length of the continuance of the diarrhoea than upon the primary 
 exciting causes. The majority of cases of infantile diarrhoea which continue 
 for four days or longer might be designated, in a classification founded upon 
 morbid anatomy, as entero-colitis, and, moreover, the extent of the inflam- 
 matory changes is measured largely by the duration of the diarrhoea. In 
 cases terminating fatally within four days, in previously healthy children, even 
 the superficial epithelium may be normal, while in other of these cases 
 there may be some desquamation of this layer. The cases which terminate 
 fatally after from seven to ten days usually show more marked inflammatory 
 changes. The mucous membrane is swollen, the villi are prominent and pur- 
 plish, and the solitary and agminated follicles are congested and projecting. 
 In more protracted cases the inflammatory process involves the deeper layers, 
 and ulcerations in every degree, from the most superficial to those extending 
 down to the muscular coat, may appear. 
 
 It would be as unscientific to attempt a classification of the diarrhoeas of 
 infancy founded upon pathological anatomy as it would be to designate acute, 
 subacute, and chronic arsenical poisoning as desquamative, catarrhal, and 
 ulcerative gastro-enteritis. 
 
 Having thus discarded all classifications founded upon morbid anatomy, 
 what shall we select as a basis for the differentiation of the various forms of 
 diarrhoea in infancy ? The fundamental object in any classification must be to 
 enable the physician to treat his patient most successfully. The giving of 
 names to diseased conditions enables us to group, systematize, and most 
 advantageously use the information which we may possess, or may in the 
 future acquire, concerning the etiology, symptomatology, and treatment. Cer- 
 tainly in the class of diseased conditions now under consideration a classi- 
 fication founded upon etiological factors will be of greatest service in treat- 
 ment. But the question which arises here is this : Do we at present know 
 enough of the causes of these diseases to attempt a classification based upon 
 etiology ? In answer to this I reply that, while there is yet much to learn 
 on this point, I propose to offer a provisional classification founded upon what 
 I believe to be the most important factors in the causation of the diarrhoeas 
 
 463 
 
464 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of infancy, because I believe that such a classification, imperfect as it must at 
 present be, will be of greater service to the practitioner than one based upon 
 the morbid anatomy, which, as we have seen, is determined more largely by the 
 duration of the diarrhoea than by the nature of the exciting cause. 
 
 In attempting this classification we have the following facts to aid us: (1) 
 Some of these diarrhoeas are independent of seasonal influence. They occur 
 as frequently in winter as in summer, while the prevalence of other forms is so 
 plainly limited to the hot season that they are now quite universally designated 
 as u summer diarrhoeas." (2) Those which are apparently independent of sea- 
 sonal influence do not differ from similar diseases in adult life, save in the 
 greater susceptibility of the infant and in the greater delicacy of its organiza- 
 tion, thus rendering the disease of more serious import in the child than in the 
 adult. On the other hand, the so-called "summer diarrhoeas" are so generally 
 limited to the first two or three years of life that they may be regarded as 
 peculiar to that age. 
 
 Improper or excessive feeding, acting upon the delicate organization of the 
 child's digestive apparatus, may cause diarrhoea even when there are no toxi- 
 cogenic micro-organisms present. A small quantity of some indigestible sub- 
 stance in the intestines may increase the peristaltic movements and lead to 
 frequent stools. Taube and Escherich have shown that in the young child 
 stomachic digestion is of less importance than intestinal digestion, and that the 
 stomach is more of a receptacle into which the milk is received for coagulation 
 than a digestive organ ; thus we have the most favorable conditions for the 
 growth and activity of the bacteria which are introduced with the food. The 
 same investigators find that the younger the child the less active is digestion 
 in the stomach, and that in this organ the milk is coagulated and passed through 
 the pylorus undigested. Hammarsten has shown that this is the case in pup- 
 pies and young rabbits, and Hofmeister and Tappeiner showed that the stomach 
 does not absorb soluble substances as rapidly as does the mucous membrane of 
 the small intestines. Zweifel states — and in this he is supported by Hammar- 
 sten — that the proteolytic activity of the pancreatic juice is relatively well 
 developed in the new-born. The absorption of fats is dependent upon the 
 pancreatic juice and the bile, and the teaching of Frerichs, that the milk- 
 sugar is absorbed from the stomach, is now known to be erroneous. This 
 constituent of milk, as has been shown by Dastre, is digested by a ferment 
 found in the mucus of the small intestine. These experiments convince us 
 that the digestion of milk by the infant is nearly, if not quite, altogether accom- 
 plished in the small intestine, and explain why indigestion in the infant induces 
 diarrhoea. 
 
 The diarrhoea which results from temporary indigestion will be described 
 under the title of Acute Intestinal Indigestion. 
 
 The continued ingestion of material indigestible in character will produce 
 inflammatory processes leading to pathological lesions, and this condition will 
 be considered in this paper under the head of Chronic Intestinal Indigestion. 
 
 It must now be admitted that the so-called "summer diarrhoeas" of infancy 
 are due to the growth and multiplication of bacteria and the formation of 
 chemical poisoas by these low forms of vegetable life. Since these harmful 
 organisms are, in the great majority of cases, taken into the body in the milk 
 which constitutes the sole or chief food of the infant, I will describe the symp- 
 toms and lesions due to these causes under the title of Milk Infection, and this 
 will be subdivided, according to the severity and duration of the symptoms, 
 into Acute and Subacute Milk Infection. 
 
 I would prefer the term " milk -poisoning " for the last two of these forms 
 
DIABBHCEAL DISEASES. 465 
 
 of diarrhoea, but, bearing in mind the fact that "milk-poisoning" has long 
 been used to cover another affection, I have been debarred from using it. 
 There are, moreover, certain advantages in the adoption of the words "milk 
 infection." These bring out more prominently the part played by bacteria in 
 the causation. I wish to positively deny that I have been led to drop the old 
 nomenclature and adopt a new one for the sake of introducing a novelty. I 
 believe that the advance in our knowledge of the causation of these diarrhoeas 
 justifies the change, and that the use of the terms here suggested will, in the 
 first place, give the physician a better idea of the cause and nature of the 
 trouble with which he is dealing, and, secondly, it will tend to make parents 
 more attentive to the character of the food supplied their children. 
 
 This simple classification will, as a whole, I believe, be of most service to 
 the practitioner, and the object of this paper is to aid the physician in treat- 
 ment, and not to instruct the pathologist in morbid anatomy. It must not be 
 supposed, however, that the writer believes that this classification is perfect, 
 or that a diarrhoea originating in one of the above-mentioned causes may not 
 be influenced by other etiological factors. A child with a simple irritative 
 diarrhoea is by no means immune to milk infection, and every physician knows 
 that the intestines of an improperly-fed child furnish the best-known culture- 
 tubes for the growth of certain harmful bacteria. For these reasons the prog- 
 nosis in a case of intestinal indigestion will be influenced by the greater or less 
 probability of there being engrafted upon this abnormal condition the more 
 serious element of bacterial poisoning. 
 
 Acute Intestinal Indigestion. 
 
 Synonyms. — Simple diarrhoea ; Irritative diarrhoea ; Mechanical diarrhoea. 
 
 The number of cases of this disease is large, but, unfortunately, the physi- 
 cian is not frequently consulted concerning them until they have become 
 chronic or until the supervention of bacterial poisoning renders the symptoms 
 more grave and excites alarm. The idea that frequent stools are beneficial 
 during teething has led to neglect of these cases, and has been an important 
 factor in increasing infantile mortality. The prompt recognition and treat- 
 ment of acute intestinal indigestion are most valuable prophylactic measures 
 against the more serious intestinal disorders. Measured by the good which 
 can be accomplished by proper treatment, this disease is second to none of the 
 diarrhceal affections in importance. 
 
 Etiology. — Excessive feeding is a frequent cause of intestinal indigestion. 
 Children fed artificially are more likely to be overfed than those nursing from 
 the breast, for two reasons : In the first place, the supply is not so easily 
 exhausted, and, in the second place, the child obtains the food more easily ; 
 indeed, the milk is often poured into the child's stomach ad nauseam. To 
 these might be added the fact that the child is often given the nursing-bottle 
 when the busy mother would not stop to nurse it herself. Again the svstem 
 needs so much water, and too many mothers and nurses seem to be wholly 
 ignorant of the fact that a babe might relish a little water at times. The over- 
 loading of the stomach throws upon the digestive organs more work than they 
 can do, and the undigested portions act as foreign bodies. 
 
 Improper feeding is another fertile source of mischief. This is not the 
 place to discuss infant-feeding, and readers are referred to the special section 
 upon that subject. It may be remarked, however, that the custom of giving 
 the babe a taste of various things on the table is a pernicious one. The milk 
 of the healthy mother contains all the nourishment needed by the nursing 
 
 30 
 
466 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 infant, and should constitute its sole food at this period of life. But, unfor- 
 tunately, the mother is not always healthy, and she may on account of sick- 
 ness, excessive menstruation, or other causes be unable to supply the demand 
 either in proper quality or quantity. In these cases the knowledge of the 
 most intelligent physician is often found to be too limited. 
 
 The cause of the imperfect digestion may be in the child itself. It may 
 have tuberculosis or some other wasting disease, or the digestive organs may be 
 functionally incapacitated by some temporary ailment. The employment of 
 predigested food may be resorted to for the time, but its continued use is not 
 wise. The digestive organs, like all the organs of the body, are enfeebled 
 if relieved of their physiological duties. The too rapid absorption of peptones 
 may be harmful, and physiologically it is questionable whether proteids which 
 have been completely converted into peptones are ever largely utilized in the 
 body in building up tissue. It is probably fortunate that in the great majority 
 of instances artificial digestion is incomplete and the supposed peptones are 
 actually albumoses. 
 
 Symptoms. — Restlessness, flatulency with abdominal pain, and sometimes 
 vomiting, are the first symptoms of this form of diarrhoea. Then frequency 
 of stool, often accompanied by griping pain, follows. The appearance and 
 other physical characters of the discharges vary with the severity and con- 
 tinuance of the attack. At first they appear quite normal, and their frequency 
 is the only thing to attract attention. Then they become more watery, but are 
 not mucous, as they are when the disease becomes chronic and inflammatory, 
 nor serous, as they often are in acute milk infection. The stools are sometimes 
 green, and this may give rise to alarm, but this color is often due to trivial 
 causes, and too much importance has sometimes been attached to it. After a 
 free discharge the child becomes less restless, and may fall into a quiet sleep, 
 from which, however, it is soon aroused by abdominal pain, which continues 
 until the bowels are again relieved. A few hours of this pain tells upon the 
 features ; the countenance becomes pale, and its continuance for a few days 
 lessens the rotundity of the limbs and makes the muscles soft and flabby. If 
 the intestinal irritation be severe, convulsions may occur. Elevation of tem- 
 perature is seldom observed in this form of diarrhoea, or if it does appear it is 
 evanescent. The pulse is accelerated during the paroxysms of pain, but is 
 usually normal during the intervals. Thirst is an accompaniment, and may be 
 great when the stools are frequent and watery. 
 
 Prognosis. — This form of diarrhoea is not in and of itself fatal. Unless 
 the cause of the irritation be removed, inflammatory processes are induced in 
 the intestine, and a chronic diarrhoea results, or bacterial invasion, finding 
 favorable soil, may speedily develop an alarming condition. 
 
 Treatment. — The prompt and judicious treatment of this form of diar- 
 rhoea is in the majority of instances highly satisfactory. The administration 
 of all food should be forbidden for a number of hours. The exact period of 
 this prohibition may vary with the symptoms in the individual case, but, as a 
 rule, twenty-four hours will not be too long. The child will be restless and 
 will cry from thirst, which should be provided for by suspending bismuth sub- 
 nitrate in sterilized water, from two to five grains to the drachm, and ordering 
 that this be given in doses of a teaspoonful or more every hour when the child is 
 awake. The undigested food remaining in the intestines should be removed, 
 and the best agent for the accomplishment of this purpose is castor oil, a tea- 
 spoonful of which should be given to a child one year of age. Some physi- 
 cians prefer rhubarb (one to two drachms of the syrup), and others recommend 
 magnesium sulphate, but I am sure that there is nothing which is more certain 
 
DIABBHCEAL DISEASES. 467 
 
 and pleasant in its action than castor oil. It may be asked whether or not the 
 administration of the laxative is regarded as essential in every instance. I have 
 seen many children improve rapidly without it. In these the irritating sub- 
 stance has been swept out of the intestines by the diarrhoeal discharges, and a 
 small dose of opiate is all that is needed ; but it is impossible to tell in a given 
 case whether this fortunate removal has been accomplished by unaided nature 
 or not, and the more certain method is to administer the laxative. 
 
 After the laxative has had its effect, earlier if there be great pain, an 
 opiate in very small doses, to be repeated, if desirable, after each evacuation, 
 is generally beneficial. The opiate may be given in the form of the tincture, 
 the deodorized or the camphorated tincture. The custom of introducing opium 
 into compound prescriptions ordered for children is to be condemned. It is a 
 common practice with many physicians to write a prescription containing an 
 opiate, bismuth subnitrate, pepsin, and chalk mixture. The pepsin is use- 
 less, because the administration of food has been prohibited, and it cannot have 
 any digestive effect upon that which is already in the intestines. The syrup in 
 the mixture may ferment and be harmful, and the chalk is without value, while 
 the bismuth should be given more freely than the opiate. For these rea- 
 sons the opiate should not be incorporated in a mixture, but should be prescribed 
 by itself; and this holds good whenever opium is employed in any form of 
 diarrhoea in infants. I have said that the dose of the opiate should be small 
 — simply enough to allay the abnormal peristalsis of the intestines. From five 
 to ten drops of the camphorated tincture or a half minim of either of the other 
 tinctures will usually suffice for a dose for a child one year of age. After twelve 
 hours of this treatment the condition of the child will usually be found to be 
 much improved, but the diarrhoea will return as soon as the improper feeding 
 begins. It is well to order the continuation of bismuth subnitrate at longer 
 intervals for some days, and the physician must give his attention to the cha- 
 racter of the food, which must now be resumed. He must endeavor to ascertain 
 wherein the feeding was at fault, and thus avoid a repetition of the trouble. 
 If the child is nursing and the harm has come from the giving of additional 
 food, such addition must be forbidden. If the mother's milk is at fault, and 
 if this cannot be improved, the selection of a good wet-nurse is the best thing 
 that can be done. If neither of these is practicable, or if the child has been 
 artificially fed, the selection and preparation of the best food suited to the case 
 must be undertaken. For aid upon this point the reader is referred to the sec- 
 tion on infant-feeding. 
 
 Chronic Intestinal Indigestion. 
 
 Synonyms. — Chronic diarrhoea ; Chronic irritative diarrhoea ; Chronic 
 intestinal catarrh ; Chronic entero-colitis. 
 
 Etiology. — Chronic intestinal indigestion, with consequent diarrhoea, is a 
 common affection of infancy. The undigested food ferments, and the products 
 of this fermentation, acting as irritants upon the sensitive mucous membrane, 
 induce a catarrhal condition which is most marked in the ileum and colon, 
 where ulceration not infrequently results. All this may occur without the aid 
 of toxicogenic germs, and probably without the intervention of any adven- 
 titious bacteria whatever, since those normally present are capable of accom- 
 plishing these results when digestion is arrested or markedly retarded. Chronic 
 intestinal indigestion may occur at any season of the year, but it becomes of 
 more serious import during the hot months, when toxicogenic germs abound 
 and the chances of their invasion are greatly increased. It is self-evident that 
 
468 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 this affection is more common among those infants artificially fed than among 
 those who draw their sole and sufficient nourishment from the breast of a healthy 
 mother. It is equally plain that it is most prevalent among those suffering 
 from debilitating and wasting disorders, either inherited or acquired, such as 
 syphilis, tuberculosis, rickets, or chronic broncho-pneumonia; and among those 
 who have had their vitality impaired by an acute infectious disease, such as 
 pertussis, scarlatina, or measles. Children who suffer from neglect, insufficient 
 clothing, and exposure to cold are also prone to this affection. Some children 
 seem to be born with an inability on the part of the intestines to properly 
 digest and absorb food. I have seen such a child weighing less when sixteen 
 months of age than at the time of birth, and yet recovery resulted, and the 
 child, now eight years of age, weighs as much and is as robust as the average. 
 Frequent attacks of acute indigestion lead to the chronic form, though it is 
 probably true that the majority of cases of chronic indigestion develop insidi- 
 ously and without any marked preliminary acute attack. 
 
 Symptoms. — The discharges from the bowels become, as a rule, gradually 
 more frequent, increasing from one to two, to from four to six or more per day. 
 The child usually becomes nervous, fretful, and fails to sleep well. Flatulency 
 is a more or less marked symptom, and when great the distention of the bowels 
 may cause severe pain. The stools are generally quite characteristic in certain 
 particulars. In consistency they may be semi-solid or more watery, or they 
 may vary in this respect from time to time. The odor is quite invariably dis- 
 tinctly offensive. So marked and common is this that the stools are frequently 
 designated as putrid. The presence of undigested food is indicated by the 
 color. Lumps of coagulated casein and masses of unchanged fat may be seen. 
 With the progress of the disease and the development of inflammatory changes, 
 mucus appears, pus may be detected with the microscope, and, when hard lumps 
 are present, they may be streaked with blood. The color will vary with the 
 kind of food and the extent to which it fails to digest. Pale, putty-like stools 
 are common, while the presence of a large amount of fat may render the excre- 
 tions gray or even white. The green stools are quite common in this affection, 
 and in some instances at least this coloration is due to the growth of chromo- 
 genic bacteria. There are likely to be periods of exacerbation, when the 
 number of evacuations becomes much greater and their consistency thinner 
 and more watery. At these times the pain usually becomes more severe, and 
 fever, with vomiting and increased restlessness, makes the case more alarming. 
 The diarrhoea, more or less marked, may continue for weeks. In rare instances 
 the increased frequency of the discharges may be borne by the child for a long 
 time in a surprising manner. The rotundity of the limbs is not lost, and the 
 infant may not only hold its own, but may gain slightly in weight. Such cases, 
 however, make the exceptions. Usually the child loses day by day. Emacia- 
 tion becomes marked, the muscles of the limbs and the trunk melt away, and 
 the head appears by contrast to be abnormally large. The gradual loss of sub- 
 stance and strength may end in exhaustion and death. However, this is not 
 common, death in the majority of instances resulting not from the disease 
 itself, but from the intercurrence of milk infection. 
 
 In cases terminating favorably recovery is usually a slow and gradual pro- 
 cess, liable to many partial relapses. The child becomes less fretful and gives 
 less evidence of pain. The stools decrease in number, and become more like 
 the normal in form and color. The putrid odor is likely to be the most per- 
 sistent evidence of the diseased condition. 
 
 Throughout the course of a chronic intestinal indigestion it often happens 
 that the appetite is unimpaired. The child, while it is losing weight and after 
 
DIARRHEAL DISEASES. 469 
 
 it has been reduced to a mere shadow of its former self, may take more food 
 than it did when well. It has often been observed that while such a child 
 does not give any evidence of craving food, and while its restlessness is not 
 increased by prolonging the intervals between feeding, it readily and, possibly, 
 voraciously swallows any food offered ; and it may seem that the larger the 
 quantity of food taken, the more rapidly do the tissues melt away. Indeed, 
 this is not altogether a merely apparent thing ; it may be a reality. When 
 the food is not digested, excessive feeding increases the irritation, deepens 
 the inflammatory processes, multiplies the number of stools, draws upon the 
 vital resources, and hastens the period of exhaustion. 
 
 The stomach often remains surprisingly free from involvement in this affec- 
 tion, and vomiting seldom occurs save during the exacerbations already referred 
 to. The tongue is usually dry and red, though it may be covered heavily with 
 a yellowish or brownish coat. Thrush and follicular stomatitis are not rarely 
 seen, and the teeth may rapidly decay. These are, however, by no means 
 constant symptoms. The vexatious cases of prolapsus ani in infants are most 
 common among those suffering from chronic intestinal indigestion. The general 
 vitality of the little patient is often so low that the replaced bowel is not 
 retained, and when it becomes inflamed and swollen it may cause great pain. 
 The skin with which the discharges come in contact may become highly 
 inflamed, and, unless attention be given to frequent changes and the employ- 
 ment of protective powders, the inflammatory process may lead to ulceration. 
 
 The temperature is usually normal, though it may be elevated during the 
 periods of exacerbation. A subnormal temperature persisting for some days 
 is an alarming indication, and is usually followed by death. However, in 
 cases of marked debility and exhaustion the extremities are generally cool, 
 and need warm clothing and at times the application of artificial heat. The 
 pulse becomes weak, and the respiration is often irregular and shallow. The 
 ankles may become cedematous, and this condition does not necessarily imply 
 nephritis, though structural changes in the kidney, with albuminuria, may 
 occur. 
 
 Diagnosis. — The history of the case and careful inspection of the stools, 
 which should always be made, will seldom leave any doubt in the mind of the 
 intelligent physician concerning the correctness of his diagnosis. There is one 
 point, however, which should always be considered in reaching a correct esti- 
 mate of the nature and gravity of the individual case. I refer to the necessity 
 of a careful examination of the child in every part of its anatomy. If atten- 
 tion is given exclusively to the bowels, important conditions may be over- 
 looked. In some instances — and the number of these is not small — the failure 
 of the digestive organs to perform their functions properly is due to the exist- 
 ence of some constitutional disease and to the effects of poisons generated in 
 such an affection. On the other hand, the wasting which follows long-con- 
 tinued intestinal indigestion renders the child highly susceptible to the invasion 
 of specific germs, and especially to those of tuberculosis. The diagnosis must 
 therefore embrace any constitutional coexistent affection. Otherwise the phy- 
 sician is likely to be led astray in his prognosis and treatment. 
 
 Prognosis. — This will be influenced largely by the parentage of the child, 
 by the cause of the indigestion, by the duration of the disease, by the season 
 of the year, and by the presence or absence of constitutional disease. In some 
 families the children are prone to digestive troubles ; especially is this true 
 when one or both parents are tuberculous or syphilitic. This is also likely to 
 be the case when a child is born to very youthful parents. If the cause of the 
 indigestion can be traced to some special error in diet, the chance of curing 
 
470 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the disease after the removal of the cause is, of course, greatly increased. The 
 greater possibility of the supervention of milk infection leads to a less hopeful 
 prognosis when this form of indigestion occurs during the hot months ; and the 
 coexistence of chronic broncho-pneumonia, tuberculosis, scorbutus, syphilis, or 
 rachitis may render temporary improvement doubtful and permanent recovery 
 impossible. Still another and most important subject to be considered in 
 forming a prognosis is the sanitary surroundings of the patient and the prob- 
 ability of securing improvement when needed. 
 
 Treatment. — So long as the cause of the indigestion is unknown, the 
 treatment is likely to be wrongly directed and ineffective. Some error in diet 
 is suspected. If the child nurses, does it obtain all its food from this source ? 
 If the answer to this be in the affirmative, then the health of the mother must 
 be investigated. Is she pregnant ? is she exhausted by excessive menstru- 
 ation, prolonged lactation, by care and loss of sleep, or by some constitutional 
 disease ? If any of these be demonstrated to be the real cause, the employ- 
 ment of a suitable wet-nurse, when such a rare and valuable aid in treatment 
 can be found, is the best thing that can be done. However, it is far better to 
 take the chances with artificial feeding than to trust the child to a dishonest, 
 vicious, or diseased wet-nurse. I have known of more than one instance of 
 the children of respectable parents contracting syphilis from such a woman. 
 When the infant is artificially fed, it is not enough for the physician to merely 
 inquire about the character of the food, but he must know how it is prepared 
 and in what quantities and how frequently it is administered. The source of 
 the food may be exceptionally good, but if it is kept in unclean vessels, in a 
 contaminated atmosphere, or if it is administered in excessive quantities, the 
 doctor's drugs will be of little service until the fault is discovered and removed. 
 The physician who depends solely upon his prescriptions, and neglects the more 
 important matter of diet, will not have reason to congratulate himself upon the 
 success of his treatment. The child will often improve and gain in flesh when 
 the quantity of its food is diminished. When the stools contain lumps of 
 coagulated casein and masses of fat, or when they are acid from the fermenta- 
 tion of the sugar of milk, it is best to wholly discontinue the use of milk for 
 some days and feed the child solely upon meat broths and egg-albumin. On 
 the other hand, if the stools be alkaline and putrid, barley gruel, rice-water, 
 and solutions of dextrin or soluble starch obtained by roasting or boiling 
 wheat flour, may be used. As a rule, the indigestion is confined to the inability 
 of the digestive fluids to act upon either the carbohydrates or the proteids. If 
 the trouble lies in the former, the stools are likely to be acid and the formation 
 of gas in the intestines marked. In such cases a diet consisting exclusively 
 of proteids should be tried and continued, unless it should prove positively 
 harmful, for three or four days, and if beneficial effects follow it may be longer 
 continued. Proteid indigestion is likely to produce fetid, alkaline stools, and 
 a diet of carbohydrates will prove beneficial. I do not claim that any absolute 
 rules can be founded upon the above-mentioned facts, because fermentation of 
 one of these food-constituents naturally and necessarily prevents the complete 
 digestion of the other ; but I do hold that the physician gains no information 
 by continuing a mixed diet, and, although he may be in error in his first trial, 
 he has made, as it were, a physiological test, and he is now better prepared to 
 treat the case rationally. Many physicians recommend the employment of 
 artificially digested milk, but my experience has led me to prefer the selection 
 of an exclusive diet of either carbohydrates or proteids ; and by this I do not 
 mean the employment of halfway measures, but the exclusion of one of these 
 food-principles should be complete. Moreover, there are, as I have stated, 
 
DIARRHCEAL DISEASES. 471 
 
 grave physiological doubts about the capability of the organism to utilize pep- 
 tones in the repair of wasted tissue. 
 
 The physician must never lose sight of the fact that chronic intestinal indi- 
 gestion is accompanied and may be caused by lowered vitality and general loss 
 of tone. Tonics are indicated, and the best of these is an abundant supply of 
 pure, fresh air. Removal from the crowded city and its contaminations to the 
 better air of the country, and especially to that of the mountains, is often of 
 the greatest service, and should be urgently recommended to parents who are 
 able to provide for such a change. Arsenic and nux vomica may be used, but 
 they are poor substitutes for fresh air and improved sanitary surroundings. 
 Alcohol in the form of port or sherry is often advantageous, and cod-liver oil 
 is of service in protracted cases. 
 
 The occasional administration of laxative doses of castor oil or from two 
 to three grains of calomel will be of service. 
 
 Opiates are to be avoided as far as possible, and are never indicated save 
 in the painful exacerbations which may occur. 
 
 Much has been written concerning the use of intestinal antiseptics, but 
 only a few of these are of any real value. The same is true of astringents. 
 Bismuth subnitrate has both antiseptic and astringent properties in a mild 
 degree, and of all such drugs it has best preserved its reputation. It should be 
 given in large doses, fifteen grains or more, six or eight times per day, and, as 
 in acute indigestion, it should be kept free from combination with opiates. 
 Sodium salicylate and salol in some cases seem to be of benefit. 
 
 The lesions in the small intestines are best reached by the administration 
 of the large doses of bismuth subnitrate, while those of the large intestine are 
 most successfully treated by enemata. These should be employed three or four 
 times per week. First, the bowels should be irrigated with warm water con- 
 taining a little castile soap until they are completely emptied. This must be 
 thoroughly done, and in order to secure this thoroughness the physician must 
 either do it himself or trust it only to a trained nurse or assistant. The hips 
 should be elevated, and a large-sized flexible catheter attached to a fountain 
 syringe should be passed into the colon. The passage of the catheter will be 
 facilitated by allowing the water to flow at the time. From three to four quarts 
 of water should be used, the excess returning by the side of the tube. After 
 the large intestines have been cleansed in this manner, one-half pint of water, 
 containing from one to two drachms of bismuth subnitrate in suspension, should 
 be injected and left in the bowel. Instead of the bismuth, thirty grains of 
 tannic acid may be used. The temperature of the water, both that used in the 
 irrigation and for the injection, should be that of the body. 
 
 The possibility of the intercurrence of serious complications should always 
 be borne in mind and place the medical attendant on his guard. The frequency 
 with which relapses occur necessitates continued attention to the diet, sanitary 
 surroundings, and general health of the little patient for weeks and months 
 after apparent recovery. 
 
 MILK INFECTION. 
 
 The diarrhoeas which prevail among infants during the summer, especially 
 in cities and among the poorer classes, produce a fearful mortality; conse- 
 quently, they have given rise to much discussion concerning their nature and 
 causation. The theories which have been advanced to explain the origin of 
 these diarrhoeas have included nearly everything which a lively imagination 
 
472 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 could suggest. Learned arguments have been made to show that the most 
 important etiological factors lie in mysterious and unknowable meteorological or 
 telluric conditions ; while, on the other hand, the keen perception of a medical 
 genius detects "that the fatality of the disease has been appreciably increased 
 by the introduction and universal use of the child's carriage." The limit set 
 upon the writer of this paper by the editor will not permit indulgence in an 
 historical sketch of these varied theories, nor will it allow of any argumentative 
 discussion. I shall have to content myself with a bare statement of those etio- 
 logical factors the existence of which has, in my opinion, been demonstrated. 
 
 These diarrhoeas are due to toxicogenic (poison-producing) bacteria. There 
 is not a specific micro-organism, as there is in tuberculosis, but any one or 
 more of a large class of germs, the individual members of which differ from 
 one another sufficiently morphologically to be regarded as distinct species, may 
 be present and may produce the symptoms. 
 
 Only a very brief summary of our knowledge concerning the intestinal bac- 
 teria can be given here, while the reader is referred for more extended informa- 
 tion to the works of Escherich, Booker, Baginsky, and Jeffries. The intestinal 
 contents during foetal life are sterile, and remain so for a short time after birth. 
 However, within a few hours after birth bacteria find their way into the intes- 
 tines. The meconium contains quite constantly two species of bacilli and a 
 micrococcus. One of these bacilli is a long, slender rod with a bright, glisten- 
 ing spore, and is known as the " head-bacillus." The other appears to be 
 identical with bacillus subtilis. The micrococcus is a large circular or ellip- 
 tical organism. Breslau taught that this is taken in with the air which the 
 child swallows immediately after birth, but Escherich thinks that these bacilli 
 found in the rectum find entrance through the anus. However, these bacteria 
 wholly disappear with the last passage of meconium. 
 
 The normal bacterial flora of the healthy nursing child is yet more limited, 
 so far as species are concerned, the number being two — the bacterium lactis 
 aerogenes and the bacterium coli commune. These are known as obligatory 
 " milk-faeces " bacteria, and are constantly present. The upper part of the 
 duodenum is quite free from bacteria. Lower down, the small intestines con- 
 tain large numbers of the bacterium lactis aerogenes, while in the lower part 
 of the ileum the bacterium coli commune appears, and grows more abundant in 
 the colon, throughout the whole length of which this germ is found. Other 
 "inconstant" bacterial forms are found in the large intestines of the healthy 
 milk-fed child. Both the bacterium lactis aerogenes and the coli commune are 
 pathogenic to some of the lower animals when injected subcutaneously. 
 Whether either of these ever develop pathogenic properties in diseased con- 
 ditions or not is a question which has been much discussed, but which cannot 
 be considered as positively settled at present. 
 
 The contents of the intestines in the so-called summer diarrhoeas of infancy 
 swarm with bacteria of many species, and some of these produce most power- 
 ful poisons. These bacteria multiply outside of the body, and are disseminated 
 widely and abundantly only when the atmospheric temperature reaches 60° F. 
 or higher. This is the reason for the restriction of these diarrhoeas to the hot 
 months of summer. 
 
 The most suitable culture-medium for the growth of these bacteria is milk, 
 and this is the food with which they most commonly find their way into the 
 intestines of the child. A knowledge of these facts has led to the employment 
 of the most effective prophylactic measures for these diarrhoeas. These 
 measures may be grouped into (a) those which prevent the contamination of 
 milk, and (b) those which destroy any germs with which the milk has already 
 
BIABBHCEAL DISEASES. 473 
 
 been contaminated. Since these diarrhoeas are limited to children artificially 
 fed in whole or in part, our prophylactic measures are devoted exclusively to 
 cow's milk. Some years ago I formulated the following rules concerning the 
 care necessary to prevent milk undergoing these putrefactive changes : 
 
 (a) The cows should be healthy, and the milk of any animal which seems 
 indisposed should not be mixed with that from the healthy animals. 
 
 (b) Cows must not be fed upon swill or the refuse from breweries or'glucose- 
 factories, or upon any other fermented food. 
 
 (c) Milk cows must not be allowed to drink from stagnant pools, but must 
 have access to fresh, pure water. 
 
 (d) The pasture must be freed from noxious weeds, and the barn and yard 
 must be kept clean. 
 
 (e) The udders should be washed, then wiped dry, before each milking. 
 (/) The milk must be at once thoroughly cooled. This is best done in the 
 
 summer by placing the milk-can in a tank of cold water or ice-water, the water 
 being of the same depth as the milk in the can. It would be well if the water 
 in the tank could be kept flowing, and this will be necessary unless ice-water 
 is used. The tank should be thoroughly cleansed each day to prevent bad 
 odors. The can should remain uncovered during the cooling, and the milk 
 should be gently stirred. The temperature should be reduced to 60° F. or 
 lower within an hour. The can should remain in the cold water until ready 
 for delivery. 
 
 (g) Milk should be delivered during the summer in refrigerator cans or in 
 bottles about which ice is packed during transportation. 
 
 (h) When received by the consumer it must be kept in a clean place and at 
 a temperature some degrees below 60° F. 
 
 If all the milk used in the artificial feeding of infants could be obtained 
 and marketed with the care demanded by the above rules, milk infection would 
 be practically unknown and the sterilization of the infant's food would be 
 unnecessary. However, since it is impossible for the city consumer to know 
 that the milk, which has been transported through a long distance and has 
 passed through the hands of several dealers, has been kept from infection, the 
 only safe plan for him to adopt consists in the sterilization of all of that which 
 is fed to children. There is no doubt in the mind of the writer that whole- 
 some, uninfected milk in the raw state is a better food for the infant than 
 cooked milk. The heat of sterilization robs the nuclein of the milk of its 
 vital properties, as can be demonstrated by experiments. But I am equally 
 positive that it is better to feed the city child upon sterilized milk than it is to 
 use that which, with the prevailing ignorance and carelessness of dairymen 
 and dealers, is likely to be infected. The risk in using unsterilized milk is 
 too great, and the question with the parent or physician is not, Am I giving 
 the child the best food ? but, Am I giving it a poison ? The choice is easily 
 made when the matter is looked at in this light. 
 
 The toxicogenic germs grow and multiply in the milk both before and after 
 it has been taken into the alimentary canal of the child, and elaborate chemical 
 poisons which induce the diarrhoea and other untoward symptoms. The num- 
 ber of these poisons is probably as great as that of the bacteria which produce 
 them. While they may differ in the intensity of their toxic properties, all are 
 gastro-intestinal irritants, just as we have a number of metallic poisons which 
 act in a similar manner. Some of these poisons have been isolated and their 
 effects upon the lower animals have been studied. Tyrotoxicon, first found in 
 poisonous cheese, later in ice-cream and other milk-products, has been isolated 
 from a sample of milk a part of which had been administered to a healthy child 
 
474 AMERICAN TEXT- BO OK OF DISEASES OF CHILD BEN. 
 
 and had caused a severe choleriform diarrhoea. This is a most potent poison, 
 inducing severe and continued vomiting and purging with speedy prostration, 
 and death within a few hours if the quantity administered is sufficient. Post- 
 mortem examination shows but little change. The mucous membrane of the 
 small intestine is bleached and softened, and possibly deprived here and there 
 of its superficial epithelium. These are the symptoms and the post-mortem 
 appearances in the choleriform diarrhoea of infants. 
 
 In 1890 proteid poisons were isolated by the writer from cultures of three of 
 the toxicogenic germs found by Booker in the intestines of infants suffering 
 from milk infection. These proteids are highly poisonous, and when injected 
 under the skin of kittens or puppies they cause vomiting and purging, and, 
 when employed in sufficient quantity, collapse and death. Post-mortem 
 examination shows the small intestine pale throughout and constricted in 
 places. The heart has been invariably, so far, found in diastole and filled 
 with blood. 
 
 A small amount of the proteid from bacillus x, dissolved in water, was 
 injected under the skin on the back of a kitten. Within one half hour the 
 animal began to vomit and purge, and death resulted within eighteen hours. 
 The small intestines were pale, contracted in places, and contained a frothy 
 mucus. The stomach was distended with gas, and contained mucus stained 
 yellow with bile. The liver was normal, the spleen and kidneys were congested, 
 and the heart was distended. 
 
 Another kitten was treated with the proteid from bacillus a, dissolved in 
 water. The vomited and faecal matters in this case were green. The animal 
 died after fifteen hours, and presented appearances practically identical with 
 those mentioned above. 
 
 A third kitten was treated with some of the proteid from bacillus A, sus- 
 pended in water, and presented substantially the same symptoms and post- 
 mortem appearances. 
 
 Concerning the amount of one of these proteids necessary to produce a 
 fatal result in the animals experimented upon the following tests were made: 
 Fifteen milligrammes of the dry proteid from bacillus a was injected under the 
 skin of the back of a guinea-pig. This caused death within twelve hours. Of two 
 kittens treated with fifteen milligrammes of the a proteid, one died after forty- 
 eight hours, and the other recovered after two days of vomiting and purging. 
 Two puppies of about five pounds weight had each forty milligrammes, and after 
 serious illness of two days speedily recovered. During these two days of vomit- 
 ing and purging these dogs were constantly shivering as with cold, but the 
 rectal temperature stood at from 102.5° to 103.5° F. 
 
 Baginsky and Stadthagen have isolated from cultures of the "white lique- 
 fying germ" obtained by the former from diarrhoeal stools a poisonous proteid 
 which produces in mice, after about five hours, slight dyspnoea. The coat 
 becomes rough, the animal sits with drooping head, and when forced to move 
 does so sluggishly, but without any evidence of paralysis. The marked apathy 
 increases, and death results after two or three days. Section shows an infiltra- 
 tion about the place of injection, congestion of the spleen, liver, and perito- 
 neum. The intestine is hypersemic throughout its entire length, and its upper 
 portion contains a reddish-brown fluid. The same bacterium produces a 
 poisonous base. 
 
 With our present knowledge of infected milk and the chemical poisons 
 which may be generated therein the causation of the summer diarrhoeas in 
 infancy has been divested of the mystery which formerly obscured our views. 
 Uninfected milk improperly administered may, as we have seen, cause intestinal 
 
DIABBHCEAL DISEASES, 475 
 
 indigestion, and thus prepare the way for milk infection ; but it can never 
 directly induce the severer forms of diarrhoea which make infantile mortality 
 so alarmingly great. The relation between these forms of diarrhoea may be 
 likened to that between catching cold and infection with tuberculosis. The 
 popular idea is that tuberculosis originates in frequent colds, but the physician 
 knows that this is not true, and that the only causal relation between the two 
 is that which grows out of the lowered vitality, lessened resistance, and greater 
 susceptibility. If parents were willing to pay for wholesome, uninfected milk 
 half the fancy price which they readily give for some prepared baby food, 
 their children would be better nourished and disease among them would be less 
 frequent. 
 
 Acute Milk Infection. 
 
 Synonyms. — Cholera infantum ; Choleriform diarrhoea. 
 
 Etiology. — Fortunately, this form of milk infection is not so common as 
 those of a milder type. It practically never occurs among children fed exclu- 
 sively from the breast. The exceptions to this, if there be such, must arise 
 from the introduction of powerful toxicogenic germs into the alimentary canal 
 in some unusual manner. There are recorded cases in which, after a night 
 of debauch, the milk of a wet-nurse has proved intensely poisonous to the 
 child. It may possibly happen that an infant creeping about a filthy apart- 
 ment, and investigating every object upon which it can lay its hands, by 
 the sense of taste or by sucking its dirty fingers, may thus infect itself. It 
 may also happen that a like misfortune may result from bacteria taken from 
 the exterior of the breast of a filthy mother. However, as stated above, these 
 are unusual methods of infection, and the rule holds good that choleriform 
 diarrhoea is limited to the artificially fed. 
 
 The diligent researches of able bacteriologists — among whom Booker and 
 Jeffries in this country and Escherich and Baginsky in Germany deserve men- 
 tion — have failed to discover a specific micro-organism in cholera infantum. 
 Booker found bacteria belonging to the proteus group most frequent in these 
 cases. 
 
 As has been stated, the writer found tyrotoxicon in one sample of milk, 
 the administration of which to a healthy child was followed within two hours 
 by the development of a most violent form of this kind of poisoning. This 
 demonstrates that the poison may exist preformed in the milk at the time of its 
 administration. Holt has observed that cholera infantum "is most frequently 
 engrafted upon a mild dyspeptic diarrhoea." This is undoubtedly often the 
 case, but it so happens that in the writer's experience the violent symptoms have 
 suddenly appeared in previously healthy children, and Christopher makes a 
 similar observation. It certainly is an error to say that acute milk infection 
 begins as a mild diarrhoea. The former may supervene on the latter, but one 
 is no part of the other. 
 
 Choleriform diarrhoea never occurs save in the hot months of summer, at a 
 time when poison-producing germs are most abundantly distributed. The cause 
 is invariably in the food, and the poisons which induce the symptoms are not 
 known to originate in any other food than milk or some milk preparation. I saw 
 one case in a child fed upon condensed milk, and the mother noticed when she 
 opened the can that the ends were distended by accumulated gases, and the first 
 feeding from this can was followed by severe vomiting and purging. Bacteria 
 were abundant in the contents of the can. Another case resulted from the first 
 feeding from a can of a baby-food preparation. Every case of this affection is 
 one of poisoning from the elaboration of chemical products by the growth of 
 
476 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bacteria in milk. There may be enough of the poison in the food at the time 
 of its administration to develop the symptoms as quickly as they would result 
 from the giving of a poisonous dose of arsenic, or the greater part of the toxic 
 substance may be generated by the growth of the bacteria in the alimentary 
 canal. 
 
 Symptoms. — No one can see a little patient suffering from acute milk 
 infection without being deeply impressed with the similarity of the symptoms 
 with those induced by some powerful gastro-intestinal irritant. The child, 
 which may have been perfectly well or suffering from some mild form of diar- 
 rhoea, suddenly begins to vomit and purge. These symptoms may continue 
 almost incessantly until death results within a few hours. The color leaves 
 the face, and a deathly pallor spreads over the countenance. The eyes sink 
 into their sockets, while anxiety and alarm make themselves visible in every 
 feature. Any food-contents of the stomach are soon removed by the vomiting, 
 but this distressing symptom continues, and mucus colored with bile is thrown 
 off. The frequency of the vomiting is increased by the administration of food 
 or drink. The stools at first contain formed faecal matter and undigested food; 
 then they become more watery and copious, and at last they are composed almost 
 solely of blood-serum. At first they are yellow or green, but as they become 
 more abundant they lose all color. The odor is peculiar and musty. Thirty 
 or more stools may be passed in the severer cases within twenty-four hours. 
 So long as the stools contain undigested food they may be acid, but the serous 
 passages are alkaline. The flesh rapidly disappears, and there is no other dis- 
 ease, with the exception of Asiatic cholera, in which the wasting proceeds more 
 speedily and exhaustion results more quickly. The skin is usually cool and 
 clammy, but the rectal temperature is elevated, usually from 102° to 104° F., 
 and in the severer cases it may read as high as 107° or 108° before death. The 
 pulse is weak, thready, and rapid. The respirations are shallow, irregular, 
 and hurried. At first the child cries, then only moans, and later falls into a 
 comatose condition, but there may be great restlessness, wild delirium, and con- 
 vulsions. Thirst is usually great, and everything offered is swallowed and 
 almost immediately vomited. The abdomen is not distended, but is usually 
 retracted. Sometimes the vomiting and purging suddenly cease, and the parents 
 are rejoiced at this apparently favorable turn. However, it may be but the 
 precursor of death. The physician is not cheered by the cessation of these 
 symptoms if the child remains in a stupor, for this is most likely to deepen 
 into coma. 
 
 In rare instances the child quickly passes into an algid state in which the 
 temperature is subnormal. This indicates that the amount of the poison 
 absorbed is large and the chances of recovery are small. In these cases the 
 child lies in a stupor, with the eyelids half open and the eyes apparently cov- 
 ered with a film. The angles of the mouth are retracted and the lips open. 
 The fontanelle is depressed, the pulse weak, and the respiration irregular. The 
 urine is scanty and there may be complete suppression. 
 
 In other cases the symptoms are not so grave as those indicated above. 
 The stools are not so frequent and copious, and the vomiting not so incessant. 
 The little patient may brighten up at intervals, and sufficient of the poison may 
 be removed by the vomiting and purging to give great relief and lead to 
 speedy recovery. 
 
 Cases of acute milk infection terminate either in death or in marked im- 
 provement within forty-eight or at the most seventy-two hours. The improve- 
 ment may be rapid and complete, or it may reach a certain point and there 
 remain comparatively stationary. 
 
DIABBHCEAL DISEASES. All 
 
 Diagnosis. — There is only one disease which presents symptoms with which 
 those resulting from acute milk infection can be confounded. This is Asiatic 
 cholera, and at times of the prevalence of this foreign scourge a differential 
 diagnosis between the two cannot be made without the aid of a bacteriological 
 study of the stools. At all other times the suddenness of the onset, the inces- 
 sant vomiting, the frequent and copious watery stools, and the speedy prostra- 
 tion are so striking and characteristic that there can be no hesitancy in making 
 a diagnosis. It is true that some writers have tried to confound acute milk 
 infection and sunstroke. The points of similarity are the suddenness of the 
 prostration and the high temperature, but in the former of these there is a dif- 
 ference. The prostration of sunstroke is like a lightning flash, while in milk 
 infection it develops only after a few hours. In thermic fever there may be 
 one or two copious discharges from the bowels, but frequent purging does not 
 occur and the stools are never serous. The attempt to make acute milk infec- 
 tion identical with thermic fever arose from our former ignorance of the exist- 
 ence of the powerful poisons which may be elaborated in milk, and the idea 
 does not now find any support. 
 
 Prognosis. — It is quite necessary that the physician appreciate the gravity 
 of these cases of acute milk infection. The usual termination is in death. 
 The physician who speaks too hopefully in the first hours of the attack is 
 likely to find himself disappointed in a very short time. The more persistent 
 the vomiting and purging, and the more marked the nervous symptoms, the 
 less are the chances of recovery. If the stools become less frequent and less 
 watery, and if at the same time the pulse grows less frequent and stronger and 
 the nervous symptoms improve, hope may be indulged in, but in the most 
 favorable cases there is always the possibility of a relapse into the subacute 
 form, and so long as this continues danger is imminent. Unfortunately, the 
 name "cholera infantum" has been made to cover all the diarrhoeas prevail- 
 ing during hot months, and the physician must not be led astray by the reported 
 success of various methods of treatment. 
 
 Treatment. — These are cases of acute poisoning, and prompt, energetic 
 treatment is demanded as truly as if the child had swallowed a toxic dose of 
 arsenic or antimony. It is certainly true that the physician who hesitates or 
 temporizes loses his patient. 
 
 The first thing to be done is to positively forbid the further administration 
 of the poison. Not a drop of milk should be given. This is a sine qud non in the 
 treatment. This prohibition of milk must be absolute. Sterilized milk is not 
 to be thought of, and even the breast of the mother or wet-nurse must be denied. 
 Prepared baby foods should be thrown out of the window. The most danger- 
 ous foe with whom the doctor has to contend in the treatment is the grand- 
 mother or other good-hearted old lady, who knows just what will agree with 
 the baby, and who persists in giving it food as soon as the doctor turns his 
 back. The most valuable ally that he can have is a trained, conscientious 
 nurse who will carry out directions to the letter. 
 
 The second thing to do is to remove so far as is possible the poison already 
 in the alimentary canal. Take a lesson from nature. The vomiting and 
 purging are attempts to eliminate the harmful substance, but, like many other 
 attempts on the part of nature, they are ineffectual and exhausting. Wash out 
 the stomach and intestines on the first appearance of the symptoms. Do not 
 postpone these measures in the hope that resort to them may not be necessary. 
 What would be thought of the physician who when called to see a person who 
 had swallowed a drachm of white arsenic should say, " Well, the symptoms are 
 not at present alarming ; I will call around after a few hours, and if it be 
 
478 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 necessary I will then wash out the stomach " ? Acute milk infection is poison- 
 ing with a substance more powerful and deadly than white arsenic. The wash- 
 ing of the stomach and intestine will not exhaust the little patient half so much 
 as the continued vomiting and purging, and the artificial measures are much 
 more effective. The bowels should be thoroughly irrigated with warm water 
 and castile soap, not less than a gallon of the water being used. After the 
 large intestine has been cleansed in this manner, an injection of cool water, con- 
 taining fifteen to thirty grains of tannic acid to the pint, should immediately 
 follow. Some of the poisons formed are, as we have seen, proteids which are 
 precipitated by tannic acid, but until the great mass of proteid in the large 
 intestine has been removed no good can be expected from this agent. The 
 object of the tannic-acid irrigation is to render inert any soluble poisonous pro- 
 teids which may remain in the intestines after the first washing. 
 
 The stomach should be washed with warm water containing a teaspoonful of 
 common salt to the pint. After this organ has been thoroughly cleansed, from 
 three to five grains of calomel should be administered. 
 
 These irrigations should be repeated as soon as the vomiting or purging 
 returns. These may appear to be heroic measures, but the strength of the 
 patient is conserved thereby to the extent to which the vomiting and purging 
 are allayed. 
 
 The calomel is given for its antifermentative action and in order to reach 
 the small intestines, which are inaccessible by the processes of irrigation. 
 
 After the vomiting has been allayed by irrigation, stimulants may be given 
 by the mouth. I prefer whiskey to all other alcoholic stimulants. Brandy, if 
 pure, would be equally good, possibly better, but unadulterated brandy is a rare 
 article in this country, while good whiskey is easily obtainable. The stimulant 
 is best given in ice-cold water (the water should be boiled, and then ice-packed 
 about the container ; the ice should not be put in the water) containing 0.1 per 
 cent, of hydrochloric acid. This dilute acid may be used at any time to allay 
 thirst. 
 
 I agree with Holt that the hypodermatic use of very small doses of morphine 
 and atropine (one-hundredth of a grain of the former and one eight-hundredth 
 of the latter) may be of benefit as a heart stimulant, but the dose must not be 
 repeated too frequently. I have feared digitaline too much to try it in these 
 cases, nor have I employed sparteine. 
 
 When the temperature is above 103°, an ice-cap on the head is desirable, 
 and in some instances it seems to favorably affect the vomiting. When the tem- 
 perature goes up to 104° or higher, some more efficient means of reducing it 
 should be resorted to. The use of the coal-tar derivatives for this purpose is not 
 to be considered, and the same may be said of all drugs. Frequent sponging 
 and friction with cloths wet with cold water may be sufficient. The friction is 
 important on account of the coldness of the surface. When the temperature is 
 more alarming, the child should be placed in w T arm water, and the temperature 
 of this gradually lowered by the addition of ice to 85°, the child being rubbed 
 all the while it is in the bath. It should not be kept in the bath more than ten 
 minutes after the temperature has been lowered to the above-mentioned point. 
 Bathing the extremities in hot mustard-water and the use of friction are bene- 
 ficial in the state of collapse. 
 
 With the exception of the above-mentioned stimulants the child should 
 have no food for twenty-four hours or even longer. Then warm meat broths, 
 given a teaspoonful at a time, and to be discontinued if they provoke vomiting, 
 are most likely to be borne. The absolute prohibition of milk should hold 
 good for several days. 
 
DIABBHCEAL DISEASES. 479 
 
 There is scarcely a drug which has been shown to have, or supposed to 
 have, germicidal properties that has not been used in this disease. Among 
 others, mercuric chloride, carbolic acid, creasote, salicylate of sodium, benzo- 
 ate of sodium, salol, naphthalin, and resorcin may be mentioned. These and 
 others may be given by the mouth and by the rectum. Much harm and no 
 good can be obtained from them. To attempt to disinfect the alimentary canal 
 bv means of these agents is a waste of time and energy which might be given 
 to the more rational treatment outlined above. 
 
 The diapers from children suffering from milk infection should always be 
 disinfected, and, what is of more importance, the nurse's hands should be disin- 
 fected after she has removed the diaper. 
 
 Subacute Milk Infection. 
 
 Synonyms. — Summer diarrhoea ; Gastro-intestinal catarrh ; Infectious 
 diarrhoea ; Entero-colitis. 
 
 Etiology. — This is the disease which carries off so many thousands of 
 children in the large cities every summer. It prevails only during the hot 
 months, when the atmospheric temperature stands above 60° F. for several con- 
 secutive days. It is due to the action of poisons generated by the growth and 
 multiplication of bacteria. These germs are certainly more widely distributed 
 than those which induce the symptoms described under Acute Milk Infection, 
 but the chemical poisons produced by the former are less powerfully toxic than 
 those of the latter. However, the milder poisons induce the greater number 
 of deaths, on account of the greater number of individuals invaded by the 
 germs which produce them. There are also greater variations in the symptoms 
 of subacute cases. When the chemical poisons have been studied more 
 thoroughly, these variations will doubtless be better understood and a more 
 exact classification of them can be made. 
 
 Symptoms. — In the milder forms the symptoms gradually develop. The 
 movements of the bowels increase in frequency and become more watery. 
 Thev consist largely of undigested food, and contain lumps of coagulated 
 casein and masses of fat. The color may be brown, yellow, or green, and the 
 odor, though it may be disagreeable, has not the peculiar putrid property 
 characteristic of chronic intestinal indigestion. J. Lewis Smith has made a 
 microscopical study of the faeces, and has the following to say concerning them : 
 " In addition to undigested casein, I have found epithelial cells, single or in 
 clusters (sometimes regularly arranged as if detached in mass from the villi), 
 fibres of meat, crystalline formations, mucus, and occasionally blood. In one 
 instance I observed an appearance resembling three or four crypts of Lieber- 
 kiihn united, probably thrown off by ulceration. If the stools are green, 
 colored masses of various sizes, but mostly small, are also seen under the 
 microscope." 
 
 The continuance of the intestinal fermentation sets up inflammatory pro- 
 cesses, and the stools then contain mucus. This condition may go on for weeks, 
 and the anatomical changes in the intestines become gradually more serious. 
 Ulcerations may occur, especially in the ileum and colon. The general nutri- 
 tion of the child becomes impaired, the appetite is not good, the tongue is 
 covered with a white or grayish coat, and there is a gradual loss of flesh. The 
 temperature is the best indication of the rapidity with which inflammatory 
 changes are occurring in the intestines. There is always fever, at least during 
 some portion of the twenty-four hours, but in the milder cases it may be so 
 slight that it is likely to escape detection. These cases, in the earlier stages 
 
480 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and before marked inflammatory changes have occurred in the intestines, are 
 often readily amenable to treatment, especially to proper change in food, and 
 marked improvement may be produced in a short time. Other cases are more 
 obstinate and drag on for weeks, and are likely to terminate fatally from some 
 exacerbation, from exhaustion, or from some intercurrent disease. Children 
 who have suffered from this slow poisoning during the summer are likely to 
 fall victims to pneumonia the succeeding winter. 
 
 In these protracted cases there is usually more or less vomiting. This may 
 be an early symptom, in which case it is due to fermentation in the stomach ; 
 or it may appear later when stomachic digestion is impaired by the general 
 failure in nutrition. The vomiting is not so incessant as it is in acute milk 
 infection. 
 
 During the progress of the protracted cases there are likely to be many 
 exacerbations, or acute infection may result from the introduction of more 
 virulent toxicogenic germs. 
 
 In other instances the development of these symptoms is more abrupt. The 
 child becomes restless, and cries with pain due to distention of the intestines 
 with gas, and there may be convulsions. Vomiting occurs early, and the tem- 
 perature may rise to 103°. The diarrhoea begins, and the expulsion of the 
 stools is accompanied by large quantities of gas. This gives relief from the 
 pain, the nervous symptoms disappear, and the child falls asleep, from which it 
 is soon awakened by new accumulations of gas. In these cases unaided nature 
 is frequently successful in removing the offending contents of the intestines, 
 and unless the administration of infected food is continued a speedy return to 
 health may follow. Under other conditions the severe initial symptoms abate, 
 but putrefactive processes continue in the intestines for an indefinite period of 
 time. 
 
 Whether the symptoms come on gradually or begin more abruptly, the con- 
 tinuance of bacterial fermentation in the intestines leads to the development 
 of those anatomical changes which constitute what is generally designated 
 as entero-colitis. That the fermented intestinal contents are irritant in their 
 action is shown by the erythema which appears on the buttocks and thighs 
 when frequently soiled by the discharges, and which may develop into super- 
 ficial ulceration of the skin. It is generally believed that the structural changes 
 in the intestines are due to the direct action of the bacteria on the intestines, 
 but these alterations are more probably due to the irritating action of the 
 chemical products of the germs. The upper parts of the small intestines, the 
 duodenum and the jejunum, are generally free from inflammatory changes, 
 which are marked in the lower part of the ileum. This is easily explained by 
 the fact that the contents of the small intestines accumulate here before passing 
 through the ileo-c^ecal valve. If the destructive processes in the intestinal walls 
 were due to the direct action of the bacteria burrowing into the tissue, the 
 explanation of the location of the catarrhal inflammation and the ulceration in the 
 lower ileum would not be easy. Inflammatory changes in the colon are invari- 
 ably present in protracted cases, and they are generally more marked than 
 those of the small intestines, due to the fact" that the intestinal contents become 
 more irritating the longer they are subjected to the fermentative action of the 
 bacteria. While the anatomical changes are frequently found along the entire 
 course of the colon from the ileo-caecal valve to the sigmoid flexure, they are 
 most marked just above the last-mentioned point. This is again explained by 
 the delay which occurs here in the passage of the irritating substance. The 
 rectum is usually free from inflammatory lesions, or shows only those of the 
 most superficial character. 
 
DIABBHCEAL DISEASES. 481 
 
 The extent to which these anatomical lesions are developed depends upon 
 the character and quantity of the irritating substances formed, but most of all 
 upon the duration of the diarrhoea. A milder irritant acting through a longer 
 time may cause deeper and more dangerous tissue-changes than a more power- 
 ful agent acting for a shorter time. The character and extent of these lesions 
 may be to some extent judged by the contents of the stools. There may be 
 much fluid mucus in the passages, and in such cases it is customary to say that 
 the child is suffering from " catarrhal diarrhoea," or there may be lumps or 
 clots of mucus stained with blood, and this is designated as " dysenteric 
 diarrhoea." The presence of shreds of mucous membrane has led to the use 
 of the term "croupous diarrhoea," and the detection of considerable pus is 
 deemed sufficient to pronounce the case one of "follicular ulceration." How- 
 ever, as all of these changes may result from one and the same poison in differ- 
 ent degrees of concentration or acting through varying periods of time, a 
 classification based on the anatomical lesions is wholly irrational. It must not 
 be concluded from this repudiation of an anatomical basis of classification that 
 the physician should pay no attention to the stools. Careful inspection should 
 be made frequently, and the statements of attendants should not be relied upon 
 to the extent of failing to give this matter personal attention. Because one 
 knows that his patient is poisoned with arsenic, this is no reason why he should 
 shut his eyes to the amount and extent of gastro-intestinal irritation caused 
 by the poison, or even to the condition of the circulation, respiration, and 
 nervous functions. Learn all you can about your patient, and you will often 
 find yourself even then knowing too little to effect a cure. 
 
 Complications. — Erythema of the buttocks and thighs from the irritation 
 of the discharges is frequent, and, as has been stated, superficial ulceration 
 may be developed and may form a very distressing complication. Thorough 
 cleansing, the use of a mild soap, and subsequent dusting with starch or other 
 protective powder should be advised. 
 
 Boils over the head and face often appear, and the destruction of tissue 
 may be so deep that permanent scars are formed. 
 
 In strumous children the lymphatic glands in the inguinal region, more 
 rarely those about the throat, may enlarge and possibly suppurate. I once 
 saw a case in which the suppuration from the glands of the neck was so pro- 
 fuse that it endangered life. The urine, which was normal before the glands 
 began to swell, contained a considerable quantity of blood, and the hsematuria 
 continued for more than a week. The glands were freely opened and antisep- 
 tically treated, and the child ultimately recovered completely. 
 
 In the great majority of these cases the stomach remains surprisingly free 
 from any lesion, and this is true even when there has been frequent vomiting. 
 In a small number some hyperaemia of the mucous membrane of this organ is 
 found after death, and in rare instances minute ulcers have been observed. 
 
 Stomatitis is frequently a complication, and aphthous ulceration an occa- 
 sional one. 
 
 Hypostatic congestion of the lungs is frequent, and a subacute broncho- 
 pneumonia is a common complication of this form of diarrhoea. It is most 
 marked in the posterior and dependent portions of the lungs, and it often con- 
 stitutes the immediate cause of death. The condition of the patient in pro- 
 tracted cases renders it specially susceptible to specific micro-organisms, and 
 tuberculosis is sometimes developed. 
 
 Holt thinks that the frequency of nephritis as a complication has been over- 
 estimated since the writings of Kjellberg called attention to it, and J. Lewis 
 Smith doubts the correctness of generally attributing the vomiting to uneinic 
 
 31 
 
482 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 poisoning. My own observation and belief support the views of these Amer- 
 ican authorities. 
 
 Diagnosis. — Subacute milk infection is distinguished from the acute form 
 by the milder character of the former. The vomiting and purging are less 
 violent, the temperature does not rise so high, the prostration is not so great, 
 and the large serous stools, so characteristic of the acute form, are wanting. 
 From chronic intestinal indigestion there may be great difficulty in making a 
 differential diagnosis. The season of the year, the character of the food, and 
 the hygienic surroundings must be taken into consideration. The temperature 
 is also another valuable indication, as an elevation is exceptional in indigestion 
 except during periods of exacerbation. From intussusception, subacute milk 
 infection is to be distinguished by the suddenness and violence of the attack, 
 the tenesmus and pain, the absence of fever, and the stercoraceous vomiting 
 which characterize the former. 
 
 Prognosis. — As in the case of chronic intestinal indigestion, the prognosis 
 will be influenced by the parentage of the child, by its sanitary surroundings, 
 and by the period of time through which the poisoning has continued, and con- 
 sequently by the extent and character of the anatomical lesions. Cases develop- 
 ing at the beginning of a hot summer, especially when the parents are not able 
 to transfer the child from the crowded and possibly filthy quarter of a city to a 
 salubrious country place, are less likely to recover than those occurring among 
 the same classes late in the fall. The probability of relapses, when the sur- 
 roundings remain unfavorable, should always be borne in mind. 
 
 Treatment. — Preventive treatment intelligently carried out would save 
 thousands of lives annually in our large cities. The best of all these measures 
 is that the mother should nurse the child, and the mother who allows anything 
 short of absolute inability to prevent her doing so places the life of her child 
 in jeopardy. Daily bathing should be practised; and again I must call atten- 
 tion to the desirability of having nurses disinfect their hands after they have 
 changed the diapers of the infant. This should be done whether the child is 
 sick or well. Reports showing that all the children in a hospital fed by a certain 
 nurse have simultaneously developed a diarrhoea, while those fed with the same 
 food by other nurses have remained well, are given by some writers in order to 
 prove the contagious character of the disease. It is more than likely that these 
 cases were due to direct infection of the food from the hands of the nurse or from 
 the use of unclean receptacles. Soiled diapers, even those from healthy infants, 
 should not be allowed to dry in the air which children breathe. When the 
 mother cannot nurse her infant, the fresh, uncooked, uninfected milk of a 
 healthy cow is the best substitute. When this cannot be obtained with any 
 certainty, sterilized milk is the next best food from a prophylactic standpoint. 
 Fresh air, and plenty of exercise in it, are essential to the proper growth of 
 the child. 
 
 When we come to the curative treatment the question of feeding is one of 
 the most perplexing with which the physician has to deal, and the writer rej oices 
 that for the details on this point he can refer the reader to the high authority 
 who deals with the subject of Infant-feeding in this volume. However, it is 
 not fair to shirk all responsibility in this matter, and a brief statement of the 
 dietetic treatment will be given. 
 
 We will assume that the child has been artificially fed in whole or in part. 
 All milk food should be prohibited for from two to four days, possibly longer. 
 Escherich has shown that the bacterial flora of the infant's intestines changes 
 radically and speedily when milk is excluded from the diet. In fact, this is 
 one of the most potent agents at our command for destroying toxicogenic germs 
 
DIABRHCEAL DISEASES. 483 
 
 in the intestines. Their best culture-medium is milk, and in this they will 
 thrive and multiply most abundantly. Exclude milk from the food, and these 
 bacteria give place to others which, if toxicogenic at all, are less powerfully so. 
 The proteids of the milk may be replaced by animal broths and solutions of 
 egg-albumin, which should always be freshly prepared. The meat extracts of 
 trade are worse than worthless in these cases. Their nutritive value is prac- 
 tically zero. They contain extractives which may be used as stimulants, but 
 these are not specially indicated in the cases now under discussion. The carbo- 
 hydrates are best supplied in the form of soluble starch and dextrin, obtained 
 by boiling rice or arrow-root or by baking these or other foods rich in starches. 
 A return to a milk diet should be made cautiously: sterilized milk should be 
 employed, and at first in very small quantities, the greater part of the food still 
 consisting of the articles mentioned above. 
 
 Shall the medicinal treatment be begun by the administration of a laxative? 
 The answer to this depends upon the period in the development of the disease 
 when the physician first sees the patient. In dispensary work, and often in 
 private practice, the physician does not see these cases until the diarrhoea has 
 persisted for days, possibly for weeks, and after the little one has been dosed 
 with domestic remedies, which are practically unlimited in number and variety. 
 If the child is seen early, give from one to two teaspoonfuls of castor oil, fol- 
 lowed by one or two drops of the tincture of opium. If, on the other hand, 
 the' child is already exhausted from the continuance of the diarrhoea, begin at 
 once the administration of stimulants, whiskey or brandy, and give opium in 
 small doses, which may be repeated sufficiently to allay any pain and lessen the 
 peristaltic action of the intestines, but never sufficiently to induce constipation. 
 Irrigation of the intestines, as before described, should be resorted to in all 
 cases. After the large intestine has been cleansed by irrigation, from two to 
 three drachms of bismuth subnitrate should be suspended in from six to eight 
 ounces of water and retained as long as possible. The irrigation of the intes- 
 tines, with the subsequent injection, may be practised from two to four times 
 per week so long as the stools remain abnormal. Tannic acid, ten to fifteen 
 grains to the ounce of water, may be used instead of the bismuth. Irrigation 
 of the stomach is seldom indicated — never unless the vomiting be a marked 
 symptom. Bismuth subnitrate suspended in water or in some mucilaginous 
 drink should be given by the mouth in quantities of one or two drachms per 
 day. 
 
 Antiseptics are practically without value, and, as unnecessary dosing is cer- 
 tainly to be avoided, medication should be without them. The astringents, 
 both vegetable and mineral, such as catechu, coto-bark, silver nitrate, and lead 
 acetate, which are so frequently found in diarrhoea mixtures, are not only 
 valueless when given by the mouth, but they are likely to interfere with the 
 digestive action of the stomach, which, as we have seen, usually escapes involve- 
 ment in the diseased process, and consequently they are harmful. 
 
 In protracted cases general tonic treatment is often of great value. Dilute 
 nitro-hydrochloric acid, three or four drops in as many ounces of water, is one 
 of the best in the list of tonics. Fowler's solution, two or three drops three 
 times per day, may be of service, and the tincture of nux vomica has been 
 much praised. Iron and cod-liver oil are most appropriate after the digestive 
 disturbances have disappeared. 
 
 In the more acute forms, where tenesmus is marked, relief may be obtained 
 by the use of suppositories containing one-fourth of a grain of cocaine. Hot 
 applications over the abdomen may also be of value. 
 
 I must again emphasize the need of attention to the local sanitary con- 
 
484 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ditions in all cases of milk infection. These are of more importance than the 
 climatic influences; and, moreover, the former can be improved, while the 
 latter can be bettered only by a change in residence. Unhygienic surround- 
 ings tell most unfavorably upon the young child, whose organism requires time 
 in order to adapt itself to its environment. 
 
DYSENTERY. 1 
 
 By SAMUEL S. ADAMS, M. D., 
 
 Washington. D. C. 
 
 Dysentery is an inflammation of the mucous membrane of the large 
 intestine. In retaining the term " dysentery " in the nomenclature of diseases 
 of the intestines it is not because it is recognized as a distinct form of disease, 
 but because it is a convenient term to express the most prominent symptoms 
 resulting from the lesions in the colon and rectum. 
 
 There are three varieties — the catarrhal, the diphtheritic, and the amoebic. 
 
 I. Catarrhal Dysentery. 
 
 This affection may be acute or chronic, sporadic, endemic, or epidemic. 
 
 Etiology. — Catarrhal dysentery may occur at any age from birth to 
 puberty, but it is most frequent between the first and tenth year as an inde- 
 pendent affection. Sex exerts no influence, as it occurs as frequently in boys 
 as in girls ; and the same statement is true of race ; so if it happen to occur 
 more generally among any particular nationality in a community, it must be 
 attributed to other than racial influence. It occurs under all social conditions 
 from the highest to the lowest, and, while it is more prevalent among the 
 pauper and laboring classes, its severity is not tempered by high social stand- 
 ing. It is more frequent in the city than in the country, but occurs in the 
 latter with as great severity as in the former. Neglect, poverty, ill-ventilated 
 and uncleanly apartments, and insufficient and foul clothing act as predisposing 
 causes by depressing the general resisting powers of the child. Hence it is 
 met with more frequently among the inhabitants of the tenement-houses than 
 among those in sanitary dwellings. The liability to dysentery is increased by 
 such vices of constitution as tuberculosis, congenital syphilis, rickets, and 
 athrepsia, which enfeeble the general health. 
 
 As dysentery frequently occurs during the period of the eruption of the 
 deciduous teeth, there is a popular belief that it is the direct result of dentition. 
 After careful observation and study of the relation of dentition to diseases of 
 the alimentary tract in 288 infants, the author feels free to assert that neither 
 the evolution nor eruption of the teeth was found to be an etiological factor in 
 any of them. Similar investigations may convince the skeptical that improper 
 alimentation, and not "teething," is the most potent etiological factor in the 
 disorders of the alimentary tract of infants. So in order to establish a direct 
 relation between dentition and dysentery every other etiological factor must be 
 excluded. 
 
 The most frequent as well as the most powerful causative factor is improper 
 
 1 At the meeting of the American Pediatric Society, held at West Point in May 1893, it 
 was agreed to drop the term " Dysentery " from the nomenclature of diseases and substitute 
 for it " Ileo-Colitis." 
 
 4S5 
 
486 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 feeding. The food may be faulty in quality or quantity, or in both. Pure 
 food may act deleteriously if given in too large quantities ; and the correct 
 amount of impure food will certainly prove injurious. It occurs most often in 
 the artificially fed, although the nursling is not exempt. The former is not 
 only subjected to the perils of impure or ill-prepared cow's milk, but also to 
 the dangers of the indiscriminate use of indigestible "table-food." We fre- 
 quently see a baby lying in its crib or carriage with a half-filled bottle of 
 decomposed cow's milk, or, still worse, a concoction of some patent " infant 
 food," lying beside him, to the foul fly-infected tip of which he applies his lips 
 for comfort day and night. Changing the drinking-water, whether it be impreg- 
 nated with harmful germs or not, may irritate the intestinal canal. The author 
 has in his possession records of at least fifty children who undoubtedly con- 
 tracted dysentery by drinking the water from an impure city well. In this 
 instance the disease prevailed very generally among the children in an area 
 of several blocks, but those who did not use that pump-water were almost 
 entirely exempt. Seeds, uncooked vegetables, unripe or decayed fruit, toys, 
 coins, and many other indigestible substances may induce dysentery by injuring 
 the intestines in their passage through them. Weaning has been noted by 
 some as an etiological factor, but it must be remembered that coincident with it 
 is the introduction of artificial food — a recognized factor. Sudden changes of 
 temperature, particularly sudden and rapid falls, or exposure to draughts of 
 air, may chill the body and cause dysentery. It is now very generally accepted 
 that bacteria play an important part in the production of this disease, but as yet 
 experimentation has failed to detect a specific germ for the catarrhal form. 
 Finally, the anatomical lesions of catarrhal dysentery vary so much that we 
 are forced to the inevitable conclusion that no single etiological factor will 
 cause them. 
 
 Morbid Anatomy. — The lesions of catarrhal dysentery are usually con- 
 fined to the lower part of the colon and rectum, but in some cases may extend 
 along the upper part of the colon, and even into the ileum. They are charac- 
 terized by more or less intense hypersemia of the mucous membrane, either 
 general or confined to circumscribed areas, and there may be slight punctiform 
 haemorrhages into the mucosa or submucosa. The congested mucous mem- 
 brane varies in color from bright-red to dark-purple, and is never uniform ; it 
 is usually covered with thick, tenacious mucus. The large intestine is usually 
 empty, while the small is distended with gas and contains a thin greenish fluid. 
 The mucous membrane is commonly swollen and grayish in color. The solitary 
 lymph-follicles along the colon are swollen, sometimes to the size of a small 
 bean, and surrounded by an area of hyperemia. Between these inflamed 
 areas the mucous membrane is normal in appearance. Ulceration may take 
 place. The ulcers at first are round and superficial, but soon enlarge, two or 
 more coalescing and forming ulcers from one-half to one inch in diameter, often 
 exposing the muscular coat of the intestine. Their edges are everted and flat- 
 tened, and they assume an irregular, serpentine, or rodent shape. Ulcerations 
 in different stages of development may often be found in the same individual. 
 Patches resembling pseudo-membrane may also be found. Cicatrization begins 
 upon the floor of the ulcer, its edges being drawn toward the base. Perfora- 
 tion and peritonitis, which are seldom seen in children, may result from the 
 ulcerative process extending through the intestinal coats. The liver, which is 
 usually congested, may be the seat of multiple abscesses. The mesenteric 
 glands are enlarged and softened and dark blue in color. 
 
 ^ Bouchut found thrombi in the sinuses of the dura mater in 35 of the 38 
 children who had died of "dysenteric convulsions," and in the other 3, en- 
 
DYSENTERY. 487 
 
 cephalitis. Busey verified by his cases the results obtained by Bouchut. Cere- 
 bral anaemia, which is the commonly accepted cause of convulsions or death, 
 max be found alone or coexisting with thrombosis of the sinuses of the dura 
 mater. Busey has also observed, in a few fatal cases in very young children, 
 oedema of the lower extremities and discoloration of the skin of the feet and 
 legs, which he attributes to the formation of thrombi in the pelvic veins, 
 causing venous stasis and serous transudation into the subcutaneous tissues. 
 The following reports of necropsies illustrate some of the principal macro- 
 scopic lesions of dysentery : 
 
 Child, aged fourteen months, great emaciation, muscles flabby, and rigor mortis 
 deficient. Lungs. — Hypostatic congestion of lower lobes. Heart. — Large ante-mortem 
 clot in right auricle, and a smaller one in left auricle. Glands. — Mesenteric glands 
 enlarged and congested. Intestines. — Patches of congestion in lower part of small intes- 
 tine. Large intestine much thickened and deeply congested throughout its course. A 
 few superficial ulcers, especially near the ileo-csecal valve. 
 
 Busey's case. Necropsy twenty-four hours after death. Aged two years, emaciated, 
 abdominal walls retracted, and rigidity slight. Brain. — Weight 2 pounds b\ ounces, 
 anaemic, effusion into arachnoid cavity (estimated) 1 pint, slight in ventricles. Black 
 clots in all the sinuses, and a large white fibrinous thrombus at the junction of the right 
 lateral with the petrosal sinus. Heart. — Weight 1^ ounces ; effusion into pericardium ; 
 white fibrinous clot in superior vena cava extending into right auricle and firmly 
 attached to base of tricuspid valve. No blood in either ventricle, and valves intact. 
 Lungs. — Weight 1\ ounces, float in water ; left normal, right contained in middle lobe a 
 cheesy mass as large as a hen's egg ; this lobe was firmly attached to pleura. No tuber- 
 cular deposits. A cheesy bronchial gland as large as a pigeon's egg. Abdomen. — 
 Abdominal walls thin and destitute of fat. Omentum contains but little fat. Mesen- 
 teric glands slightly enlarged and congested. Small intestines contain faeces, and 
 nothing abnormal noted. Patches of intense inflammation all along the tract of large 
 intestine from caecum to anus. Liver anaemic, buff-colored; gall-bladder distended. 
 Large deposits of pus at lower extremity of either kidney. Weight \\ ounces each. 
 
 Fig. 1. 
 
 Showing Dysenteric Ulcer of Colon. 
 
 Microscopical Appearances. — There is considerable loss of surface epi- 
 thelium and of that lining the tubular glands. The glands frequently contain 
 pus-cells and degenerated epithelium. The interglandular tissue is infiltrated 
 
488 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 with serum and pus-cells. The mucous membrane softens, and necrosis extends 
 for a considerable distance into it. Here the glands are broken down, their 
 confines are lost and they may fall out or remain incarcerated in cast-off 
 epithelium, mucus, and pus. There may be ulceration accompanying these 
 changes. The ulcers are shallow and without well-defined borders. They 
 result from softening, suppuration, and exfoliation of the tissues into the sub- 
 mucosa or even down to the muscular coat. The solitary follicles are swollen 
 to the size of two or three millimetres in diameter, and vary in color from 
 transparent gray to opaque white. The swelling is due to an increase of round- 
 cells or hyperplasia of lymphatic tissue. Large epithelial and pus-cells, 
 mingled with lymphocytes, may be seen in the nodules. If the destructive 
 process continue, the epithelium over the lymph-nodules breaks down and an 
 ulcer is formed. The lymph-nodules then appear elevated, with a central 
 depression. 
 
 Symptoms. — The onset may be sudden, without premonitory symptoms, 
 accompanied by one or more chills or preceded by diarrhoea. The tempera- 
 ture is usually elevated two or three degrees, depending upon the intensity 
 of the inflammation ; the pulse soon becomes rapid, small, and compressible ; 
 the strength is rapidly diminished ; and the face presents a pinched, pallid, and 
 anxious expression. The tongue is moist and covered with a whitish fur. 
 There is seldom abdominal pain or tenderness on pressure. There is constant 
 desire to go to stool, with pain and straining during and after evacuation. The 
 stools, which at first contain faecal matter, soon become small, frequent, odor- 
 less, and consist of blood, mucus, and pus. Sloughs are rarely seen. The 
 stools vary in number from eight or ten to forty or fifty in the twenty-four 
 hours. As the inflammatory process advances to ulceration the stools contain 
 shreds, resembling " washed raw meat," mingled with blood and pus, and may 
 be passed involuntarily. The straining now becomes more severe, and prolapse 
 of the rectum frequently results from it. The abdomen becomes tympanitic, 
 and tenderness marked along the entire course of the colon. The tongue 
 becomes dry, with brown centre and red margin. Vomiting may supervene, 
 and prove to be intractable. The pulse becomes rapid, thready, and intermit- 
 tent, and syncope threatening. The respirations become sighing and the voice 
 inaudible. The eyelids are partially closed, and the pupils are widely dilated. 
 The child becomes restless, and tosses from one side of the bed to the other, 
 and delirium or convulsions may be present. The urine is high-colored and 
 scanty, or there may be total * suppression, with vesical tenesmus. 
 
 If examined microscopically, the typical "dysenteric stool" contains traces 
 of ingesta, various kinds of bacteria, fat, epithelial cells, round cells, mucus, 
 blood-corpuscles, and pus-corpuscles mingled together. 
 
 Cases. Nellie E , aged eighteen months, had been suffering several days with 
 
 loose bowels. The evacuations becoming frequent, small, bloody, and slimy, the parents 
 called in a physician. He found that she had a dozen or more dysenteric stools daily, 
 accompanied by great tenesmus, and that there was marked prostration. The disease 
 yielded to treatment, and she recovered in three days. 
 
 John B , aged twenty-two months, had had frequent bloody discharges for sev- 
 eral days, and had been dosed with numerous remedies for " summer complaint " which 
 had been prescribed by other physicians for other people's children. As he rapidly grew 
 worse, I was summoned. Found him running about the room, but he would frequently 
 assume the squatting position and strain. He had had twenty bloody, slimy, offensive 
 stools, and as many of " a stain of blood and slime," during the previous twenty-four 
 hours. The pain did not seem to be so severe, but he would strain until drenched with 
 perspiration. He could not be kept in bed. Finally, his symptoms became so much 
 worse that he was held by one of his parents, but not in recumbency. This modified 
 rest did but little good, as the rectum was soon prolapsed to about half an inch. After 
 
DYSENTERY. 489 
 
 exhausting the usual methods of treatment the disease succumbed to suppositories of 
 cocaine and ergotin, on the eighth day of my service. 
 
 Lottie E , aged four years, was seen forty hours after the dysenteric symptoms 
 
 began. She was now having frequent, offensive, muco-sanguinolent stools, accompanied 
 by exhausting tenesmus. The pulse was frequent and small, and the temperature was 
 not 100° F. The symptoms rapidly grew worse and she seemed liable to die at any 
 moment from cardiac failure. The rectum protruded, became cedematous, and blood 
 exuded from the mucous membrane. The prolapsed gut seemed to be about two inches 
 in length. On the ninth day of the disease the dysentery yielded to treatment, but the 
 prolapse lasted for a week longer. 
 
 Dimple G , aged seven years, had been sick for five days with dysentery. The 
 
 bloody discharges had increased in number, the pain had become more intense, the desire 
 to stool more imperative, and the evacuations were characterized as small, bloody, and 
 slimy. She was suffering from strangury produced by turpentine stupes, which had been 
 used for several days. She had had two hundred and eighty-one bloody, slimy stools in 
 thirty-six hours (four hundred and sixty-three during the five days of her illness). 
 Dr. D. obtained this history, and the following day called me in consultation. She now 
 had the appearance of being extremely ill. Her pulse was small, frequent, and com- 
 pressible ; the eyes were sunken and the pupils dilated ; the cheeks were pale and sunken, 
 and the lips livid and pinched; the tongue was slightly coated and very dry, and thirst 
 was intense ; there was nausea, but not vomiting, although she had vomited in the early 
 part of the illness ; the abdominal walls were flabby, and there was no pain upon pres- 
 sure over the abdomen. She had not slept for several days, and was continually begging 
 for sleep. The discharges were involuntary and had become so frequent that cloths were 
 kept under the nates to catch them ; they were small, bloody, and offensive. There was 
 great pain and straining. The voice was almost inaudible, and the respiration was sigh- 
 ing. Cerebral anaemia was well marked. She had frequent attacks of syncope, although 
 not permitted to raise her head from the pillow. Her condition was so critical that a 
 physician remained in her room. Stimulants and food were systematically given until 
 the stomach and rectum refused to retain them, when brandy and, finally, ether were 
 given hypodermatically. The attacks of syncope became more and more frequent, and 
 she died of exhaustion and heart failure seventy-two hours after the first consultation. 
 
 Diagnosis. — In sporadic cases of dysentery there may be some difficulty 
 in differentiating it in its early stage from acute intestinal catarrh, but when 
 the characteristic stools have once made their appearance all doubt will dis- 
 appear. In dysentery the stools contain mucus, blood, pus, and small masses 
 of faecal matter, and are odorless or have a "fresh-meat odor;" tenesmus is 
 always present, a small quantity is expelled from the bowel after a violent 
 effort, and the patient is bathed in a cold, clammy sweat, is exhausted, and 
 probably faints. In acute intestinal catarrh the evacuations are larger; the 
 blood, when present, is in streaks and not mixed with mucus ; the pain is more 
 intense and paroxysmal ; and tenesmus is seldom present. 
 
 The differentiation of sporadic from epidemic dysentery can be made by 
 the prevalence of the latter in the community. 
 
 Prognosis. — The prognosis in acute catarrhal dysentery in children is 
 usually favorable. The ordinary duration is from eight to ten days, but it 
 may prove fatal in twelve, twenty-four, forty-eight, or seventy-two hours. 
 The favorable symptoms are absence of foul odor, diminution in frequency 
 and improvement in the character of the stools, and disappearance of tormina 
 and tenesmus ; the absence of nervous depression and of anxious and care- 
 worn expression of countenance ; and increase of heart-power and arterial 
 tension. 
 
 The unfavorable symptoms are increased blood-loss, ashy aspect of counte- 
 nance, nausea, vomiting, hiccough, tympanitic and tender abdomen, nervous 
 depression, sleeplessness, tossing about the bed, moaning, delirium, convul- 
 sions or other marked cerebral disturbances, and suppression of urine. When 
 convulsions appear, death is not far distant. Busey observes that in many 
 cases death takes place under exactly similar circumstances — viz., one, two, or 
 
490 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 three convulsions, followed by coma and death, and in none of his cases did 
 consciousness return after the first convulsion. 
 
 II. Amcebic Dysentery. 1 
 
 This form, which is also known as tropical dysentery, is characterized by 
 the presence in the stools of the amoeba coli (Lbsch), amoeba dysenterioe (Coun- 
 cilman and Lafleur). It is this form which occurs in such fatal epidemics in 
 the tropics. " The amoeba is a unicellular, protoplasmic, motile organism, 
 from ten to twenty micro-millimetres in diameter, consisting of a clear outer 
 zone, ectosarc, and a granular inner zone, endosarc, containing a nucleus and 
 one or more vacuoles. It was first described by Lambl in 1859, and subse- 
 quently by Lbsch, who considered it the cause of the disease " — (Osier). The 
 disease is not infrequently seen in Europe and North America, but its home is 
 in tropical and subtropical countries. The most frequent source of infection is 
 unquestionably the drinking-water. 
 
 Morbid Anatomy. — Like the other varieties, the lesions are situated in 
 the colon, but in some cases they are also found in the lower portion of the 
 ileum. These lesions consist in ulcers, which result from infiltration into the 
 submucosa. At first small elevations appear along the mucosa ; the mucous 
 membrane covering them sloughs off, exposing an ulcer with a grayish -yellow 
 floor. Councilman divides these ulcers into four forms : (1) " Ulcers character- 
 ized by cellular infiltration, softening, and cavity-formation in the submucosa ; 
 these have a small opening in the mucous membrane and often communicate 
 with neighboring ulcers by passages in the submucosa. (2) Ulcers with slight 
 undermining of the edges, representing simple excavations in the thickened 
 submucous tissue. (3) Ulcers with smooth sides and clean bases. (4) Ulcers 
 with extensive adhering sloughs." These simply represent different stages of 
 the same process. The non-adjacent mucosa remains unaffected. 
 
 Osier says the "microscopical examination shows a notable absence of the 
 products of purulent inflammation. In the infiltrated tissues polynuclear 
 leucocytes are seldom found, and never constitute purulent collections. On 
 the other hand, there is proliferation of the fixed connective-tissue cells. 
 Amoebae are found more or less abundantly in the tissues at the base of, 
 and around, the ulcers, in the lymphatic spaces, and occasionally in the blood- 
 vessels. 
 
 " The lesions in the liver are of two kinds : firstly, local necroses of the 
 parenchyma, scattered throughout the liver and possibly due to the action of 
 chemical products of the ameebse ; and, secondly, abscesses. These may be 
 single or multiple. When single they are generally in the right lobe, either 
 toward the convex surface near its diaphragmatic attachment or on the concave 
 surface in proximity to the bowel. Multiple abscesses are small and generally 
 superficial. In an early stage the abscesses are grayish -yellow, with sharply 
 defined contours, and contain a spongy necrotic material, with more or less 
 fluid in its interstices. The larger abscesses have ragged, necrotic walls, and 
 contain a more or less viscid, greenish-yellow or reddish-yellow purulent 
 material mixed with blood and shreds of liver-tissue. The older abscesses have 
 fibrous walls of a dense, almost cartilaginous toughness. A section of the 
 abscess-wall shows an inner necrotic zone, a middle zone in which there is 
 great proliferation of the connective-tissue cells and compression and atrophy 
 
 1 The writer has depended almost entirely upon the valuable contributions of L. Emmett 
 Holt, Osier, and Lafleur and Councilman in preparing the sections on amcebic and diphtheritic 
 dysentery. 
 
DYSENTERY. 491 
 
 of the liver-cells, and an outer zone of intense hyperemia. There is the 
 same absence of purulent inflammation as in the intestine, except in those 
 cases in which a secondary infection with pyogenic organisms has taken place. 
 The material from the abscess-cavity shows chiefly fatty and granular detritus, 
 few cellular elements, and more or less numerous amoebae. Amoebae are also 
 found in the abscess-walls, chiefly in the inner necrotic zone. Cultures are 
 usually sterile. Lesions in the lungs are seen when an abscess of the liver — as 
 so frequently happens — points toward the diaphragm and extends by con- 
 tinuity through it into the lower lobe of the right lung. The gross and micro- 
 scopical appearances are similar to those of the liver." 
 
 Symptoms. — Sometimes the onset is sudden and at other times gradual. 
 The severer forms are characterized by a sudden onset. The diarrhoea inter- 
 mits, while loss of strength and emaciation are progressive. Moderate fever is 
 usually present, although some cases are unattended by this symptom. In 
 some, tormina and tenesmus and nausea and vomiting are marked at the onset, 
 while in others they are not observed. Twelve or fourteen grayish-yellow 
 stools, containing blood and mucus are voided daily. This condition persists 
 for weeks. The amoebae are found in great numbers in the stools during the 
 diarrhoeal attacks, but gradually decrease, and finally disappear as the attack 
 subsides. 
 
 Diagnosis. — This form is differentiated from the catarrhal by the frequent 
 exaggeration and remission of the diarrhoeal symptoms, but more especially by 
 the presence of amoebae in the stools. 
 
 Prognosis. — The duration varies from six to twelve weeks. The progno- 
 sis is not as favorable as in the catarrhal form ; and convalescence is slow, 
 owing to the depletion, the relapses, and the chronic tendency. 
 
 HE. — Diphtheritic Dysentery. 
 
 Diphtheritic or croupous inflammation of the intestinal tract is the most 
 fatal variety. It usually begins in the intestine, but may result from diphtheria 
 situated in the mouth, pharynx, or nose. 
 
 Morbid Anatomy. — Macroscopically, there is nothing significant in the 
 appearance of the intestinal contents unless patches of pseudo-membrane are 
 found upon washing. The stools vary in color from yellowish-green to greenish- 
 brown, and consist of mucus, faecal matter, occasionally digested blood — seldom 
 pure blood — and perhaps pieces of pseudo-membrane. 
 
 The lesions are situated over the entire colon and the lower portion of the 
 ileum, but are most numerous near the caecum. The intestinal wall is greatly 
 thickened and the rugae are obliterated. Small grayish-white, opaque masses 
 are seen upon the congested mucosa. These masses cling to the surface, and 
 can only be removed by tearing off a portion of the mucous membrane. These 
 small areas may coalesce and form a patch which involves the greater part of 
 the intestine, converting it into a thick, inflexible tube. Where the membrane 
 is extensive it is marked by numerous transverse and longitudinal fissures, 
 which give it the appearance of separate patches. The mucous membrane 
 devoid of the patch is intensely congested and roughened, or the only changes 
 may be confined to the diphtheritic areas. 
 
 Microscopical Appearances. — There is infiltration of the mucosa, and in 
 some cases, of the submucosa. The pseudo-membrane is composed of fibrin, 
 necrotic cells, and sometimes blood-corpuscles. The tubular glands are usually 
 unrecognizable, but their remains may often be detected in the necrotic masses. 
 The thickening of the intestine is due to the infiltration of the submucosa, the 
 
492 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dense mass of fibrin, the engorged blood-vessels, and extravasations of red 
 blood-corpuscles. Ulcers are seldom present in children, but when found are 
 usually of the follicular variety. 
 
 Symptoms. — This form is not seen in infants and is uncommon in children. 
 In some cases the onset is insidious, and may be mistaken for the catarrhal, 
 while in others it is abrupt and alarming. The symptoms are similar to, but 
 more severe than, those of the catarrhal or amoebic. The pathognomonic 
 symptom is the presence of pseudo-membrane in the stools. 
 
 Treatment of Dysentery. 
 
 Prophylaxis. — Acute catarrhal dysentery may often be avoided by 
 promptly and energetically treating the simpler forms of intestinal disease. 
 It too often happens that disorders of digestion are regarded as trifling, and 
 skilled assistance is only summoned when the signs of severe anatomical 
 lesions become manifest. 
 
 Hygiene. — Personal and domiciliary hygiene should be carefully supervised. 
 The child should be bathed at least once a day, and in very hot weather twice. 
 His clothing should be changed sufficiently often to protect him from sudden 
 variations in temperature ; especially is this true during the cool nights of 
 autumn. If not already too ill, he should be removed from the heat of the city 
 to some salubrious resort in the mountains or at the seashore. If circumstances 
 compel him to remain at home, he should be placed in a room where pure, fresh 
 air will be admitted freely. An occasional sponge-bath of equal parts of alcohol 
 or bay-rum and water will prove to be grateful, and will reduce the body heat 
 as well as allay nervous irritability. The infant's diapers should be removed 
 and placed in a disinfecting solution as soon as soiled, and in older children the 
 evacuations should be immediately disinfected. For this purpose solutions of 
 carbolic acid, 1 : 20, corrosive sublimate, 1 : 500, milk of lime, or some other 
 germicidal drug must be kept in some convenient place. 
 
 It is none the less important that the hygiene of the premises should be 
 scrupulously watched and every means possible used to prevent the accumula- 
 tion of filth. 
 
 Rest. — Rest in the recumbent posture must be enjoined from the start. 
 The stools should be passed in this posture, as any other will increase the pain 
 and straining. 
 
 Dietetic. — The diet should be prescribed in the very beginning, and but 
 little discretion given to parent or nurse. The nursing infant should continue 
 at the breast unless some condition of the mother, or of her milk, contraindicates 
 it. In all others sterilized, Pasteurized, or peptonized milk, beef-tea, beef- 
 juice, or mutton-broth, or all alternately, should be given in small quantities 
 at frequent intervals. Care should be taken not to overfeed, lest harm 
 be done. When the blood and mucus have disappeared from the stools, we 
 may gradually but cautiously return to a more liberal and mixed diet. A 
 liberal supply of natural mineral water, distilled water, or boiled city water 
 must be allowed. If the child refuse or is unable to swallow, food must be 
 administered by gavage — a method not at all difficult, and attended with 
 satisfactory results. 
 
 Medicinal. — There are no specifics for this disease, although different 
 remedies have been specially recommended by different writers. Some believe 
 the best results are to be obtained from ipecacuanha, others from opium, pur- 
 gatives, or vegetable or mineral astringents, while, latterly, many rely upon 
 the administration of intestinal antiseptics, as salol, mercuric chloride, naph- 
 
DYSENTERY. 
 
 493 
 
 thol, and sulpliocarbolate of zinc. While it may be admitted that all of these 
 methods have their advantages in individual cases, still, no one has proved to 
 be uniformly successful in the hands of those who treat the greatest number 
 of cases. 
 
 Usually the first indication for treatment is the removal of undigested or 
 indigestible food from the alimentary tract. For this purpose the mild saline 
 purgatives are especially indicated, or a stronger purgative, as for a child aged 
 6 years : 
 
 ty. Pulv. ipecac gr. ss. 
 
 Mass. hydrarg gr. iij . 
 
 Pulv. aromatic, comp gr. v. 
 
 Sacchar. alb gr. xv. — M. 
 
 Ft. chart. No. X. 
 Sig. One every two hours. 
 
 ^. Tinct. opii deodorat gtt. xij. 
 
 Olei ricini fjss. 
 
 Pulv. acacias q. s. 
 
 Aquae rosae q.s. adf^ij. — M. 
 
 Sig. Tablespoonful every two hours. 
 
 As soon as the scybala and undigested masses have been removed this 
 treatment should be suspended. 
 
 Of the mineral astringents the subnitrate of bismuth, in large doses, holds 
 the highest rank. The author has, at times, received benefit from the follow- 
 ing, which is both astringent and antiseptic : 
 
 3^. Plumbi acetatis gr. iv. 
 
 Acidi acetic q. s. 
 
 Acidi carbolic gr. ij. 
 
 Liquor, calcis q. s. ad f§ij. 
 
 Mix the first, third, and fourth, and add enough of the second to make a 
 
 perfectly clear solution. 
 Sig. Teaspoonful every three hours. 
 
 If the pain and straining are intense, relief may be derived from the 
 following : 
 
 3^. Cocain. muriat 
 
 gr. j. 
 
 Ext. ergot, aq 
 
 .... gr. x. 
 
 Ext. opii aq 
 
 . . . . gr. ij. 
 
 Aristol 
 
 . . . . gr. v. 
 
 Olei theobrom 
 
 . . . . q. s. — M 
 
 Ft. Suppos. No. X. 
 
 
 One every two or three hours. 
 
 
 Sig. 
 
 Stimulants are imperative, but should be administered with great care. 
 The dose of whiskey or brandy must be regulated by the age of the child and 
 the exigencies of the case. When these fail, the more powerful and diffusible 
 cardiac stimulants should be given, perhaps hypodermatically. 
 
 Local. — In the light of modern science the most rational treatment of 
 dysentery is intestinal irrigation. By it the irritating contents of the colon 
 and rectum are washed out and the pain and straining are mitigated, and in 
 
494 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 some cases entirely relieved. A distinction has been drawn by Dr. W. W. 
 Johnston, of Washington, D. C, between intestinal irrigation and injection. 
 The former is more correctly the application of a running stream to the inflamed 
 gut, in which the fluid has free egress, while in the latter the fluid is intro- 
 duced to painful distention. In the former a second tube permits a free out- 
 pouring and in the latter the fluid must escape between the nozzle of the 
 syringe and the anal sphincter or be forcibly expelled by the disabled intestine 
 after the tube is withdrawn. The former is preferable when the lesions are 
 below the sigmoid flexure, and the latter when they are above it. 
 
 To irrigate the rectum a double injection-tube, attached to a fountain 
 syringe, should be passed from three to five inches into the bowel, through 
 which a current of water is kept flowing at the pleasure of the operator. As 
 the passing of such an instrument is nearly always attended with great pain, 
 it is better to use two soft rubber catheters, well oiled ; the larger is attached 
 to the tube of the syringe, while the smaller is used as the escape-pipe. Pres- 
 sure on the flexible tubes by the operator's fingers will regulate the inflow and 
 outflow of the fluid. 
 
 To irrigate the entire colon in a child of eight or ten years it is necessary 
 to inject one or two pints immediately after a stool, but an infant requires much 
 less. The author has never succeeded in injecting such large quantities into 
 the bowel, but has obtained very satisfactory results from small quantities by 
 forcing it to be retained for a short time, by pressing a napkin against the 
 anus. This fluid must be slowly injected, so as to allow the inflamed and 
 infiltrated coats to adapt themselves to the increased tension. 
 
 The irrigating apparatus being ready, the child is placed on his left side, 
 with the hips on a plane higher than the body, or, still better, in the knee- 
 chest posture, so as to favor the inflow. The first irrigation should be given 
 by the physician, who will thus instruct the nurse to follow his particular 
 method. When the pain and tenesmus are severe, and the introduction of the 
 tube intensifies both, the rectum may be partially or completely anaesthetized 
 by suppositories of ice, aristol, europhen, or cocaine, or by the injection of a 
 2 or 4 per cent, solution of cocaine or carbolic acid. 
 
 The frequency of irrigation is best determined by the number of stools, 
 the object being to prevent the patient from having stools by washing out the 
 intestinal contents through the tube. At first the irrigation should be given 
 after every stool ; then, as the pain and tenesmus lessen and the blood and 
 mucus decrease, it must be given at longer intervals ; and, finally, when the 
 movements border on the natural, a daily irrigation for a few days may prevent 
 a relapse. 
 
 Hot or cold water, either plain or holding in solution one of the numerous 
 antiseptics, may be used as the irrigating fluid. In some cases very hot water 
 will afford marked benefit, while a large number, in the author's experience, 
 have received almost immediate relief from cold or ice-water. The temperature 
 of the water must be gradually lowered when irrigating the infant's bowel, as 
 the shock from ice-water might prove fatal. 
 
 Every writer has a favorite antiseptic for dysentery, but mercuric chloride, 
 1:10,000, is most extensively employed. The bowel must be quickly and 
 thoroughly emptied of this fluid to insure protection against its poisonous 
 effects from absorption. Some of the other antiseptics are carbolic acid, 
 boracic acid, hydrochloric acid, salicylic acid, aseptol, thymol, sulphocarbolate 
 of zinc, nitrate of silver, alum, quinine, and creolin. While it is advisable to 
 use some antiseptic solution in the graver forms, the great benefit to be derived 
 from irrigation in catarrhal dysentery is the cleansing. 
 
DYSENTERY. 495 
 
 In amoebic dysentery, Councilman and Lafleur have used solutions of qui- 
 nine. 1 : 5000. 1 : 2500, 1 : 1000, in five cases. In 3 cases improvement was 
 marked, in 1 the injections were suspended owing to a fatal complication, and 
 in the other the amoebae did not decrease during the quinine injections. Losch 
 found by experimentation that solutions of quinine, 1 : 5000, would kill amoebae 
 outside of the body, so Councilman and Lafleur were led to use it by intes- 
 tinal irrigation. The patient should be placed in the knee-chest posture, and 
 a half-pint or a pint of the quinine solution injected thrice daily, the enema 
 being retained for fifteen minutes. These writers claim that the enemata kill 
 the amoebae in the intestine, but have little or no effect upon those in the 
 tissues. 
 
 In diphtheritic dysentery the same rules of treatment that are recommended 
 in the other forms are applicable, but must be more vigorously employed. 
 Irrigation with solutions of mercuric chloride, silver nitrate, or hydrogen 
 peroxide seems to be the most rational procedure. 
 
CHRONIC CONSTIPATION. 
 
 By J. HENRY FRUITNIGHT, A. M., M. D., 
 
 New York. 
 
 Chronic Constipation, or the absence of a regular, periodical expulsion 
 of fgecal excrement from the bowels, is very prevalent in infancy and early 
 childhood. In childhood a daily evacuation should be the rule, whilst in 
 infancy two, three, and sometimes even four, motions are usual. 
 
 Excluding acute bronchitis, habitual constipation is the most common ail- 
 ment met with in early life. It is rather an aberration from the normal func- 
 tional activity of the bowels than an essential disease, but if not relieved may 
 in time seriously affect the general health of the patient by interfering with the 
 functions of other organs and with the processes of nutrition, and, as an ulti- 
 mate result, life even may be endangered. It often proves a very intractable 
 disorder, and, despite all that is done, it may continue throughout the period 
 of childhood, interfering with healthy development as well as with comfort. 
 Children who are artificially fed are more prone to constipation than those who 
 are suckled at the breast. 
 
 Etiology. — The cause of the constipation may exist in the person of the 
 patient, or the condition may be the result of some extraneous influence. We 
 will first speak of the former. 
 
 In the child the small intestine is comparatively longer and its lumen nar- 
 rower than in the adult, and its walls are feeble and not so thick. Again, the 
 ascending and the transverse colon are shorter, while the descending colon is 
 longer relatively than in the adult. Finally, the many curves of the intestinal 
 canal, the deep cul-de-sac in the sigmoid flexure just above the rectum, and the 
 contracted conformation of the pelvis in children, with the consequent crowding 
 of the intestines into a relatively small space, are well known. All of these 
 anatomical peculiarities act as causal factors. Another element of importance 
 in infancy, but which lessens in force as the child develops, is feeble peristalsis, 
 due to the imperfectly-developed state of the muscular coat of the intestines. 
 
 A diminution in the amount of intestinal secretions, especially of the bile, 
 favors the occurrence of constipation, for under such conditions the faecal mass 
 becomes hard and scybalous, and is apt to be too long retained. Then, too, if 
 fermentable food be taken, large quantities of flatus are generated and pain and 
 abdominal distention attend the constipation 
 
 Certain pathological conditions, obstructive in nature, are often present. 
 Among such conditions are tumors, congenital malformations, and uterine retro- 
 flexions; constricting bands resulting from acute or chronic peritonitis; intes- 
 tinal displacements, stenosis at the ileo-caecal valve, and a nest of lumbricoid 
 worms. Local disorders seated in the rectum may also cause constipation. 
 Chief among these is fissure of the anus, for in this disease, as pain is produced 
 when defecation is attempted, the patient refrains from the act of evacuation 
 and the constipated habit is gradually formed. 
 
 496 
 
CHRONIC CONSTIPATION. 497 
 
 In diseases of the central nervous system, as tubercular meningitis, hydro- 
 cephalus, microcephalus, and myelitis, which interfere with the innervation of 
 the abdominal and intestinal structures or which produce a spastic contraction 
 of these parts, constipation is generally present. The various constitutional 
 dyscrasiae, as tuberculosis, rachitis, syphilis, and the like, may, by weakening 
 the muscles engaged in the act of defecation, act as causes. 
 
 Any condition depriving the organism of water in large quantities renders 
 the faeces dry and predisposes to sluggish bowels : profuse perspiration and the 
 polyuria of diabetes come under this head. Want of attention in infancy and 
 the neglect to respond to the calls of nature on the part of older children are 
 potent factors, for by repeated stimulation and over-distention of the rectum by 
 its contents, its muscular activity is worn out and an atonic condition is the 
 result. Constipation sometimes results from diarrhoea. In such cases it is due 
 to atony and paresis of the muscular envelope of the intestines caused by 
 excessive and persistent irritation. Insufficient peristalsis, accumulation of 
 faeces, dilatation of the entire bowel or of certain parts, accompanied by reflex 
 symptoms due to interference with other functions of the body, are additional 
 factors conducing to this result. Some authors say that all cases of habitual 
 constipation are accompanied by a considerable amount of chronic irritation 
 and subacute inflammation of the caecum and colon and neighboring cellular 
 tissue. The effect of this is to reflexly arrest peristalsis. 
 
 We will now consider what may be called the extrinsic causes of constipa- 
 tion, or those which operate from without the body. Constipation in infants at 
 the breast may be the consequence of a constipated habit on the part of the 
 mother. In such cases the maternal milk may be deficient in fat, sugar, or 
 salt. In older children improper food is a very frequent cause. On the one 
 hand, food may be given to the child which after digestion leaves very little 
 residue in the bowel, so that no stimulation of the intestines is produced for the 
 expulsion of its contents. On the other, too coarse foods may be given, and the 
 residue may be so great that by constant over-stimulation of the muscular 
 coats of the intestines their tonicity is exhausted. Excess of farinaceous foods 
 will act in this manner, and all foods that are prone to fermentation by pro- 
 ducing accumulations of gas will hinder free action of the bowels. Lack of 
 moisture in the intestinal contents, resulting from scanty ingestion of water, is 
 another factor ; and still more potent are the indiscriminate use of medicinal 
 agents, especially castor oil ar>d spiced syrup of rhubarb — laxatives having a 
 secondary astringent action — and the repeated use of enemata, which destroy 
 the natural sensibility and reflex activity of the rectum. 
 
 In older children an in-door, sedentary life, negligence in regard to the for- 
 mation of a regular habit of evacuating the bowel, and a faulty posture at stool 
 are active in producing the constipated habit. In regard to the last element, 
 it may be said that in the physiological act of defecation the individual should 
 assume such an attitude that every muscle of the back and abdomen which 
 causes the bowel to be quickly and thoroughly emptied of its contents may be 
 brought into action. 
 
 Pathology. — The pathological condition to be found in constipation varies 
 from a simple hyperemia to a catarrhal or even ulcerative condition of the 
 mucous membrane of the intestines. Yet in many cases nothing whatever is 
 to be discovered in the intestinal canal. The intestinal walls are apt to become 
 thin, and some authors maintain that fatty degeneration of the muscular coat 
 of the intestines supervenes, resulting in a loss of contractility and expulsive 
 power. A swollen and distended condition of the bowels and a chronic inflam- 
 mation, with induration and thickening in the region of the caecum, are occa- 
 
 32 
 
498 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 sionally met with. Herniae, particularly umbilical, prolapsus ani, varicocele, 
 fissure, cystitis, and haemorrhoids may be the results of the violent and oft- 
 repeated straining, and the liver may be pressed upward and congested from 
 interference with the portal circulation. 
 
 Symptoms. — When constipation is due to obstruction, faecal matter accu- 
 mulates above the occluded point and produces distention of the abdomen, accom- 
 panied by eructations of gas, vomiting, impaired appetite, and a consequent 
 deterioration of the general health. If the intestinal contents be composed of 
 hard masses or contain coarse, undigested material, there is danger of complete 
 obstruction which will place the patient in a very perilous position. 
 
 In mild cases of functional constipation there is simply a retention of 
 the faeces in the rectum or lower bowel ; then there are no marked symptoms 
 with the exception of a sensation of fulness, distention, and weight in these 
 parts. 
 
 Generally speaking, the symptoms vary in degree according to the grada- 
 tion from the mild to the very grave forms of the disorder, but it is surprising 
 how frequently even severe cases of constipation are unattended by serious 
 symptoms. Very often, in consequence of local irritation from the retained 
 faeces, a conservative purging is excited, and the patient suffers alternately 
 from diarrhoea and constipation. The bowel, however, is not always fully 
 emptied of its contents when such a diarrhoea occurs, and the retained faeces 
 in time undergo decomposition, with the generation of noxious gases, which in 
 turn distend and irritate the bowels and cause severe colic. Faecal and gase- 
 ous distention also interferes with the action of the diaphragm, and produces 
 labored respiration or even great dyspnoea; it may also obstruct the venous 
 circulation in the viscera and interfere with the cardiac action and the circula- 
 tion in the thoracic cavity, leading to palpitation of the heart, irregular pulse, 
 and vertigo. Again, pressure upon the abdominal and portal venous systems 
 hinders the return circulation from the lower extremities, and produces slight 
 oedema of the ankles and feet; finally, obstruction of the portal ducts and 
 vessels, with attendant resorption of bile, may give rise to jaundice. In aggra- 
 vated cases of chronic constipation the pressure of the retained faeces may 
 cause inflammation of the mucous lining of the gut, when abdominal tender- 
 ness and fever will be noted. Sometimes the inflammation extends to ulcera- 
 tion, or even perforation, with their attendant symptoms. 
 
 When a constipated patient attempts to evacuate his bowels, he will expe- 
 rience great tenesmus, and the expelled mass may be streaked with blood and 
 smeared with mucus, indicating that the lining membrane of the rectum has 
 suffered in the violent effort at expulsion. 
 
 In infants constipation is accompanied by fretfulness ; the little patient draws 
 up his legs in pain, and, if he be nervously irritable, is very prone to an attack 
 of eclampsia. 
 
 In all cases of long-standing retention the fluid elements of the faeces are 
 reabsorbed, to be eliminated from the body by other emunctories. When this 
 occurs the blood becomes contaminated, and there is impairment of the gene- 
 ral health, with the production of such symptoms as languor, a foul breath 
 and furred tongue, headache, nausea, and more or less complete anorexia ; irri- 
 tability of temper or hypochondriasis and moroseness. The abdominal ner- 
 vous plexuses also are affected, and the sufferer, when old enough, complains 
 of formication, fatigue, and pain in the abdomen and lower extremities. 
 
 Diagnosis. — While the recognition of the existence of constipation is of 
 course very easy, it is often a difficult problem to detect the condition — the 
 actual disease — leading to the functional disorder of the bowels; and this 
 
CHRONIC CONSTIPATION. 499 
 
 problem must be correctly solved before successful treatment can be inaugu- 
 rated. 
 
 Such conditions as hernia, haemorrhoids, and continued tenesmus should 
 always lead one to expect the presence of the constipated habit. On the other 
 hand, all children who have small or infrequent faecal evacuations are not con- 
 stipated, as such features may be noticed when the food is too concentrated or 
 is allowed in insufficient quantity. 
 
 Prognosis. — Simple idiopathic chronic constipation never endangers life. 
 If, however, the condition depends upon some structural abnormality, the 
 prognosis is more grave. In its consequences, both immediate and remote, 
 constipation is of serious import. It will lead, as has been said, to fissures, 
 haemorrhoids, and other local troubles ; it impairs the general health, and if 
 not attended to early a lifelong habit is formed. 
 
 Treatment. — To secure, if possible, the removal of its cause should be our 
 first consideration in the treatment of constipation. If, on account of struc- 
 tural or pathological reasons, this be impossible, our efforts must be directed to 
 the minimization of its ill effects. In nurslings drugs should, as far as possi- 
 ble, be avoided, attention being paid to the food and to the diet of the mother 
 or nurse. If the mother's milk be deficient in fat, sugar, or salts, her diet 
 should be so modified that a larger quantity of these principles are presented 
 for assimilation ; she should also partake of laxative foods. If the child be 
 nourished by a wet-nurse, the same ends may be accomplished by a change to 
 one who is in an earlier stage of lactation and whose milk contains more fat 
 and less albumin. When, in spite of these measures, the constipation con- 
 tinues, some simple laxative is indicated. I frequently use a little molasses or 
 melted sugar and butter or sweet oil in teaspoonful doses. If the constipation 
 be due to an insufficiency of fluids, as indicated by dry and brittle motions, it 
 is wise to insist upon the child's being given water several times daily — an item 
 often overlooked by parents and nurses. Sometimes oatmeal-water may be 
 substituted for plain water with advantage, particularly in older children taking 
 a mixed diet. 
 
 When these simple measures fail, the next resort is to suppositories or 
 enemata, which act by local stimulation of the rectal muscles. Suppositories 
 should be conical in shape and made either of soap or molasses candy, or should 
 contain either gluten or glycerin. I prefer those containing glycerin, as being 
 most prompt and efficient in action. But whatever variety is selected, it should 
 be well oiled before insertion, and then gently introduced and pushed up well 
 beyond the internal sphincter. Glycerin may also be used by injection, in 
 the proportion of ten to twenty drops to two fluidrachms of water. Such an 
 injection is followed in from five to ten minutes by a full and painless motion. 
 The efficiency of the glycerin is due to its hygroscopic action ; it abstracts 
 water from the mucous membrane of the rectum, inducing hyperaemia of the 
 part and increasing peristaltic action through nervous excitation. Cold-water 
 injections are also recommended. These may be given at first three times, 
 then twice, and finally once, daily until a cure is effected. The addition of a 
 little table salt increases the activity of these enemas. As to the bulk of the 
 injection, one or two fluidrachms will usually suffice in infants. Too large 
 enemata not only dilate the bowel and paralyze its muscular coats, but may 
 also give rise to much pain, and even interfere with the respiration and circu- 
 lation. 
 
 If it be necessary to resort to drugs, the most simple are to be chosen, as 
 small doses of calomel, castor oil, solution of citrate of magnesium, carbonate 
 of magnesium, and phosphate of sodium, in properly graded doses. The last 
 
500 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. 
 
 remedy has given me great satisfaction in doses of one to five grains according 
 to the age of the patient. I frequently administer it in the following com- 
 bination : 
 
 Jfy. Sodii phosphatis ........ gr. xxiv. 
 
 Syr. niannae f^iiss. 
 
 Aq. anisi q.s. ad f liij. — M. 
 
 Sig. One teaspoonful three times daily, for a child under one year old. 
 
 Calomel may be given in one-sixth grain doses several times daily, but 
 must not be employed habitually ; laxatives that can be used more freely are 
 carbonate of magnesium in one- or two-grain doses in a little milk or aromatic 
 water, and the solution of the citrate of magnesium in doses of one to four 
 fluid drachms. 
 
 Older children must be trained to the formation of the habit of regular 
 daily evacuation of the bowels at a fixed time. Neglect of this very important 
 rule is very often the cause of constipation persisting through adult life, with 
 its disagreeable train of symptoms. Attention should also be directed to the 
 posture assumed in the act of defecation, in order that all the necessary mus- 
 cles may be brought into play. It is important, too, at this age to encourage 
 outdoor exercise, and to so regulate the diet that the child will receive plenty 
 of water and an abundance of laxative food. In this class belong fruit, either 
 in its natural state or cooked, oatmeal or cracked-wheat porridge, corn and 
 brown bread, green vegetables, molasses, etc. Farinaceous foods must be 
 restricted, but milk may be taken freely if the digestion be good. In the 
 proscribed list come cheese, uncooked dried fruits, fruits having numbers of 
 small seeds, and spices. 
 
 In the administration of medicine select the particular one that agrees best 
 with the patient; seek the appropriate dose to secure an evacuation; then 
 gradually reduce the dose until the constipation is ended. One of the most 
 useful drugs is calomel, given alone or in combination with powdered rhubarb, 
 half a grain of the former to one grain of the latter. This may be repeated 
 several times daily, but care must be taken not to administer calomel repeat- 
 edly in either tuberculous or rachitic children. If any rectal irritation be 
 present, compound licorice powder combined with sulphur is very useful. If 
 flatus be present, carbonate of magnesium combined with asafoetida will afford 
 relief. The fluid extract of cascara sagrada in one- or two-drop doses is a very 
 good remedy. Dr. Earle of Chicago recommends "in the case of a child two 
 years of age to clean out the bowels with two or three grains of calomel com- 
 bined with a little compound licorice powder, followed for a few days with car- 
 bonate of magnesium 3y in f lj of water, one to three teaspoonfuls daily until 
 the bowels are relaxed. Then give non-astringent iron preparations, nux 
 vomica, and possibly magnesium sulphate or cascara, until the cure is complete." 
 
 It has also been suggested that small doses of ipecacuanha, either alone or 
 combined with calomel, are very useful. 
 
 When there is great distention of the bowels it will be of advantage to 
 bandage the abdomen in order to assist in the restoration of muscle-tone. The 
 colon may be punctured with a hypodermatic needle when its distention is so 
 great that collapse is imminent from heart displacement. When there are large 
 collections of faecal matter in the colon, the more active cathartics must be 
 exhibited, accompanied by irrigation of the bowel through a rectal tube. If 
 the faeces are very hard, it is advisable to add to the fluid injected inspissated 
 ox-gall in the proportion of 3ij to the pint. I frequently add to the ox-gall 
 
CHBONIC CONSTIPATION. 501 
 
 the following mixture, which stimulates the bowel to relieve itself of its con- 
 tents, and also helps to carry off flatus: 
 
 1^. 01. terebinthinae f-5j. 
 
 Tr. asafoetidae, 
 
 01. ricini da f^iv. — M. 
 
 Sig. Add to a quart of warm water, and use for irrigation. 
 
 The suds of ordinary brown washing soap may also be added to this mix- 
 ture. If the rectum be impacted, instrumental and manual assistance must 
 be given; injections of small quantities of yeast have been also used with suc- 
 cess. Gradual dilatation of the sphincter has also been successfully employed. 
 If constipation be accompanied by the symptoms of indigestion, the diet should 
 be revised; pepsin with muriatic acid and cascara or taraxacum should be pre- 
 scribed. I again desire to call attention to the phosphate of sodium ; in older 
 children it may be given in doses of from five to eight grains dissolved in water. 
 
 The constipation which succeeds a diarrhoea requires the use of tonics. Of 
 these, strychnine stands first in efficacy, administered either alone or in the 
 favorite combination of iron, quinine, and strychnine. When atony of the mus- 
 cular coat occasions the trouble, nux vomica combined with belladonna, ergot, 
 and phosphorus are very valuable remedies. 
 
 As each case must be treated on its own merits, many of the cathartic 
 remedies which have not been alluded to by name will undoubtedly meet spe- 
 cial indications in special cases. Thus when there is an interference with the 
 hepatic functions the following is an excellent prescription : 
 
 1^5. Resinae podophylli g r -j- 
 
 Alcohol f.5iss. 
 
 Syr. rubi idaei . q. s. ad f^iij. — M. 
 
 Sig. A teaspoonful to a dessertspoonful every morning, according to the 
 obstinacy of the constipation. 
 
 When a copious evacuation is desirable the following is recommended: 
 
 Jfy. Tr. nucis vomicae Ttlxij. 
 
 Tr. belladonnae ITLxxiv. 
 
 Inf. sennae f^j. 
 
 Inf. calumbae q. s. ad f^iij. — M. 
 
 Sig. One teaspoonful for a dose. 
 
 The constipation which attends the various diathetic conditions demands 
 individual attention, but by no means to the exclusion of the diathesis itself. 
 Cod-liver oil and the syrup of the iodide of iron, both somewhat laxative in 
 nature, are especially useful in these cases. A very good formula is that pre- 
 scribed by Dr. J. Lewis Smith : 
 
 1^. Olei morrhuae f ^ij. 
 
 Liquor, calcis, 
 
 Syr. calcii lactophosphatis .... aaf^j. — M. 
 Sig. Give from one-quarter to one teaspoonful three times daily, accord- 
 ing to age of child. 
 
 For anaemic children mineral waters containing iron are beneficial. Thus 
 Friedrichshall is serviceable, as it has a tonic and laxative effect, and also 
 
502 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 favors the elimination of uric acid. In such cases a mixture of sulphate of 
 magnesium, sulphate of iron, and tincture of nux vomica is also serviceable. 
 
 Galvanism has its use in the treatment of constipation. The negative pole 
 is passed well up into the rectum, and the positive along the course of the 
 colon over the abdomen, for the negative pole excites local contraction, and the 
 positive pole peristalsis. Galvanism is to be preferred to faradism, being 
 more efficacious. 
 
 In conclusion, attention must be directed to one of the most important 
 measures used in the treatment of chronic constipation — namely, massage of 
 the abdomen and its contents. The technique of massage in children, though 
 it differs in no essential particular from the same procedure in adults, should 
 be modified in conformity with the position of the digestive organs at the various 
 periods of the child's life. As the main cause of constipation in children, exclu- 
 sive of the weak muscular coat of the bowel, resides in the descending colon, it is 
 rarely necessary to practise the manipulations on the right side of the abdomen. 
 The application of massage for as short a time as three minutes has been known 
 to produce the desired effect, and the sitting should not last more than ten minutes. 
 It may be repeated two or three times a day. The method of application is as 
 follows : The operation is preferable before nursing or feeding, excepting when 
 the child is very fretful or when the abdominal walls become very tense on 
 handling. In such cases it can be accomplished during the act of feeding, for 
 when the walls are very tense nothing can be effected. The hands should be 
 clean, warm, and dry. The resistance and rigidity of the muscles will deter- 
 mine the amount of pressure to be used. The production of pain should be 
 avoided ; hence the pressure should be gradually made, and until the child 
 becomes accustomed to it the manipulation should be very gentle. The finger- 
 tips placed upon the skin of the abdomen are moved about with the skin over 
 the intestines, but not rubbed. For the first two or three minutes concentric 
 circles are described by the manipulation in the region of the umbilicus ; then 
 in a similar manner the descending colon is treated, more pressure being made 
 in the downward than in the upward movement. More manipulation is re- 
 quired in the left iliac fossa than elsewhere, for obvious reasons. The caecum 
 and ascending colon may at times also require to be manipulated in the same 
 way. In older children sudden tapping of the abdominal walls with the finger- 
 tips, which will excite an instantaneous contraction of the abdominal muscles, has 
 been found to be of value. The results obtained by massage have been very 
 gratifying, and it should always be added to whatever other treatment may be 
 instituted at any period of infancy or childhood. 
 
SIMPLE ATROPHY 
 
 By LOUIS STARR, M. D., 
 
 Philadelphia. 
 
 Simple Atrophy, or the slow wasting commonly termed 
 is a familiar occurrence in hand-fed babies, and one of the most frequent 
 causes of death in early infancy. It is a condition in which there is extreme 
 wasting of the soft tissues of the body, either without special organic lesions 
 or with catarrhal inflammation of the mucous membrane of the gastro-intestinal 
 canal. 
 
 Etiology. — Wasting usually occurs during the first twelve months of life, 
 though it may begin in the second year, and is most frequently encountered 
 among children of the poor. It arises both in breast-fed babies and in those 
 brought up by hand, being in either case due to insufficient nourishment. The 
 child wastes because he is starved. 
 
 Food can be insufficient in two ways : first, when it is supplied in amounts 
 too limited to meet the demands of the system ; and second, when it contains a 
 minimum of the elements essential to nutrition or presents them in a form 
 ill adapted to the feeble digestive powers of infancy. For example, nursing 
 infants waste in consequence of feeding either from a breast that yields too little 
 good milk, or from one that secretes abundantly a poor, watery fluid entirely 
 unfit for nourishment. With artificially-fed children, on the other hand, it 
 rarely happens that the quantity of food is too small ; the fault lies, rather, in 
 the direction of quality. Undiluted cows' milk, milk thickened with starchy 
 materials, farinaceous foods, and even table food — meat, vegetables, and bread — 
 are given to babies a few weeks or months old. Now, all of these are highly 
 nutritious, but the digestive apparatus is not sufficiently developed to prepare 
 them for absorption. They are strong foods, adapted to nourish and strengthen 
 much older children and adults, but as the infant cannot appropriate them, he 
 starves no less surely, if more slowly, than when taking no food at all. Such 
 aliment also, while remaining undigested in the stomach and intestines, under- 
 goes fermentation, with the formation of irritant products, causing vomiting 
 or diarrhoea — conditions that still further lower the vital powers and hasten 
 atrophy. 
 
 It is often possible to trace the disease directly to want of cleanliness 
 in the feeding apparatus, and especially to the use of a form of bottle that 
 has until lately been very popular in this country, as it is still in England. This 
 bottle has, in place of a plain gum tip, an arrangement of glass and rubber 
 tubing of small calibre. One extremity of the rubber tubing, which is eight 
 or nine inches long, terminates in a small nipple-shaped tip and bone shield ; 
 the other, after penetrating an ornamental rubber cork, is fitted to a bit of glass 
 tubing long enough to extend quite to the bottom of the bottle. By this plan 
 the trouble of holding the bottle and keeping it at a proper angle during feed- 
 ing is avoided. This seeming advantage, though, is counterbalanced both by 
 the minor drawback that the child, left to itself, is apt to continue suction long 
 
 503 
 
504 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 after the bottle is exhausted, thus swallowing a quantity of air, and by the 
 greater disadvantage that the tubing can never be kept clean. 
 
 For a number of years the author made it a rule to ask for the bottle of 
 every hand-fed infant presented for treatment, and few days passed without his 
 seeing several of the complicated contrivances referred to. In almost every 
 instance, notwithstanding the most careful and frequent cleansing, a sour 
 odor could be detected, and if milk were present it contained numerous small 
 curds ; while in cases of carelessness the odor was intolerable, and the interior 
 of the tubing was encrusted with a layer of altered curd. "With simple bottles 
 and tips, on the contrary, alterations in the character of the milk and coating 
 of the interior of the tips were very infrequent. As there is little difficulty in 
 keeping the bottles themselves clean, there can be only one reason for this 
 difference — namely, in the simple instrument the nipple is readily removed and 
 as easily inverted and cleaned, but in the other there is no way of cleaning 
 thoroughly the twelve or more inches of fine tubing. The latter cannot be 
 inverted, and the passage of a stream of water or of a stiff brush only imper- 
 fectly removes the milk clinging to the interior. This, of course, soon under- 
 goes decomposition, and in this state quickly inaugurates change in the next 
 supply of milk placed in the bottle. It is evident that a constant supply of 
 food, no matter how good originally, thus rendered acid and partially curdled, 
 must, like an excess of farinaceous or other unsuitable food, produce irritation 
 of the alimentary canal, interfere with the processes of nutrition, and lead to a 
 state in which the features of wasting and disordered digestion are com- 
 bined. 
 
 The custom of preparing in the morning, without sterilizing, a supply of 
 food sufficient for the whole day is another fruitful cause of atrophy. If this be 
 done, no matter how carefully the mixture be proportioned or how well adapted 
 to the age and digestion of the child, it becomes unfit for consumption after 
 standing eight or ten hours. The change may or may not be appreciable to 
 the senses, but test-paper will always show acidity and the microscope demon- 
 strate the existence of actively-moving bacteria. Again, food upon which a child 
 has thrived for three or four months, perhaps, can become unsuitable, and conse- 
 quently lead to wasting, if the digestive powers be suddenly reduced by an inter- 
 current disease. 
 
 Wasting, while it is less serious in babies suckled at the breast, frequently 
 occurs in a modified form under these circumstances. There are several addi- 
 tional causal factors. Thus, an infant may be given to a wet-nurse whose own 
 baby is much older than her foster-child. In this case the milk is too strong, 
 for it is a well-known fact that as lactation advances human milk bcomes pro- 
 portionately richer in curd and cream, and the nursling, unable to digest and 
 assimilate it, ceases to thrive, and may even, in consequence, suffer from indi- 
 gestion or diarrhoea. Human milk is also affected by dietetic and emotional 
 influences, and, altering with the state of the general health of the mother, 
 may deteriorate in quality or otherwise become unfit for food. Finally, it hap- 
 pens at times that, although the mother may be healthy and have an abundant 
 breast, and although the infant may be robust, yet it does not thrive on the 
 milk supplied. Here the fault is generally an over-richness in cream. While 
 noting these facts, it must be remembered that in many cases of wasting in 
 nursing infants the fault is not with the mother's milk, but in the digestive 
 organs of the child, an attack of catarrh having temporarily impaired the pro- 
 cess of digestion. Without care and proper management the derangement 
 may be prolonged, and not infrequently leads to unnecessary weaning. 
 
 Morbid Anatomy. — After death the muscular and other tissues are found 
 
SI2IPLE ATROPHY. 505 
 
 in a state of atrophy, and there is a total disappearance of normal fat from the 
 body. Fatty degeneration of the kidneys, lungs, and brain may be discovered; 
 the stomach is sometimes ulcerated, and hemorrhagic effusions into the cranium 
 are not uncommon. 
 
 Symptoms. — The clinical features differ materially according to whether 
 the element of insufficiency be one of quantity or quality. They may, there- 
 fore, be divided into two classes — viz. those developed by food that is suitable 
 but not sufficient, and those resulting from unsuitable food. 
 
 The first group of symptoms is most frequently encountered in children who 
 have been nursed at the breasts of feeble or overworked mothers, in whom the 
 milk is often both scanty and of poor quality. There is a gradual loss of 
 plumpness, the muscles grow flaccid, and there seems to be an arrest of growth. 
 The face is white, the lips pale and thin, the skin harsh and dry or too moist, 
 and the anterior fontanelle level or slightly depressed. The temper is irritable 
 and sleep restless and disturbed ; or the child is abnormally quiet, dozing con- 
 stantly, and sucking his fingers until they become raw. When nursed the child 
 seizes the nipple ravenously ; then, if there be little milk, he quickly drops it 
 to cry passionately, as if disappointed at not being able to satisfy his hunger ; 
 but if the milk be abundant, though thin, he will lie a long time quietly at the 
 breast, and often fall asleep with the nipple in his mouth. The bowels are 
 inclined to constipation, the stools being scanty, hard, and dry. Physical signs 
 connected with the chest and abdomen are negative, and no indication of dis- 
 ease of any special organ of the body can be detected. 
 
 In the second class, features of wasting are associated with those of irritation 
 of the alimentary canal, and the symptoms altogether are much more grave 
 than in cases of the preceding group. The subjects are almost invariably hand- 
 fed infants. Emaciation progresses with a rapidity and to an extent depending 
 upon the original strength of the child's constitution, the age at which artificial 
 feeding was begun, and the sort of food employed. It is often so extreme that 
 an infant several months old weighs less and appears smaller than at birth, and 
 this even after a large quantity of food, such as it is, has been consumed. The 
 combination of great wasting with a voracious appetite is very striking, and is 
 only apparently contradictory, since hunger — the demand of the tissues for 
 reparative material — cannot be appeased by food which, from its bad quality, 
 is incapable of digestion or proper preparation for absorption and assimilation. 
 Unsuitable food, too, by irritating the mucous membrane of the stomach, creates 
 a fictitious appetite. 
 
 Sooner or later the face becomes pinched, the eyes sunken ; the lips are pale, 
 and when moved display a deep furrow about the angles of the mouth ; the 
 facial expression is uneasy or languid, and the anterior fontanelle is deeply 
 depressed. The skin, generally, is dry, harsh, and yellowish, hangs in loose 
 folds over the bones, and may be mottled by an eruption of strophulus or urti- 
 caria, or present red patches of intertrigo in the neighborhood of the genitalia 
 and over the buttocks and inner surface of the thighs. The extremities are 
 cold and the hands claw-like. The tongue is heavily furred or red and dry, and 
 with the mucous membrane of the mouth may be the seat of aphthous ulceration 
 or thrush deposit. As already stated, the appetite is often ravenous, and the 
 ories of hunger are violent, oft repeated, and only temporarily silenced by food ; 
 •hirst is increased ; colic is common ; the bowels are constipated, and the stools, 
 yhich are voided with difficulty and straining, are composed of a few light- 
 ©lored, cheesy lumps partly covered with greenish mucus. 
 
 Attacks of acute vomiting and diarrhoea often interrupt the regular course 
 oi the disease. At such times there is moderate fever during the night, though 
 
506 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 ordinarily the temperature is subnormal. Again, chronic vomiting and chronic 
 diarrhoea are apt to arise as complications, and greatly increase the danger of 
 a fatal termination. 
 
 Sleep is restless and disturbed, and many hours, particularly during the 
 night, are spent in fretful crying. A common group of symptoms connected 
 with the nervous system is "inward spasms." When these occur the upper 
 lip becomes livid, somewhat everted, and tremulous ; the eyeballs rotate or there 
 is a slight squint, and the fingers and toes are strongly flexed. They fre- 
 quently usher in true convulsions. 
 
 Sometimes the nervous manifestations are much more complex. Thus, I 
 have seen cases where there was retraction of the head, boring of the head 
 into the pillow, an approximation to the "gun-hammer" decubitus, general 
 hyperesthesia, and the tache cerebrale, — all suggestive of tubercular meningitis. 
 Such symptoms disappear under an appropriate diet with proper medicinal 
 treatment, and are to be referred to an intensely excitable nervous system — a 
 condition depending upon insufficient nourishment, and differing merely in 
 degree from that leading to " inward spasms." 
 
 There is, of course, extreme prostration, the cardiac action is weak, and 
 the respiration shallow. The urine is citron-colored or very dark yellow, has 
 a specific gravity of 1009 to 1012.5, a strong, characteristic odor, and is 
 diminished in quantity. It is always cloudy or milky, only becoming clear on 
 the approach of recovery. The sediment deposited on standing contains 
 variously-shaped cylinders ; fatty elements with tinted nuclei ; mucus ; colored 
 uric acid ; urates in a crystallized or amorphous condition ; pigment, etc. The 
 reaction is sometimes highly acid. The proportion of urates is decidedly, that 
 of uric acid notably, and of coloring matter and extractives somewhat, increased. 
 Albumin is always present in variable quantity, and sugar also may be fre- 
 quently detected. 
 
 Death may be preceded by convulsions or the symptoms of spurious 
 hydrocephalus, or may result from prostration. 
 
 Diagnosis. — Great emaciation may result from inherited syphilis or acute 
 tuberculosis, but both of these conditions are attended by characteristic symp- 
 toms, rendering their diagnosis a matter of little difficulty. In inherited syph- 
 ilis the child snuffles and cries hoarsely. The skin is dry, wrinkled, old-parch- 
 ment-colored, and mottled with coppery or rust-colored spots. Often the buttocks, 
 perineum, genitalia, and upper portion of the thighs are the color of the lean 
 of ham. Mucous patches are present at the margin of the anus and of the 
 lips. The corners of the mouth are fissured, the nostrils red and excoriated, 
 and the bridge of the nose is flattened. Enlargement of the spleen can 
 frequently be detected on abdominal palpation. 
 
 In acute tuberculosis there is fever, the rectal temperature reaching 100° to 
 101° F. in the evening; cough with irregularly distributed bronchial rales, and 
 usually slight oedema of the legs. 
 
 When symptoms resembling those of tubercular meningitis are present, it 
 is often necessary to delay a definite opinion. In simple atrophy, however, 
 the open fontanelle is level or depressed; the belly is never scaphoid; the 
 bowels, though frequently constipated, are never locked ; vomiting is apt 
 to be associated with diarrhoea; the respiration and pulse are regular in 
 rhythm ; the temperature, as a rule, is subnormal ; there is no hydrencephalic 
 cry ; and the antecedent history and the course are different from the tuber- 
 cular disease. 
 
 Prognosis. — A vast number of cases die annually in our large cities, y«t 
 the results of appropriate management are often rapidly and surprising^ 
 
PLATE Xin. 
 
 CASE OF SIMPLE ATROPHY, set. tliree months, 
 'eight at birth, 4 lbs. ; weight on admission to Children's Hospital, sy 2 lbs. Fed on a mixture of cane-sugar and water 
 
 (Died twelve hours after admission to hospital.) 
 
SIMPLE ATROPHY. 507 
 
 successful. Patients should never be given up unless there be extreme wasting 
 and prostration, or unless the symptoms of spurious hydrocephalus arise, 
 convulsions occur, or obstinate chronic vomiting or diarrhoea be developed. 
 
 Treatment. — For the arrest of wasting from insufficient nourishment, the 
 first and main thing to be attended to is the diet. Without entering at length 
 into this subject, 1 it may be stated, as a uniform rule, that in selecting a diet 
 the object should be to fix upon one suited to the age and digestive powers 
 of the child, so that he may be able to digest, and, therefore, be nourished by, 
 all the food consumed. 
 
 Generally, infants under twelve months who have to be either partially or 
 entirely "brought up by hand" do well upon cows' milk, diluted with lime- 
 water or with barley-water. Often it is well to sterilize the milk, or — a method 
 which has been most uniformly successful in my hands — to add to the 
 milk mixture peptogenic milk powder, and subject to a temperature of 155° 
 F. for six minutes. The food should be administered from a bottle capable 
 of holding half a pint, made of colorless glass, so that the least particle of dirt 
 can be seen, and provided with a soft India-rubber tip. Unless sterilized or 
 Pasteurized, the whole quantity of food intended to be given in a day should 
 never be prepared at once, but each portion must be made separately at the 
 time of administration. Thus, a bottle of the sort described, absolutely clean, 
 may be filled with a mixture of one part of lime-water to two or three of sound 
 milk, or with one part of barley-water to two or three of milk, to either of 
 which may be added from one to two tablespoonfuls of cream and a tea- 
 spoonful of pure sugar of milk. The bottle must next be placed in hot water 
 until the contents become warm, when it is ready for the child. 
 
 The degree of dilution of the milk and the proportion of cream added vary 
 with the age and feebleness of digestion, but it is upon the latter that we must 
 chiefly base the composition of the food. Lime-water is the preferable diluent 
 when there is frequent vomiting or acid eructation. Both it and barley-water 
 are of service in preventing the formation of large, compact curds — an object 
 that is even better accomplished by peptogenic milk powder, and by the 
 process of partial predigestion. In some cases it may be necessary to discon- 
 tinue milk foods entirely, putting the child temporarily upon weak broths or 
 raw beef juice. 
 
 After digestion has been brought into good condition, the food may be 
 cautiously increased to a standard suitable for a healthy child of the same age. 
 At eight or ten months from two to four fluidounces of thin mutton or chicken 
 broth, free from grease, may be allowed each day in addition to the milk ; at 
 twelve months, the yolk of a soft-boiled egg, rice and milk, and carefully 
 mashed potatoes moistened with gravy ; and at the end of the second year, 
 a small quantity of finely-minced meat. 
 
 Once daily the patient should be bathed in warm water, or at least sponged 
 over with warm water, and every morning and evening a teaspoonful of warm 
 olive oil or of cod-liver oil should be rubbed into the skin over the abdomen 
 and chest. At the same time the belly must be completely covered with a 
 soft flannel binder, and the feet and surface generally kept warm by woollen 
 clothing. In this way attacks of colic, if not entirely prevented, are rendered 
 much less frequent and severe. 
 
 If there be intertrigo, cleanliness and the free use of oxide-of-zinc oint- 
 ment usually suffice to effect a cure. 
 
 Of medicines, bicarbonate of sodium, pepsin, pancreatin, nux vomica, and 
 cod-liver oil are perhaps the most useful. Cod-liver oil should not be given 
 1 For the details of diet and general management, see Introduction. 
 
508 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 until the digestive powers have been brought into a comparatively normal state 
 by proper food, antacids, and digestants and the general tone increased by 
 tincture of nux vomica. The oil is most easily borne when given in emulsion, 
 and may be advantageously combined with lactophosphate of lime or with the 
 hypophosphites. 
 
 Such symptoms as constipation, diarrhoea, and vomiting demand, of course, 
 appropriate treatment. 
 
DISEASES OF THE (LECUM AND APPENDIX. 
 
 By JOHN ASHHURST, Jr., M. D., 
 
 Philadelphia. 
 
 Inflammatory Affections of the C^cum and Appendix. 
 
 Under the names of typhlitis, perityphlitis, appendicitis, caecitis, perityph- 
 litic abscess, etc. are included by systematic writers certain cases of inflam- 
 mation, usually severe and sometimes ending in suppuration or in general 
 peritonitis, met with in the right ilio-lumbar region. While these cases are 
 met with at all ages, they are sufficiently common in children to make their 
 consideration proper in a work devoted to the maladies of childhood, and they 
 are so often attended with danger and lead to such serious consequences that 
 their importance can hardly be overestimated. 
 
 The terms typhlitis and ccecitis are strictly applicable to inflammation, catar- 
 rhal or parenchymatous, affecting the caecum (blind gut) or caput coli ; peri- 
 typhlitis to an inflammation of the areolar or connective tissue behind the 
 caecum, where this portion of bowel is usually uncovered by peritoneum ; peri- 
 typhlic abscess to a collection of pus occurring in the same region ; and the 
 somewhat barbarous term appendicitis to an inflammation of the pouch or 
 diverticulum known as the appendix vermiformis. Without denying that 
 the caput coli itself may be primarily the seat of inflammation, as indeed 
 may any portion of the intestines, constituting the grave condition enteritis, 
 and while acknowledging at least the possibility of a true perityphlitis, per- 
 haps leading to extra-peritoneal suppuration, there can, I think, be no doubt 
 that in the large majority of instances the appendix vermiformis is the part 
 primarily involved, and that the resulting abscess, when pus is formed, is 
 intra-peritoneally situated, though fortunately, in most cases, walled off by 
 adhesions which prevent the general infection of the peritoneal cavity. 
 
 Morbid Anatomy. — The pathological lesions found in cases of inflamma- 
 tion of the caecum and appendix are quite variable. In the majority of cases 
 the inflammation does not advance beyond the stage of lymph-formation, and 
 even after repeated attacks (for the disease is often recurrent) the parts will be 
 found indurated and thickened, and matted together by dense adhesions ; but 
 there will be no abscess. In other instances, and particularly when the patient 
 is tuberculous, pus will form at an early period, usually as the result of ulcer- 
 ation and perforation of the intestinal wall, but sometimes without perforation, 
 simply from the intensity of the inflammation. Foreign bodies, such as grape- 
 seeds, etc., are occasionally found lodged in the caecum or appendix, or loose in 
 the surrounding abscess ; but more commonly what are supposed to be foreign 
 bodies are really concretions of earthy phosphates with faecal matter and inspis- 
 sated mucus, or of inspissated mucus alone. The caecum from its shape and 
 position is apt to become the lodging-place for concretions of this character, 
 which set up irritation and may lead to ulceration of the caecal wall, while small 
 
 509 
 
510 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 concretions may enter the appendix, or, as is more commonly the case, the mouth 
 of the appendix becoming occluded by catarrhal inflammation and thickening, 
 concretions form in situ by inspissation of the retained secretion of the part, 
 which in the normal condition is poured into the caecum, and forms a natural 
 lubricant for the faecal mass in its passage through the large intestine. When 
 pus forms in these cases, it may make its way into an adjoining segment of 
 bowel; may become more or less thoroughly encysted and form a fluctuating 
 tumor in the iliac fossa ; may burrow in various directions, coming to the sur- 
 face in the lumbar region above the iliac crest, or, passing downward in the 
 course of the psoas muscle, below Poupart's ligament; or, finally, may infect 
 the general cavity of the peritoneum, causing diffuse purulent peritonitis, which 
 quickly proves fatal. In exceptional cases the pus has been known to perfor- 
 ate the diaphragm, causing pleurisy and empyema, or to enter the hip-joint. 
 
 Etiology. — The causes of typhlitis and appendicitis may be divided into 
 the predisposing and the exciting causes. Among the former may be men- 
 tioned sex, these affections being much more common in the male than in the 
 female, in the proportion, it is said, of six to one ; age, most cases occurring in 
 early life ; the presence of tubercle, tuberculous patients being not only more 
 exposed to appendicitis than the non-tuberculous, but the disease in them more 
 quickly running on to suppuration, and convalescence after an operation, 
 should such be necessary, being effected more slowly and with more interrup- 
 tions ; and habitual constipation, the retention of faecal matter in the caecum, 
 which is sometimes distended to an enormous size, maintaining a constant 
 source of irritation, and exposing the intestinal wall to the dangers of ulcer- 
 ation and perforation. The exciting causes are the entrance of foreign bodies 
 into the appendix — seeds, pins, hairs, etc. ; the ingestion of indigestible food ; 
 exposure to cold or wet ; falls, blows, or strains of the abdominal parietes ; and 
 the abuse of drastic purgatives. 
 
 Symptoms. — The symptoms of typhlitis and appendicitis are variable and 
 often deceptive. Sometimes beginning with a chill, the early symptoms are more 
 often those of enteritis generally, pain, vomiting and constipation, fever, and 
 tenderness with some fulness in the region of the inflamed part. The pain is 
 usually greatest in the right iliac fossa, but is sometimes referred to the navel, 
 and may even be most marked on the left side of the abdomen ; but even when 
 the pain is misplaced, the greatest tenderness will, unless general peritonitis 
 be impending, be found upon the right side, and especially at a point distant 
 an inch or an inch and a half (in the adult two inches) from the anterior supe- 
 rior spinous process of the ilium, and in a line drawn from that point to the 
 umbilicus. This tender spot, which is known as " McBurney's point," corre- 
 sponds to the position of the appendix, and, as already mentioned, it is the 
 appendix which is primarily involved in the large majority of cases. At a 
 later period, when pus has formed, the "soft spot" which precedes pointing 
 of the abscess may sometimes be detected in precisely the same locality. Coin- 
 cidently with the development of tenderness in the right iliac region, gentle 
 palpation will reveal a fulness, followed at a later stage by tenderness and 
 tumefaction, in the position of the caecum ; and in order to relieve the inflamed 
 part from pressure of the superjacent tissues, the patient will usually secure 
 relaxation of the abdominal wall by lying on his back, slightly turning to the 
 right side, and with the right knee drawn up. 
 
 The vomiting is often distressing, attended with considerable effort, and 
 aggravates the pain by succussion of the inflamed parts: the ejected matters 
 consist at first of the contents of the stomach, and afterward of the intestinal 
 juices with bile : faecal vomiting does not, as a rule, occur, even when general 
 
DISEASES OF THE C^ECUJI AND APPENDIX. 511 
 
 peritonitis follows, this being a point of some importance in the diagnosis of 
 these conditions from intussusception and other forms of mechanical obstruction 
 of the bowel. The constipation in appendicitis and typhlitis is not complete : 
 there may be an occasional discharge of flatus ; evacuations may be secured 
 by the use of enemata. and the administration of salines may cause even free 
 catharsis without modifying the other symptoms of the disease. The fever is 
 not very intense, the temperature varying from 101° to 102° F., and is accom- 
 panied with a quick pulse, furred tongue, and intense thirst : when suppura- 
 tion occurs the fever may assume a hectic type, and in the cases which ter- 
 minate unfavorably the tongue becomes brown and dry, sordes accumulate 
 about the lips and teeth, and the patient passes into a decidedly "typhoid" 
 condition. 
 
 When suppuration occurs the symptoms undergo some modification. The 
 pain and tenderness are usually increased ; rigors may occur at irregular inter- 
 vals ; the tumefaction in the right iliac region becomes somewhat boggy, the 
 overlying integument being perhaps congested and slightly oedematous; a "soft 
 spot" may be observed; and, if the pus be not evacuated, fluctuation, with 
 ultimately pointing, as in abscesses elsewhere. There are sometimes pain in the 
 right knee and ankle, and oedema of the leg. The pus in these cases commonly 
 has a strong faecal odor from proximity to the bowel, even though no perfora- 
 tion be discoverable. 
 
 Diagnosis. — The diagnosis of appendicitis and typhlitis can usually be 
 made without difficulty if the symptoms be carefully noted, the affections in 
 regard to which confusion is most likely to occur being enteritis, intestinal 
 obstruction, psoas and iliac abscess, and hip disease. Enteritis — by which term 
 is meant inflammation involving all the coats of a segment of intestine — is well 
 described by Sir Thomas Watson as "peritonitis with something more." It 
 may occur in any part of the bowel, not being limited to the right iliac region, 
 and the localizing symptoms of appendicitis — McBurney's point, etc. — are 
 therefore wanting. The paralysis of the gut is more complete, constipation 
 consequently being more absolute, with no discharge of flatus, and the vomit- 
 ing, if relief be not afforded, soon assuming a faecal character. Typhlitis, 
 using the term accurately, is of course a form of enteritis, but when the inflam- 
 mation is limited to the caecum the symptoms are less severe than when a larger 
 portion of bowel is implicated. Mechanical obstruction of the intestine in 
 children is usually of the character of intussusception, though internal strangu- 
 lation by bands or diverticula is occasionally met with. In the latter condition 
 the pain would be felt mainly at the seat of obstruction or more commonly at 
 the umbilicus ; there would be no fever, the temperature more probably being 
 subnormal, sometimes even after the development of peritonitis ; there would 
 be faecal vomiting, with absolute constipation and inability to pass wind ; gen- 
 eral tympany, from paralysis of the bowel allowing gaseous distention ; partial 
 suppression of urine ; and the patient would pass into a state of collapse, sooner 
 or later according to the position and closeness of the strangulation. In intus- 
 susception there might be fever from secondary inflammation of the affected 
 bowel ; there would be a tumor, but instead of occupying the right iliac fossa, 
 it would be found in a median position or upon the left side : there would, in 
 acute cases, be a discharge of blood and mucus from the bowel ; and digital 
 exploration of the rectum would, in children at least, probably detect the lower 
 end of the invagination. Psoas abscess is usually, though not invariably, 
 accompanied by evidences of preceding disease of the spinal column, is not 
 attended by pain or marked tenderness, and presents no intestinal complica- 
 tions; iliac abscess, if depending upon ovarian or periuterine inflammation and 
 
512 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 situated on the right side, may more closely simulate appendicitis ; but even here 
 the distinction may be made by observing the absence of bowel symptoms. In 
 hip disease the peculiar and characteristic deformity and malposition of the limb, 
 varying with the stage of the disease, will suffice, when present, to clear up the 
 diagnosis ; in appendicitis, though extension of the limb may cause great pain, 
 it is not accompanied by the arching of the lumbar spine observed in hip disease, 
 and the joint may be moved, without causing suffering, in other directions. In 
 the rare cases in which an abscess, originating in appendicitis, opens into the 
 hip-joint, causing secondary disease of that articulation, the symptoms would be 
 confused, both maladies then, in fact, coexisting in the same subject; but under 
 ordinary circumstances the absence of intestinal symptoms in the one case, and 
 the absence of joint symptoms in the other, ought to prevent the possibility 
 of error. 
 
 With regard to the special diagnostic importance of " McBurney's point," 
 a good deal of difference of opinion prevails among practitioners, and the tend- 
 ency at the present time is to consider it of but little value. For my own 
 part, I am disposed to place considerable reliance upon this symptom, and 
 believe that the detection of induration and tenderness, or at a later period of 
 a "soft spot," in this particular situation is, while perhaps not pathognomonic, 
 at least strongly significant of disease originating in the appendix. 
 
 Tumor of the kidney, perinephric abscess, carcinoma of the bowel, and 
 abscess of the abdominal wall have been mistaken for appendicitis, but careful 
 examination and investigation of the history of the case ought to prevent an 
 error in this direction. 
 
 The diagnosis of perforation of the caecum or appendix may be made when 
 symptoms of suppuration occur, or when the spread of pain and tenderness to 
 the left side of the abdomen indicates the threatened implication of the peri- 
 toneum generally. Fortunately, before or immediately after the occurrence of 
 perforation, adhesions usually form and seal off the affected part from the rest 
 of the peritoneal cavity, and even where this does not occur, an interval of some 
 hours, or even a day or two, may intervene before the development of univer- 
 sal peritonitis, giving an opportunity for prompt surgical intervention which 
 may save life even in this emergency. 
 
 Prognosis. — The prognosis in appendicitis and typhlitis is in the large 
 majority of cases favorable. Under judicious treatment the acute symptoms 
 will subside in from four days to a fortnight, although a certain amount of 
 induration and tenderness may persist for a much longer period. The patient 
 is now apt to become intolerant of the regimen and rest which has been hitherto 
 enforced, and resumes his ordinary diet and manner of living, with the result 
 that relapse occurs; and this sequence of events may be repeated indefinitely. 
 The reason that recurrence of appendicitis is so often met with is, I believe, 
 that the patients will not persist in treatment until completely recovered. If 
 thoroughly cured, a second attack is not, according to my experience, to be par- 
 ticularly dreaded. 
 
 When perforation occurs the prognosis becomes more gloomy. In the rare 
 cases, if such exist, in which the opening is in the caecum behind the peri- 
 toneum, a burrowing abscess will result, and convalescence will, under the most 
 favorable circumstances, be tedious. If the perforation be intra-peritoneal, 
 peritonitis, local or general, is inevitable ; in the former case, the infected area 
 being separated by adhesions from the general cavity, recovery after operation 
 may be hoped for ; in the latter, though by prompt intervention a patient may 
 occasionally be snatched, as it were, from the very jaws of death, yet the large 
 majority will perish; diffuse suppurative peritonitis is almost always a fatal 
 
DISEASES OF THE CjECUM AND APPENDIX. 513 
 
 affection. In tuberculous patients the prognosis, cceteris paribus, is always 
 less favorable than in others. 
 
 Treatment. — The treatment of appendicitis and typhlitis may be either 
 prophylactic or curative. As preventive measures, care should be taken to avoid 
 constipation by regulation of the diet, by encouraging defecation at a fixed 
 hour daily, and, if necessary, by the use of laxatives. The patient should be 
 warmly clad, especially around the abdomen, should keep the feet dry, and 
 should avoid exposure to cold and wet generally. When the disease actually 
 occurs, the indications for remedial treatment are — (1) to keep the inflamed 
 part at rest ; (2) to relieve the congestion ; (3) to prevent pain ; and (4) to 
 maintain the patient's nutrition without overtaxing the impaired powers of 
 digestion. If suppuration occur, the pus must be promptly evacuated by 
 incision and drainage. The first indication is met by keeping the patient in 
 bed and by avoiding the use of purgatives, which under these circumstances 
 can only do harm. The constipation and consequent accumulation of faecal 
 matter in these cases are owing to paralysis of the bowel, more or less com- 
 plete, due to its inflamed state ; or, in other words, are a result, not a cause, of 
 the inflammation. This is a distinction which often the friends of the patient, 
 and sometimes even the physician, seem unable to comprehend ; they cannot 
 understand that the patient is not ill because his bowels are not moved, but 
 that his bowels are not moved because he is ill. In saying this I am not 
 unmindful of the fact that salines, in small but frequently repeated doses, are 
 often used in these cases, and that the patients sometimes do well under this 
 treatment ; but the benefit is due to the action of the remedy as an indirect 
 means of effecting depletion and drainage, and if this could be accomplished 
 without catharsis it would be so much the better. The second and third indi- 
 cations are met by the application of leeches (if the symptoms are very urgent), 
 and by the use of warm cataplasms and the administration of opium. The 
 fourth indication is met by careful feeding with peptonized milk or other liquid 
 nutriment, or, if the patient vomit, by employing nutritive enemata. The course 
 of treatment may then be established as follows : The patient being strictly 
 confined to bed, a few leeches are applied over the seat of greatest pain, draw- 
 ing from two to six fluidounces of blood according to his age ; if for any reason 
 leeching be thought unadvisable, a small blister may be applied, and the part 
 afterward covered with mercurial and belladonna ointments, equal parts, spread 
 upon lint, and over this in turn a warm flaxseed or elm poultice. Enough 
 opium should be given to relieve pain, either by the mouth in the form of the 
 deodorized tincture, or by suppository ; or morphia may be given hypodermat- 
 ically if preferred. Belladonna may properly be combined with the opium, and 
 is also to be used locally with the mercurial ointment, as already described. 
 When the pain has entirely ceased, but not before, if the bowels do not move 
 spontaneously in the course of twenty-four hours, a warm enema of olive oil 
 and soap-suds may be administered ; if this fail, and if there be no tendency to 
 vomiting, small doses of the Epsom or Rochelle salt — from half a drachm to a 
 drachm — may be tentatively given every hour or two hours, the enema being 
 repeated twice daily ; if there is nausea or vomiting, the saline should be 
 omitted, and calomel in minute doses (gr. ^ - ^ 2 ), with bicarbonate of sodium 
 (gr. j-ij), may be given instead. Administered in this way, and the patient 
 being still kept under the influence of opium, I doubt if these medicines cause 
 any increase of peristalsis, and the good which they undoubtedly do is. as 
 already mentioned, due to the serous flow from the congested and inflamed 
 bowel to which they give rise. 
 
 After the subsidence of all acute symptoms the salines may be continued in 
 
 33 
 
514 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 reduced doses, so as to cause two or three passages from the intestines daily, 
 and the local use of mercury and belladonna, or a belladonna plaster, should be 
 continued until the swelling and tenderness have disappeared, when the remain- 
 ing induration may be treated by painting the part with tincture of iodine 
 every day or every other day, according to the effect produced, maintaining 
 mild but persistent counter-irritation without blistering. During the early stages 
 the rio-ht lower limb may be flexed over a pillow to relax the abdominal wall, 
 but as soon as possible it should be brought flat, and, if there is any tendency 
 to permanent contraction, weight-extension should be applied to keep the limb 
 in proper position. 
 
 In the large majority of cases, unless the patient be tuberculous, prompt 
 and persistent treatment on the lines above indicated will suffice to effect 
 recovery. After convalescence the patient should live by rule, avoiding indi- 
 gestible food, and observing all the precautions referred to in speaking of 
 prophylaxis. 
 
 If, however, instead of yielding to treatment, the symptoms persist, and the 
 evidences of deep-seated suppuration — fluctuation, superficial oedema, or a " soft 
 spot" — are manifested, no time should be lost in resorting to an exploratory 
 operation. So important is promptness under these circumstances that it has 
 been maintained that in every case the physician should associate with himself 
 a surgeon to watch the patient from the beginning of the attack, so that there 
 may be no delay when the critical moment arrives. I am not prepared to say 
 that this is always necessary, but I do say that if a physician undertakes the 
 management of a case of appendicitis alone, he should possess the tactus 
 eruditus which will enable him to recognize suppuration as soon as it occurs. 
 I have more than once been called to patients who had been treated many 
 days, if not weeks, by practitioners who had not detected the presence of pus, 
 the signs of which were yet, to the surgical sense, quite obvious. 
 
 Operations for Appendicitis. — It was formerly recommended, when 
 suppuration was believed to have occurred in cases of csecal or appendiceal 
 inflammation, to verify the diagnosis by the introduction of an exploring 
 needle ; but the feeling of modern surgeons is against the use of this instru- 
 ment, as being very apt, on the one hand, to miss striking the purulent col- 
 lection, and, on the other hand, if it should reach the abscess, apt to infect 
 the peritoneal cavity as it is withdrawn ; and a careful incision of moderate 
 extent is, I have no doubt, safer in every way than the blind thrust of a needle- 
 point, as well as more likely to discover the seat of suppuration. Before 
 making the incision the abdominal wall should be thoroughly cleansed and 
 purified, but with great care and gentleness, as it would be quite possible 
 for a vigorous antiseptic scrubbing to break through the limiting adhesions 
 and diffuse the contents of an abscess through the peritoneal cavity. Opera- 
 tors differ as to the best line for incision : when it was believed that the purulent 
 collection was formed outside of the peritoneum, the rule, as laid down by 
 Willard Parker, Hancock, Buck, and Sands — who may be regarded as the 
 pioneers in this branch of surgery — was to make the incision above Poupart's 
 ligament, as in tying the external iliac artery, and endeavor to reach the 
 abscess by cautiously working upward and pushing the serous membrane out 
 of the way ; but since it is now generally recognized that, as taught by Weir, 
 the abscess is actually intra-peritoneal in origin, the marginal incision is no 
 longer thought important, and surgeons aim to reach and evacuate the pus by 
 the most direct route. If the case is so far advanced that fluctuation is 
 manifest, the incision should be made where this is most perceptible; but 
 under other circumstances the best position, I think, is in the general direc- 
 
DISEASES OF THE CuECUM AND APPENDIX. 515 
 
 tion of the right linea semilunaris, taking care that a part of the wound shall 
 be through the so-called " McBurney's point," which, as already mentioned, 
 corresponds to the usual situation of the appendix. Some operators prefer to 
 place the incision more laterally, believing that they thus secure better drain- 
 age, but, upon the whole, in most cases, I prefer the anterior position. 
 
 The first cut, about four inches in length, should pass through the skin and 
 superficial fascia, and the deeper layers are then cautiously divided upon a 
 director, all bleeding being checked before the abdominal cavity is opened. 
 When the peritoneum is reached, it is cautiously raised with forceps and nicked 
 by the edge, not the point, of the knife held sideways — as in the operation for 
 strangulated hernia — the wound being then carefully enlarged with blunt- 
 pointed scissors guided and guarded by the finger as a director. As soon as 
 the cavity is opened a gush of pus will usually serve to confirm the diagnosis, 
 but if this does not occur the surgeon should cautiously explore with his finger 
 and a blunt director in the neighborhood of the caecum until the seat of sup- 
 puration is discovered. After evacuation of the pus the cavity is carefully 
 but thoroughly washed out with hot distilled water, and the surgeon then 
 searches for the appendix, which, if found, should be removed. Often this 
 can be done without difficulty, the organ, enlarged and thickened, being readily 
 separated by the finger from its adhesions and brought out at the wound ; its 
 neck should then be tied with two strong carbolized silk ligatures, and divided 
 between them. If, however, the appendix cannot readily be found, it is better 
 to allow it to remain than unduly to prolong the operation by hunting for it, 
 nothing being more deleterious in abdominal surgery than prolonged delay and 
 unnecessary manipulation of the viscera. 
 
 After a final washing with hot distilled water, a full-sized drainage-tube, 
 of glass or rubber, should be introduced, carried to the bottom of the cavity, 
 and secured with a stout ligature or safety-pin. Some surgeons merely pack 
 the wound with iodoform gauze, instead of introducing a tube, but my own 
 preference is for the latter practice. As to the choice between glass and 
 rubber, my rule is, when the abscess-cavity is completely walled off from the 
 general peritoneal surface, to use a rubber tube, which is shortened from time 
 to time as the wound heals ; but when the peritoneal cavity is opened, I employ 
 a glass tube, armed with a rubber-dam and containing a rope of absorbent 
 cotton, which is renewed as often as it is saturated without disturbing the dress- 
 ing applied to the rest of the wound, the tube being at the same time sucked 
 out with a long-beaked syringe until the secretion becomes of a pale straw 
 color, and is reduced to a minimum, when the tube is finally removed. A 
 few sutures may be applied to the extremities of the wound, but it should 
 not be tightly closed, being rather allowed to heal firmly by granulation and 
 cicatrization. 
 
 There is little or no danger of consecutive hernia in this situation, and if 
 there is any communication with the bowel, faecal fistula will be less apt to fol- 
 low in an open wound than in one which has united only superficially. Faecal 
 fistula, however, contrary to the doctrine formerly held, is really a rare com- 
 plication after the operation for appendicitis, and is not to be dreaded unless 
 some grave constitutional condition, such as general tuberculosis, interfere with 
 the healing of the wound. 
 
 All surgeons are agreed as to the propriety of operative intervention in cases 
 of acute appendicitis in which suppuration is believed to have occurred, but 
 some go further, and enthusiastic operators advise that the appendix should be 
 removed after recovery as a means of preventing recurrence of the disease. I 
 have myself operated under these circumstances, and successfully, but I think 
 
516 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 that there are very few cases in which such a course is justifiable. The time to 
 perform an operation in itself dangerous — and opening the peritoneal cavity is 
 dangerous, gynaecological and surgical enthusiasts to the contrary notwith- 
 standing — is when a greater and imminent danger may be averted by so 
 doing, and not when the patient is well ; and when we consider that the 
 very extensive statistics of the London Hospital show that 90 per cent, of 
 all cases of appendicitis end in recovery without operation, we may w r ell hesi- 
 tate before submitting a patient to a mode of treatment equally needless and 
 heroic. The only circumstances which seem to me to justify an operation after 
 convalescence are when the patient has had repeated attacks at decreasing 
 intervals and of increasing severity, and when he is going to be so placed 
 that skilled surgical assistance will not be available in the event of further 
 recurrence. 
 
 Non-inflammatory Affections. 
 
 The caecum has occasionally been found in a hernial protrusion (ccecal 
 hernia), as has the appendix, the latter particularly in the variety of rupture 
 incorrectly called congenital, in which the bowel escapes into the patulous 
 vaginal process of peritoneum. Caecal hernia is often irreducible through the 
 formation of adhesions between the portion of gut uncovered by peritoneum 
 and the adjoining structures. The appendix, even when not itself diseased, 
 sometimes acquires adhesions to other parts, and may then cause internal 
 strangulation, a loop of bowel being caught beneath the appendix and con- 
 stricted as if by a fibrous band. Should such a condition be discovered during 
 an operation for intestinal obstruction, the appendix should be divided between 
 two ligatures, or, which would be better, excised, so as to prevent the possi- 
 bility of a recurrence. Malignant growths are met with in the caecum, though 
 not often in children, and may be treated on the same principles which guide 
 the surgeon in dealing with similar affections in other portions of the bowel. 
 
INTUSSUSCEPTION. 
 
 BY JOHN ASHHURST, Jr., M. D., 
 
 Philadelphia. 
 
 Intussusception, or invagination of the bowel, is by far the most frequent 
 cause of mechanical obstruction of the intestine met with in childhood, though 
 internal strangulation by an adherent appendix or by Meckel's diverticulum, 
 or more rarely by a band of organized lymph left from a previous peritoni- 
 tis, occasionally occurs. Invagination, as the name implies, consists in an 
 ensheathing of one segment of bowel within another, the invaginated part being 
 almost always from a higher portion (that is, farther from the anus) than that 
 into which it is received. Thus, the jejunum is invaginated into the ileum, 
 that into the caecum and colon, etc. The much rarer condition, that in which 
 the lower segment is received into the upper, is called retrograde intussuscep- 
 tion. It is not uncommon for this affection to occur among the multiple invagi- 
 nations which arise during the act of dying, but direct intussusceptions are 
 those which are met with during life, and which call for treatment. Every 
 complete intussusception involves three layers of bowel, and each layer consists 
 of all the intestinal coats ; the outer layer is the sheath, or receiving layer, 
 the intussuscipiens ; and the internal or entering layer, together with the 
 middle or returning layer, constitutes the invaginated part, or intussusceptum. 
 The apex of the intussusception is at the junction of the inner and middle 
 layer — the lowest point, therefore, of the intussusceptum ; while its neck is at 
 the junction of the middle and external layers — the uppermost part of the intus- 
 suscipiens. Double intussusceptions are occasionally met with, five layers of 
 gut being then involved, either a second intussusceptum having been forced 
 into the first, which then constitutes its sheath, or the intussicipiens with its 
 contained intussusceptum being in turn invaginated into a fresh portion of 
 bowel, which then forms a second sheath. Still more rarely triple intussuscep- 
 tions, involving seven layers of bowel, have been found. 
 
 Locality. — In rather more than one-half of all cases of intussusception the 
 invagination occurs about the junction of the small and large intestines : 
 usually the caecum, and afterward the colon, is inverted, the ileum pushing before 
 it the ileo-caecal valve, which is thus found at the apex of the intussusceptum ; 
 much more rarely the ileum slips through the valve, which then constitutes the 
 neck of the intussuscipiens, and the intussusceptum grows by successive invagi- 
 nation of fresh portions of small intestine. The former variety is known as 
 ileo-ccecal, and the latter as ileo-colie intussusception. In somewhat less than 
 one-third of the whole number of cases the invagination is limited to the small 
 intestme (ileal or jejunal intussusception), and in the remainder, or about one- 
 sixth, to the large intestine {colic intussusception). 
 
 Ext ept in the ileo-colic variety, in which the neck remains fixed, an intus- 
 susception increases at the expense of its sheath, which becomes gradually 
 inverted, the apex of the intussusception remaining constant while its neck is 
 
 517 
 
hlS AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 continually changing ; in the ileo-colic variety fresh portions of ileum keep 
 passing through the valve, and the neck therefore remains unchanged while the 
 apex varies. As the entering layer carries the mesentery with it into the 
 sheath, a certain amount of traction is exerted upon one side of the intussus- 
 ceptum, and .as a result the intussusception becomes curved or even sharply 
 flexed upon itself, and at the same time the apex becomes displaced toward the 
 mesenteric side of the intussuscipiens, both of these conditions tending mechani- 
 cally to render the occlusion of the gut more complete than it would be other- 
 wise. The extent of bowel involved in an intussusception varies from a few 
 inches to six or more feet. 
 
 Though an invagination usually begins on the right side of the abdo- 
 men, its increase, in the most common or ileo-caecal variety, is mainly at the 
 expense of the large intestine ; and therefore by the time it has acquired suf- 
 ficient size to be recognized by palpation the tumor will be chiefly on the left 
 side, and eventually the ileo-ceecal valve with the apex of the intussusceptum 
 may be protruded from the anus : even when this does not occur, the apex, in 
 children at least, can very commonly be detected by digital exploration of the 
 rectum. 
 
 Morbid Anatomy. — The adjacent serous layers in an intussusception 
 soon become more or less closely united by adhesions, which, if firm, render 
 the invagination irreducible. These adhesions may join the two layers of the 
 intussusceptum to each other over a considerable space, or may be limited to 
 the region of the neck ; they are very seldom found exclusively at the apex. 
 The sheath of the intussusception may become ulcerated from pressure, and 
 even perforation may occur ; but more commonly, beyond a certain amount of 
 congestion and inflammation, no marked changes are found in this layer. The 
 intussusceptum, on the other hand, is usually more or less completely strangu- 
 lated, and becomes gangrenous, when, if there are firm adhesions at the neck, 
 the dead portion may be separated and evacuated as a whole or in segments 
 through the anus, the patient eventually recovering. Under other circum- 
 stances, the adhesions being defective, faecal extravasation into the peritoneal 
 cavity may occur, the death of the patient following ; or the adhesions, while 
 preventing death at the moment, may form the starting-point of a stricture, 
 which in turn, at a later period, may cause fatal obstruction. 
 
 Post-mortem inspection in a case of intussusception reveals the elongated 
 tumor caused by the invagination, usually on the left side of the abdomen, with 
 an apparent absence of that portion of bowel which is invaginated. The outer 
 layer or sheath of the intussusception is usually of a gray color, doughy in 
 feel, and sometimes ulcerated from distention, while the intussusceptum, when 
 exposed, is found of a deep-red color, resembling a clot of blood, or black and 
 gangrenous. The intestine above the seat of obstruction is commonly much 
 dilated, and filled with faecal matter and gas, while that below is collapsed and 
 shrunken, and is either empty or contains a small quantity of blood and mucus. 
 There is sometimes general peritonitis. 
 
 Etiology. — Nothnagel has investigated experimentally the causes of intus- 
 susception, and describes a paralytic and a spasmodic variety, the latter being 
 the more frequent. Differing from the ordinary doctrine, he believes that the 
 invagination is caused by the normal gut being drawn over the spasmodically 
 contracted part, rather than by that being mechanically driven into its sheath. 
 Treves also adverts to the influence exercised by the longitudinal muscular 
 fibres of the bowel, acting from the contracted part as from a fixed point, and 
 thus drawing the uncontracted part over the other. Age and sex are usually 
 spoken of as predisposing causes of invagination, the large majority of case's 
 
IXTUSSUSCUPTIOW. 519 
 
 occurring in male children ; the great relative length of the colon in infancy, 
 together with the width of the mesocolon, doubtless favors the displacement of 
 the gut, and in some degree accounts for the frequency of intussusception in the 
 early periods of life. Impaired general health, diarrhoea, the presence in the 
 bowel of undigested or irritating food, polypoid growths, strictures and tumors 
 of the intestine, and previously existing adhesions, are often predisposing 
 causes of more or less importance. The exciting cause is increased and irreg- 
 ular peristaltic movement, no matter how produced. 
 
 Symptoms. — The chief symptoms of intussusception are pain, nausea and 
 vomiting, tympanitic distention of the abdomen, fever, tenesmus, with discharge 
 of blood and mucus by the rectum, the presence of a tumor (usually on the left 
 side), and a corresponding depression or flattening on the right side. Abdom- 
 inal pain is usually the first symptom manifested, occurring suddenly, of a very 
 intense character, referred mainly to the umbilicus, the child writhing and 
 drawing up its limbs in agony, and accompanied by vomiting of whatever may 
 be in the stomach, and often by a liquid faecal discharge, evacuating the con- 
 tents of the bowel below^ the seat of obstruction. The pain is not constant at 
 first, but occurs at irregular intervals, each paroxysm being commonly attended 
 by a discharge of bloody mucus from the rectum, but as the case goes on the 
 pain becomes continuous, though even then marked by exacerbations. The 
 cause of the pain is at first the mechanical squeezing of the invaginated 
 bowel by its sheath ; afterward the increased peristalsis of the intestine above, 
 endeavoring to force its contents through the part which is occluded ; and 
 finally, the extreme distention of the upper bowel and the inflamed condition 
 of the intussusception itself and of its peritoneal covering. A sudden cessa- 
 tion of pain in the last stages indicates the occurrence of gangrene, which 
 may be followed by discharge of the sphacelated portion and recovery, but is 
 more often the immediate precursor of death. Abdominal tenderness, local- 
 ized at the seat of invagination, is developed in connection with the pain as 
 soon as inflammation of the affected portion of bowel has set in. 
 
 The vomiting in intussusception is a very prominent symptom, being present, 
 according to Dr. Fitz's statistics, in 70 per cent, of all cases, but is, I think, 
 less distressing, in the early stages at least, than in cases of internal strangula- 
 tion. When secondary enteritis occurs the vomiting increases, but even then 
 comparatively seldom assumes a faecal character. The vomiting diminishes 
 again with the approach of collapse. 
 
 Tympanites is not very marked in intussusception, being, according to Dr. 
 Fitz, only present in the minority of cases. Indeed, there is often a marked 
 depression in the right iliac fossa (signe de Dance) from the displacement of 
 the caecum toward the left side. 
 
 Fever is not present at the beginning of an intussusception, but is observed 
 in connection with the occurrence of secondary enteritis, the thermometer ris- 
 ing to 102° or 103° F. This is of some importance in aiding the diagnosis 
 between invagination and internal strangulation, the temperature in the latter 
 condition sometimes remaining subnormal even after the development of gene- 
 ral peritonitis. Partial suppression of urine often accompanies the fever in 
 intussusception, and appears to depend more on the acuteness than on the local- 
 ity of the disease. 
 
 Unlike other forms of intestinal obstruction, invagination is not necessarily 
 accompanied by constipation, though in the acute variety, owing to the lateral 
 displacement of the gut from traction of the mesentery and to secondary 
 enteritis, faecal discharges are absent. In chronic intussusception, however, 
 there may be little interference with defecation, and in acute cases there is a 
 
520 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 constant desire to go to stool (tenesmus), with frequent discharges of blood and 
 mucus. This symptom Mr. Pollock considered to be almost pathognomonic. 
 
 The tumor is a very characteristic symptom of intussusception, and, as 
 already mentioned, is usually found on the left side. In this it differs from 
 the tumor of faecal impaction, which is almost always found on the right side, 
 and which may often be made to pit by deep pressure over its surface. The 
 right side in intussusception is, as mentioned above, often depressed and flat- 
 tened (Dance's sign), and the tumor is painful and tender to the touch. It can 
 frequently be detected by introducing the finger into the rectum, and sometimes 
 comes so low as to protrude from the anus. 
 
 Chronic intussusceptions are sometimes met with, and have been particu- 
 larly studied by Rafinesque, who finds that 70 per cent, occur in the region 
 of the ileo-caecal valve (60 per cent, ileo-caecal, 10 per cent, ileo-colic), and that 
 the remainder are equally divided between the large and small intestine. The 
 symptoms of chronic invagination are much less distinctive than those of the 
 acute variety, the tumor changing its shape and locality from time to time, 
 faecal evacuations being often continued, diarrhoea sometimes alternating with 
 constipation, and the pain and vomiting occurring at perhaps long intervals. 
 
 Diagnosis. — Intussusception has been confounded with simple colic, appen- 
 dicitis, enteritis, dysentery, faecal impaction, and other forms of mechanical 
 obstruction. From colic it may be distinguished by the paroxysmal character 
 of the pain, the vomiting, and the tenesmus, with discharge of bloody mucus. 
 The detection of a tumor, either on the left side of the abdomen or by rectal 
 exploration, would further demonstrate the nature of the affection. From 
 appendicitis and consequent suppurative peritonitis, the diagnosis can be made 
 by noting the symptoms just referred to, and by further observing that in 
 those affections there are tympanites, tenderness, and fulness in the right 
 iliac fossa (as contrasted with the depression in invagination), and an earlier 
 development of fever. In enteritis there is also fever from the beginning, 
 with constipation, but without bloody discharges and without any well-defined 
 tumor. I have known the convexity of the lumbar vertebrae, as felt by 
 abdominal palpation, to be mistaken for the tumor of intussusception, but 
 the error could hardly be made except by carelessness. The tenesmus, pain, 
 and evacuation of blood and mucus are the only points of resemblance between 
 intussusception and dysentery, while the mode of attack and course of the sev- 
 eral affections are entirely different. In f cecal impaction there is a tumor, but 
 usually on the right side, and it can be indented by firm pressure, while the 
 peculiar evacuations of invagination are wanting. The only form of mechan- 
 ical obstruction, apart from intussusception, which is likely to be met with in 
 children is internal strangulation, and in that condition the profound and early 
 collapse, the low temperature, and the stercoraceous vomiting will clear up the 
 diagnosis. 
 
 Prognosis. — The prognosis in cases of intussusception is always grave in 
 the extreme, Leichtenstern's statistics showing a death-rate (in acute cases) of 
 73 per cent., and Fitz's smaller figures one of 69 per cent. The most favorable 
 termination is in spontaneous reduction of the invagination, which can, as a 
 rule, only be effected during the first few days of the attack, before the forma- 
 tion of adhesions. If reduction fails, there remains a chance for recovery after 
 sloughing of the intussusception, the mortality in cases in which this occurs 
 being only 41 per cent, while in those in which sloughing is absent the death- 
 rate is 85 per cent. Even when sloughing does occur, however, and the patient 
 recovers from the immediate risks of the process, he is by no means free from 
 the danger of ulterior complications, the cicatricial contraction and adhesions 
 
INTUSS USCEPTION. 521 
 
 which follow often, as already mentioned, laying the foundation for future 
 obstruction by stricture or internal strangulation. 
 
 The prognosis of chronic intussusception is also very grave : while the 
 immediate risks to life are less than in the acute cases, there is not the same 
 hope of recovery by sloughing and evacuation of the invaginated part, and, 
 unless relief be afforded by an operation, a fatal result must be anticipated. 
 
 Treatment. — The indications for treatment in acute intussusception are to 
 put the bowel completely at rest ; if the case is seen at an early period, to 
 attempt reduction ; and, if the invagination has already become irreducible, to 
 sustain the patient's strength until separation of the strangulated part may 
 occur, when recovery may be hoped for. The first indication is met by the 
 free use of opium, preferably in combination with belladonna. These remedies 
 are best given in the form of the extract, by suppository, and of the former 
 one-twelfth of a grain, and of the latter one-twenty-fourth, may be adminis- 
 tered to a child of two years, every hour or two hours according to the 
 urgency of the symptoms. Morphine and atropine may be used hypodermatically 
 instead, but the rectal administration is, on the whole, I think, to be preferred. 
 Advantage may also be derived from the employment of anodynes locally, and 
 the abdomen may be covered with belladonna and mercurial ointments spread 
 upon lint or flannel and reinforced by a warm poultice. In the attempt to 
 effect reduction the physician may employ large injections of warm water, or, 
 which is, I think, better, warm olive oil ; inflation with atmospheric air or 
 various gases ; and manipulation or abdominal taxis. 
 
 The injections may be given with an ordinary hand-ball syringe or with a 
 fountain syringe (gravity injection), the patient being etherized and held in a 
 semi-inverted position, with the hips higher than the shoulders, and the trunk 
 elevated at an angle of about 45°. The height to which the reservoir which 
 supplies the fluid should be raised will be about eight feet in the case of an 
 infant, and not more than twenty feet in that of an adult. The quantity to 
 be injected may vary from one to six quarts according to the age of the patient. 
 The injections are best administered through a large rectal tube, so that the 
 force of the current may, if possible, be directed immediately upon the apex 
 of the intussusception, and not expended upon the wall of the bowel. Care 
 must be taken not to allow the fluid to escape alongside of the tube, by pro- 
 viding this, as suggested by Mr. Lund, with an India-rubber collar, which may 
 be firmly pressed against the anus, or by wrapping it with cotton or lint, which 
 is introduced within the sphincter to accomplish the same end. 
 
 Inflation with atmospheric air may be practised through the long tube or 
 long-nozzled bellows, the same precautions being taken against escape of the 
 air alongside of the tube as in the use of enemata. Professor Senn recom- 
 mends the employment of hydrogen gas as preferable to atmospheric air, the 
 gas being supplied from an India-rubber balloon holding four gallons, which is 
 slowly but steadily compressed by the operator. Carbonic-acid gas is preferred 
 by Libur, Jate, and Ziemssen, and is furnished in a nascent state by suc- 
 cessively injecting solutions of bicarbonate of sodium and tartaric acid. Abdom- 
 inal taxis was introduced as a mode of treatment in these cases by Mr. Jonathan 
 Hutchinson, and consists in systematically compressing and kneading the 
 belly from below upward, the patient being etherized and in an inverted posi- 
 tion. In combination with the use of enemata it has occasionally proved an 
 efficient remedy, but its employment is necessarily attended with some danger 
 of injury to the bowel, and should therefore, it seems to me, be resorted to with 
 caution, and only during the early stages of the case. 
 
 Reduction by one or other of the methods mentioned is most likely to be 
 
522 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 accomplished during the first two days of an intussusception, and may occa- 
 sionally be effected as late as the fourth day, but after that period should not 
 be attempted, the physician's efforts being then directed to sustaining the 
 patient through the processes of sloughing and evacuation of the strangulated 
 intussusception. In this stage the use of opium and belladonna should be 
 continued ; little or no food should be given by the mouth, but the patient 
 should be systematically fed by means of nutritive enemata. To relieve thirst, 
 which is often distressing, water may also be given by enema, and the patient 
 may suck small pieces of ice. If the abdomen becomes very much distended, 
 the stomach may be carefully washed out through a stomach-tube, thus allaying 
 vomiting and evacuating the liquid contents of the upper portion of the small 
 intestine ; or gas and fluid may be withdrawn by puncturing a distended seg- 
 ment of bowel with the fine tube of an aspirator. Puncture of the bowel, 
 practised in this way, entails a certain risk of faecal extravasation, but is fol- 
 lowed by less shock than enterotomy, which, however, may be preferred when 
 the patient's condition does not forbid it. 
 
 Enterotomy — or, as it is sometimes called, Nelaton's operation — consists 
 in making an incision, usually in the right iliac region, and opening the first 
 distended coil of intestine which presents itself. This may be done in two 
 ways : if it is not desired to establish a false anus, a knuckle of bowel is gently 
 drawn out through the wound, and, having been packed around with sterilized 
 gauze, is opened, preferably by a transverse incision, and allowed to discharge 
 itself outside of the abdominal cavity ; if the evacuation is not sufficiently 
 complete, a full-sized drainage-tube may be introduced into the gut, and the 
 surgeon sits by the patient, keeping the bowel under observation, if necessary, 
 for several hours, until the faecal flow has entirely relieved the tension ; the 
 tube is then removed, the opening in the intestine closed with a Lembert's 
 suture, the bowel replaced, and the external wound closed and dressed in the 
 ordinary manner. If it be thought better to establish temporarily a false anus, 
 the bowel should first be stitched to the abdominal parietes, then carefully 
 opened, and the edges of the incision again stitched to the external wound so 
 as to prevent any possibility of faeces escaping into the cavity of the peri- 
 toneum. If the case does well, after the separation and evacuation of the 
 gangrenous intussusceptum the false anus may be allowed to close, as it usually 
 will without difficulty as soon as the natural passage is restored. If the open- 
 ing degenerate into a faecal fistula, a plastic operation may be required for its 
 relief. 
 
 The mode of treatment above described is that which I would recommend 
 in cases of acute intussusception. Laparotomy, which may be required in 
 cases of chronic invagination, does not seem to me desirable in cases of the 
 acute variety, and is shown by statistical investigation to have no effect in 
 diminishing the death-rate of the disease. Thus, while Leichtenstern's collec- 
 tion of 557 terminated cases, taken all together, gives 151 recoveries and 406 
 deaths (73 per cent.), the tables published in the fifth edition of my Surgery give 
 95 cases treated by laparotomy, with 26 recoveries and 68 deaths (1 undeter- 
 mined), showing an almost identical percentage of mortality. Fitz's statistics 
 present the operation in a still less favorable light, 51 cases treated without 
 operation having given 16 recoveries and 35 deaths (69 per cent.), while 36 
 operated on gave only 6 recoveries and 30 deaths (83 per cent.). The 
 objections to the operation in acute cases are that there is, as has been seen, a 
 reasonable chance of recovery without it, and that the early age at which 
 intussusception usually occurs renders operative interference peculiarly danger- 
 ous. I am well aware that a few brilliant results from laparotomy in infants 
 
IXTCSSUSCUPTIOJY. 523 
 
 have been recorded by Mr. Hutchinson, the late Dr. Sands, of New York, and 
 other operators, but these cases should be regarded as surgical curiosities, show- 
 ing what infants may sometimes safely endure, rather than as furnishing pre- 
 cedents for future guidance. In chronic intussusception the circumstances are 
 somewhat different. As the strangulation of the intussusceptum is not sufficiently 
 complete to offer a chance for recovery by the process of sloughing, when the 
 surgeon finds that reduction cannot be effected the operation may be properly 
 resorted to, particularly as in these cases the patients have usually passed the 
 period of infancy. When the bowel protrudes through the anus, the plan sug- 
 gested by Howse, and successfully employed by Mikulicz, Willard, Fuller,, and 
 others, may be tried, the protruding portion being held from retracting by 
 strong pins, and then cut off; but under other circumstances laparotomy is the 
 proper measure. 
 
 Laparotomy for intussusception may be thus performed : The patient having 
 been etherized and the abdominal wall carefully cleansed, an incision is made 
 directly over the tumor if one can be recognized, but otherwise in the median 
 line. The wound is carefully deepened until the peritoneum is reached, when 
 this is opened with every precaution against injury to the bowels or other 
 viscera. If the intussusception is found, the invaginated gut is brought out 
 through the incision, the rest of the intestine being gently pressed back with 
 warm towels or sponges, since the exposure and chilling of large portions of 
 bowel always produces an unfavorable effect on the patient. Careful attempts 
 at reduction are then to be made by gently compressing and pushing upward 
 the invaginated part from below, this being at once safer and more efficient 
 than efforts to withdraw the gut by traction from above. If the intussuscep- 
 tion is not immediately found, the surgeon introduces his hand, through the 
 incision, which in this case would be median, and explores the right iliac fossa, as 
 recommended by Mr. Treves, finding the csecum, and then searching upward or 
 downward according as that part is empty or distended with faeces. In examin- 
 ing the small intestine the direction in which the search should proceed may 
 be determined, as suggested by Mr. Head, by observing the relations of the 
 mesentery, which is attached to the posterior wall of the abdomen from the 
 left side of the second lumbar vertebra, obliquely downward to the right sacro- 
 iliac symphysis. If reduction cannot be effected, the surgeon may proceed to 
 the establishment of a false anus immediately above the seat of invagination, 
 or, if the state of the patient should permit more prolonged manipulation, he 
 may excise the intussusception bodily (enter ectomy), and restore the continuity 
 of the bowel either by direct suture (circular enter or raphy) or by Prof. Senn's 
 method of lateral anastomosis, as may be thought best. The latter procedure 
 or one of its modifications — for a description of which the reader is referred to 
 special works on surgery — is ordinarily preferable, as requiring less time than 
 the end-to-end suture. The subsequent treatment is to be conducted as after 
 laparotomy for other causes, as has been described in the article on Diseases of 
 the Appendix. 
 
INTESTINAL PARASITES. 
 
 By CHARLES W. TOWNSEND, M. D., 
 
 Boston. 
 
 The older writers on the diseases of children devote a good deal of space 
 to the subject of intestinal worms, particularly to the symptoms supposed to be 
 caused by them, and to their treatment. Text-books of to-day dwell more 
 upon the natural history of these animals — an extremely interesting subject — 
 but are apt to pass very lightly over the practical considerations of symp- 
 tomatology and treatment. Although intestinal worms, like the teeth, have 
 with propriety been dethroned from their high position as etiological factors 
 in many of the diseases of children, we must not be carried too far with the 
 swing of the pendulum and disregard entirely the parasite as a causative agent. 
 Among the laity, with exceptions among the upper classes, worms still hold a 
 very important position, and it is essential, therefore, that we should look at 
 the subject fairly, and not pass it off as of very minor importance. 
 
 There are no intestinal parasites peculiar to infancy and childhood, although 
 the round- and pin-worms are so much more common in children than in adults 
 that they are often spoken of as peculiar to children. 
 
 Omitting several varieties that are rarely encountered and are of no practical 
 importance, the species of worms that are found in children are as follows : 
 Ascaris lumbricoides, round-worm ; oxyuris vermicularis, pin-worm ; two 
 species of tape-worms, taenia mediocanellata, beef tape-worm, and taenia solium, 
 pork tape-worm ; and the unimportant trichocephalus dispar. All of these are 
 Nematode worms, with the exception of the taeniae, which belong to the group 
 of Cestodes. 
 
 As these parasites have different habits and habitats, and each requires a 
 special treatment, it will be necessary to consider them individually. 
 
 I. Ascaris Lumbricoides (Round-worm). 
 
 The male round-worm is from four to six inches in length, the female about 
 ten inches. It is of a yellowish-white color, more or less tinged with red in 
 the fresh state ; as usually shown, preserved in alcohol, it is of an ivory white. 
 The worm is cylindrical in shape, tapering to a point at both ends. The mouth 
 is situated between three lips furnished with fine teeth at the anterior extremity 
 of the body. The anus is about an inch from the posterior extremity, and the 
 vulva in the female is anterior to the middle. The sexes are easily distinguished 
 by their relative size and by the fact that the posterior extremity of the male 
 is curved, that of the female being straight (Fig. 1, a and b). 
 
 From earth-worms, which I have known to be presented by patients with 
 the intention of deceiving, they may be distinguished by their color and by 
 the fact that earth-worms, being annelids, have plainly -marked segments. 
 Female lumbricoids which have been carelessly handled and subjected to pres- 
 
 524 
 
IXTESTIXAL PARASITES. 525 
 
 sure often show the ovaries hanging out like a bunch of small worms, and may 
 deceive the superficial observer. 
 
 The ova of the round-worm are produced by the females in great quantities, 
 
 Ficx. 1. 
 
 Round-worms and Pin-worms (% Natural Size), a, Male Round-worm: b. Female Round-worm; 
 
 c, Female Pin-worm. 
 
 and pass off in the faeces, where they can easily be found with the microscope. 
 They are oval in shape, about ^^-g- of an inch long, with dark granular con- 
 tents and thick transparent coats, which are often stained vellow by bile (Fig. 
 %c). 
 
 The proper habitat of the adult ascarides is the small intestine, but they 
 are of a wandering disposition, and have been found in the stomach, oesopha- 
 gus, and mouth, occasionally getting up into the posterior nares and coming 
 out anteriorly, or going down into the larynx or even into the lungs. They 
 also wander down into the rectum, and are expelled with the faeces or slip out 
 unattended. They have even escaped into the peritoneal cavity through per- 
 forations made, not by them, as was once supposed, but by ulcerations. They 
 have been known to pass into the pancreatic and biliary ducts. "When in large 
 numbers the worms are often coiled together into balls in the intestines. The 
 ova do not develop until they have passed out with the faeces, and have again 
 found their way into the child's gastro-intestinal canal, when the embryos 
 
526 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 rapidly come to maturity. Outside of the body they resist destructive agencies 
 with great obstinacy, and it is said may retain their vitality for years. 
 
 Method of Infection. — As the ova are produced in such countless num- 
 bers — Davaine having found some three thousand eggs in a bit of faeces as 
 large as a grain of wheat — and as they are so resistant to outside destructive 
 agencies, it is not surprising that they should be very common among the classes 
 of individuals where personal cleanliness is not cultivated. As children are 
 greater barbarians in their personal habits than adults, it is natural that ascari- 
 des should be much more often found among them. The habit children have 
 of putting their fingers as well as toys and other objects into their mouths 
 might easily lead to self-infection with ova from parasites in their own intestines, 
 as well as with ova from elsewhere. In the country, infants creeping about the 
 floor may be infected by the dust brought in on the shoes from manure-heaps. 
 
 Among the upper classes ascarides are certainly very much less common, 
 and they are rarely seen in the adult. Here, where habits of cleanliness are 
 
 Fig. 2. 
 
 Comparative size of eggs of Intestinal Parasites: a, Taenia Solium; b, Tsenia Mediocanellata; c, Ascaris 
 Lumbricoides ; d, Trichocephalus Dispar ; e, Oxyuris Vermicularis. (After Striimpell.) 
 
 cultivated, infection would be more likely to come only through drinking-water 
 or food. If the contents of privies are used in the garden for manure, the 
 contained ova may readily find their way into water used for drinking or be 
 served with salads or other uncooked vegetables. By proper filtration of the 
 water or by cooking of vegetables, this danger can be escaped. 
 
 Symptoms. — It is not uncommon to find numerous intestinal worms in 
 the lower animals without any evidence of ill effect, and it is frequently the 
 case that we discover lumbricoides, in greater or less numbers, in the dejec- 
 tions of children who are well in every way and have presented none of the 
 classical symptoms of worms. It is certainly the case, therefore, that, while 
 the round-worm is confined to its proper place — the small intestine — even if 
 it be in great numbers, it may be, and generally is, entirely harmless, and 
 has no appreciable effect on the condition of the child, producing no symptoms. 
 The amount of nourishment it extracts for itself is hardly worth considering 
 unless the worms exist in great numbers. 
 
 On the other hand, when we consider the high state of nervous tension that 
 exists in the child, and the ease with which reflex phenomena are produced, 
 it is reasonable to suppose that the presence of the living worms in the intestine 
 may cause certain reflex symptoms, and in that way interfere with the general 
 health. 
 
 The common symptoms ascribed to round-worms by the laity are general 
 lassitude, with nervous fidgeting, picking at the nose, offensive breath, abdominal 
 pain, headaches, feverish attacks — called "worm fever" — and lack of flesh, 
 notwithstanding a fair, or at times ravenous, appetite. The bowels are irregular, 
 there being either constipation or diarrhoea with mucous discharges. There 
 
INTESTINAL PARASITES. 527 
 
 may be vomiting and disturbed sleep with grinding of the teeth. This is the 
 common and exact picture of a child debilitated by improper feeding and an 
 insufficiency of fresh air and exercise — a child that is cooped up with many 
 others in close school-room air, and whose whole life is poorly managed from a 
 hygienic point of view. That such children sometimes have ascarides is not 
 surprising when we consider the ease of infection, but that the parasites are the 
 cause of their condition is certainly not the case, although the nervous symp- 
 toms may undoubtedly be aggravated by them. It is probable that these 
 debilitated children, with plenty of mucus in their intestines, are more desir- 
 able habitats for the round-worms, so that the parasites thrive in this class and 
 retain their foothold, while healthier children more easily get rid of them. 
 
 The symptom, picking the nose, is often spoken of by mothers as if it were 
 pathognomonic of worms. This is not the case ; it is simply a nervous trick 
 common to debilitated children, as is often proved by the unproductive admin- 
 istration of anthelmintics. My experience is that in the majority of cases 
 where round-worms are found, their presence is unsuspected and their dis- 
 covery accidental. Having once been found, it is common enough for almost 
 any symptom to be attributed to them by the mother. 
 
 Numerous cases have been reported, however, where the connection between 
 the worms and severe nervous symptoms, such as convulsions, chorea, aphonia, 
 etc., seemed to be very intimate, the nervous symptom being relieved on the 
 evacuation of the parasites. 
 
 One such case is recorded among those in the Boston Children's Hospital : 
 
 Kate M , four years old, had had two convulsions before she came under observa- 
 tion. She was in good general condition, and no reflex cause could be found for the con- 
 vulsions except round-worms, which she had passed from time to time. She was given 
 santonin : a quantity of worms were expelled, and she remained well for six months, when 
 she had another convulsion. Worms were again brought away, but she came back a 
 month later, reporting occasional attacks of twitching and tremors, but no real convul- 
 sions. Anthelmintic treatment again expelled round-worms, and she was lost sight of 
 for three years, during which there was no history of worms or nervous phenomena. At 
 the end of this time she again applied for treatment for attacks every two or three weeks 
 of flushing and pallor, pain in the belly and convulsions. Santonin was again given, 
 bringing away worms and giving relief as before. 
 
 There is a certain mechanical danger from ascarides, owing to their habit 
 of wandering. A number of cases have been recorded of these worms entering 
 the cystic and common bile-ducts, giving rise, in the latter case, to jaundice. 
 They have even penetrated to the hepatic ducts and caused abscesses of the 
 liver. They have also been found in perityphlitic, hernial, and tubercular 
 abscesses connected with the intestine, having wandered into these abscesses 
 after their formation, and possibly in some cases contributing to the irritation 
 and suppuration there. That they may cause perforation of the normal intestine 
 is not the case, but when we consider their stiffness and activity during life, 
 and their sharply-pointed extremities, it does not seem unlikely that they might 
 break through an ulceration which needed only the last straw, so to speak, but 
 ■which otherwise might have healed. 
 
 Another danger from round-worms arises from the fact that they sometimes 
 ascend — with or without the aid of vomiting — into the fauces, whence they 
 may be drawn into the larynx and cause suffocation and death. If the 
 worm be drawn into the trachea or a bronchus and is not expelled, death is 
 not immediate, but ensues in three or four days from gangrene of the lung. 
 The fact that a child is found dead with a lumbricoid in the larynx does 
 not, however, necessarily prove that this was the cause of death, for these worms 
 
528 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 not infrequently wander away from the intestine after death from other causes. 
 In the majority of cases when the worm ascends to the fauces it is expelled 
 through the mouth, or more rarely, through the nose. 
 
 When the parasites are collected in great numbers in the intestine, they 
 may mechanically cause congestion of the mucous membrane, and even obstruc- 
 tion of the bowel, or volvulus. In these cases the worms are found tightly 
 twisted together, forming an obstructive ball. 
 
 Hillyer, in the Lancet (1892, ii., p. 773), relates an interesting case of this 
 sort, where there were at the same time extreme nervous symptoms : 
 
 A child, five and a half years old, never strong, began to have severe abdominal 
 pains, for which castor oil was given with the result of causing vomiting, but no action 
 of the bowels. Three round worms were found in the vomitus. The child then became 
 unconscious, the eyes wide open, the pupils dilated, the skin cold and clammy. Death 
 ensued on the following day. At the autopsy the ileum was found occluded at a point 
 fifteen inches above the ileo-csecal valve by a tightly- wound ball of eight round worms. 
 Forty-two worms in all were found in the intestine. There was extreme congestion of 
 the intestine above the obstruction and at that point. Below the obstruction the bowel 
 was empty, above it was distended. 
 
 Diagnosis. — This can never, and should never, be made without seeing 
 the worms themselves or their eggs. Mothers in their anxiety often mistake 
 shreds of mucus for worms, so it is essential that the physician should see the 
 suspected parasites in every case. As was stated above, debilitated children 
 with mucus in their dejections are the ones that present symptoms popularly 
 thought to be diagnostic of worms. 
 
 The ova are so numerous that they are easily found in the sediment of 
 liquid stools ; this can be scraped from the napkin or taken up with a pipette, 
 or the residue examined after filtration. If the stools are not naturally liquid, 
 they can be stirred up with water. A method suggested by Epstein is simple 
 and effective, — viz. the introduction of a Nelaton catheter into the rectum. 
 The small amount of faeces that will cling to the eye of the catheter is more 
 than sufficient for microscopic examination. The power generally used for 
 urinary sediments — i. e. about 330 diameters — answers for these examinations. 
 The eggs, which have been described above, are easily recognized (Fig. 2, c), 
 and readily distinguished from the smaller, sharper, oval eggs of the pin-worm 
 and the round eggs of the tape-worm. 
 
 Treatment. — Although ascarides, as a rule, cause no discomfort and are in 
 no wise detrimental to the host, when we consider the various accidents, some 
 of them fatal, which may be caused by them, as well as the obscure nervous 
 symptoms which occasionally owe their origin to this source, it is certainly 
 wiser to treat all cases as soon as they are discovered, and to get rid of the 
 worms. 
 
 Of the remedies that can be used for round-worms, it is hardly worth while 
 to mention more than three. These are santonin, spigelia, and chenopodium, 
 All of these have the power of killing or benumbing the parasites, but require 
 the aid of cathartics to cause their expulsion. 
 
 Santonin, made from Levant worm-seed, is probably the most widely used 
 of all anthelmintics. It is the common basis of proprietary worm-lozenges. 
 Care should be used in its administration, as it'is extremely poisonous in over- 
 doses, several fatal cases having been reported. In poisonous doses it produces 
 gastro-intestinal irritation, dizziness, tremor, yellow vision, dilated pupils, and 
 loss of consciousness, with, at times, convulsions. Santonin is an almost taste- 
 less white powder, nearly insoluble in water. It can be given in powder mixed 
 with sugar, or made up into lozenges. The dose at the age of two years is 
 
IXTESTINAL PABASITES. 529 
 
 J to | grain: at six, 1 grain; and at twelve or fifteen, 2 grains. It should 
 be oriven morning and night, or in some cases three times daily, with the 
 addition of a cathartic — calomel, castor oil, or cascara cordial — every second 
 day as long as lumbricoids continue to be passed. When it is remembered 
 that very grave symptoms have been caused by a dose of 4 grains to a child 
 four years old, and that a feeble child of five has been killed by 2 grains of 
 santonin, it is easily seen that care must be used in its administration, and that 
 there is danger in its indiscriminate use. 
 
 Spigelia, or pink-root, one of our native plants, is also an efficient and, in 
 proper doses, entirely safe drug. The freshly prepared fluid extract of spigelia 
 and senna 1 of the Pharmacopoeia of 1870 combines the necessary cathartic with 
 the anthelmintic in a manner both efficient and pleasant to the taste. The 
 dose is half a teaspoonful for a child of two years, a teaspoonful for one from 
 four to ten years old. It should be given two or three times daily, depending 
 on its effect upon the bowels. 
 
 Oil of chenopodium is the third remedy for ascarides, and is said to be 
 safer and less irritating than the others. It can be given on sugar in doses of 
 five drops to a child of three, and ten drops to one of ten years, three times 
 daily. A cathartic is required, as with the other anthelmintics, and should be 
 given every second or third day. 
 
 II. Oxytjris Vermicularis (Pin-worm, Thread- worm, Seat- worm). 
 
 This is a small worm, as the first two of its common names would imply. 
 (Fig. 1 shows the comparative size of pin- and round-worms.) The female 
 is from a quarter to half an inch in length ; the male, only about a third 
 as large, measures from -^ to ^ of an inch. Its color is nearly white, its 
 shape fusiform, tapering to a fine point in the female, having a blunter and 
 generally curved tail in the male. The mouth is situated in the middle of the 
 blunt end, and is surrounded by three slightly projecting lips (Figs. 3, 4). 
 The eggs are ovoid in shape, more pointed at one end. They measure 0.053 
 mm. in length by 0.028 mm. in breadth, are considerably smaller than the eggs 
 of ascaris, and have a thinner and smoother coating (Fig. 2, e). 
 
 This worm inhabits the rectum and large intestine throughout its entire 
 course, as well as the lower end of the small intestine. The eggs are passed 
 out with the faeces in great numbers, and, when swallowed, the embryo is set free 
 in the digestive tract and descends to the colon, rapidly developing into the 
 adult worm. The number of these parasites in one individual may be so 
 enormous that the whole mucous surface of the colon and rectum becomes coated 
 with them, as if with a layer of pus. In the caecum, where they are undis- 
 turbed, the sexes are about equally divided. In the rectum and in the stools 
 the females preponderate, as, owing to their larger size, they are less easily 
 destroyed than the smaller more fragile males. The great preponderance of 
 females is also partly apparent, as the males, from their minute size, are often 
 overlooked. Pin-worms are frequently seen alive outside the anus in the folds 
 of skin, sometimes getting into the groins, and in little girls they often crawl 
 into the vagina. 
 
 Method of Infection. — Auto-infection is constantly taking place in chil- 
 dren having pin-worms. The irritation caused by the worm leads them to 
 scratch about the anus ; numerous eggs become lodged under the finger-nails, 
 and are later taken into the mouth and stomach. It is very common to find 
 
 1 This can be written for directly. Its formula is as follows : R . Ext. spigelia? fl., f 5X. ; Ext. 
 sennae fl., f ^vj. ; Olei anisi, tt\,xx. ; Olei cari, TT^xx. 
 
 34 
 
530 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 3. 
 
 several children in one family suffering simultaneously. Food and toys that 
 are handled by these children become carriers of the infection. Vegetables 
 and drinking-water may also be infected, as in the case of round-worms. 
 
 Symptoms. — The oxyuris gives rise to a very evident symptom in nearly 
 all cases — namely, an intense itching about the anus, which leads the patient 
 to scratch vigorously, causing bleeding and 
 in some cases setting up an eczema. The Fig. 4. 
 itching occurs most severely in the early 
 part of the night while the patient is in 
 bed. It is thought to be due to the move- 
 ments of the worms in the rectum, and 
 is entirely relieved by their removal from 
 this point, even if they remain in quanti- 
 ties higher up. In fact, it is probable 
 that the parasites while in the small intes- 
 tine produce no appreciable symptoms. 
 
 As a result of the itching the sleep of 
 the child is disturbed, and various slight 
 nervous symptoms may be induced. Grind- 
 OxyurisVennicuia- ing of the teeth, crying out in sleep, invol- 
 
 ris : a, Male, Nat- ° , .. i- j ■ • 
 
 . urai size; 6, The untary twitching, and insomnia are com- 
 fafter Bened?n) d ' m ™. In one of my cases pavor nocturnus 
 was apparently caused by the reflex irri- 
 tation of the worms ; and in a very sensitive child it is 
 probable that reflex convulsions or chorea might ensue. 
 As a result of the disturbed rest and of the more or less 
 constant irritation, the patient is often debilitated, peevish, 
 and nervous, and, like all nervous children, apt to acquire 
 the trick of picking the nose, and to have occasional reflex 
 feverish attacks. He may, however, escape without a 
 symptom. 
 
 In two of the pin-worm cases at the Boston Children's 
 Hospital fainting was a prominent symptom. One of these, 
 a girl of ten years, was said to have "worm-fever" about 
 once a month. At this time she had fainting attacks and 
 passed great quantities of the parasites. 
 
 As a reflex cause of incontinence of urine these parasites 
 hold a well-recognized place. In eight of the hospital cases 
 incontinence existed. In girls vulvo- vaginitis is sometimes 
 caused by the irritation of the worms that have found 
 their way into the vagina; this, in turn, is also a cause of incontinence of 
 urine. Nine instances are recorded among 48 cases at the hospital. As 34 
 of these cases were in girls, this makes a proportion of 27 per cent, of vulvo- 
 vaginitis from this cause. The great preponderance of females in this list, 34 
 to 14, may be partly explained by the urgent symptom of vulvo-vaginitis call- 
 ing them to the hospital for treatment. Curiously enough, the same prepon- 
 derance of girls is also found in the round-worm cases — 11 girls to 5 boys. 
 Masturbation in either sex may be caused by the irritation. One of my 
 cases had a rectal polypus, probably due to rectal irritation. Prolapse of the 
 rectum may be set up by the straining. As to the age at which these worms 
 are chiefly found in children, 35 of the 48 cases at the hospital occurred in chil- 
 dren between two and seven years old, inclusive. The youngest was an infant 
 of twenty-one months. 
 
 Oxyuris Vermicularis : 
 a, Female, Natural 
 size ; b, The same en- 
 larged. (After Bene- 
 den). 
 
INTESTIXAL PARASITES. 531 
 
 As bearing on the frequency of worms in general, and of each species in 
 particular. I have examined the out-patient records of the Boston Children's 
 Hospital, and find that out of 5200 medical patients of all kinds, there were 
 65 where the diagnosis of worms was made on the evidence of the parasites 
 themselves. My general impression was that the round-worms were more 
 common than the pin-worms in children, and this is so stated by Councilman 
 in the Ci/elopcedia of the Diseases of Children. A much larger number of the 
 latter were seen at the Children's Hospital, however, owing no doubt to the 
 more urgent symptoms they produce, and the general absence of symptoms in 
 round-worms. Forty-eight of the 65 cases had pin-worms, and only 17 round- 
 worms, 3 of these being afflicted with both varieties. The remaining four had 
 tape-worms — in 1, Taenia solium ; in 1, Taenia mediocanellata ; and in 2 the 
 species was not accurately determined. 
 
 Diagnosis. — As in all cases of intestinal parasites, the diagnosis can only 
 be made with certainty by the discovery of the worm itself or the ova. The 
 history of anal pruritus in a child should always lead one to suspect the pres- 
 ence of pin-worms, and the anus and its neighborhood should be carefully 
 searched. By the use of an enema large numbers of the worms may be 
 brought to light. By examining under the microscope scrapings from beneath 
 the finger-nails, the folds about the anus, or the detritus scooped out from 
 inside the anus with a grooved director or catheter, the eggs are often found in 
 large quantities, and are easily recognized, as described above. In all cases of 
 incontinence of urine, masturbation, and leucorrhoea the oxyuris should be 
 thought of and sought for. 
 
 As in the case of lumbricoids, intestinal mucus, which in greater or less 
 quantity is mingled with faecal discharges, has often been mistaken by the 
 nurse or mother for pin-worms, as is illustrated by the following case : 
 
 Allen M , three and one-half years old, was brought to my clinic at the Boston 
 
 Children's Hospital with the history of having passed great quantities of pin-worms in 
 the last few days. His symptoms, which the mother attributed to the worms, were 
 vomiting, slight diarrhoea, with feverishness and general debility. He had a similar 
 attack a year ago, and was thought to have passed worms then. Examination in the 
 folds about the anus failed to reveal any worms, and a microscopical examination of 
 detritus from under the finger-nails, outside the anus and inside the anus was negative 
 as regards the finding of ova. The mother brought next time some of the fasces which 
 she believed to be swarming with the worms. The fsecal mass when placed in water 
 showed plenty of stringy mucus, which, gathered in thread-like clusters, certainly simu- 
 lated very closely actual pin-worms. There was in this case undoubted irritation of 
 the intestine, giving rise to various symptoms suggestive of worms, and to an extra 
 secretion of mucus. The irritation, however, was due to an improper diet, not to worms. 
 
 Treatment. — As long as any worms remain in the bowel there is a con- 
 stant source of infection. Treatment must therefore result in the complete 
 expulsion of the parasites, or we shall have, what is often unfortunately the 
 case, a relapse or return of the trouble. Besides this, measures must be taken 
 to prevent reinfection from the old sources after cure. If the worm confined 
 itself to the rectum, as is erroneously believed by some, treatment from below 
 with injections would be simple and effectual. This treatment, although giving 
 relief for a time, is of course entirely inadequate, as many of the worms are 
 out of reach in the caecum or even in the lower part of the small intestine. 
 The proper method, therefore, is to make the attack both from above and 
 below. By the mouth may be given either santonin, spigelia, or chenopodium, 
 with a cathartic, in the manner already described in the treatment of ascarides. 
 Cathartics which produce free watery discharges are found to be particularly 
 efficient in the treatment, even without a previously administered vermicide. 
 
532 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 Epsom salts, Seidlitz powder, or Hunyadi water are therefore to be recom- 
 mended, but are all unfortunately distasteful to children. The syrup of 
 raspberry disguises very well the taste of Epsom salts in a 25 per cent, 
 solution, thus : 
 
 1^. Magnesii sulphatis giv. 
 
 Syrupi rubi idsei f§ij. — M. 
 
 Sig. A tablespoonful containing one drachm of the salts. 
 
 The vermicide and cathartic may be given by the mouth two or three days in 
 the week. 
 
 Once a day the rectum should be washed out with a copious enema of cool 
 soapy water. By using a soft-rubber catheter attached to the nozzle of the 
 syringe the enema can be introduced higher up, and will be more eifectual. 
 Plenty of water should be used, so as to distend the folds of the rectum and 
 colon in which the worms are lodged. Cold water alone is effectual in washing 
 out and killing the worms, but the addition of castile soap makes it less irri- 
 tating to the bowel and more fatal to the worm ; and this addition is all that 
 is necessary if the injections be given thoroughly. Other substances are often 
 used in solution in the enema for their destructive effects on the worm. These 
 are common salt, quinine, quassia, alum, tannin, etc., but it may be doubted 
 whether these solutions are any more effectual than properly given injections 
 of soap and water. Where there is relaxation and protrusion of the rectum an 
 astringent injection is of use, as, for example, one drachm of sulphate of iron 
 to one pint of infusion of quassia ; or a solution of tannin can be given, in the 
 proportion of a heaping teaspoonful to a pint of water. All irritating injec- 
 tions should be avoided, and dangerous ones, like solutions of corrosive sub- 
 limate, had better not be used. 
 
 As the worm or its ova may live in the folds about the anus, these parts 
 should be carefully scrubbed with soap and water and anointed with an anti- 
 septic ointment. Boric-acid ointment, as in the following prescription, besides 
 destroying worms, is of use in allaying the irritation or eczema caused by their 
 presence : 
 
 3^. Acidi borici 3j. 
 
 Olei rosse gtt. iij. 
 
 Vaseline |j. — M. 
 
 Even after a complete cure, obtained by the expulsion of all the worms, 
 reinfection is likely to take place unless certain precautions are taken. The 
 bed-clothing, the blankets, as well as the linen, may contain the eggs of the 
 oxyuris ; the toys undoubtedly have some lodged in their crevices ; and the 
 carpet or floor may be more or less infected, for it must be remembered that a 
 small bit of faecal matter spilt from a vessel or napkin may contain thousands 
 of eggs. The room and its contents should therefore be almost as thoroughly 
 cleaned as in the case of one of the exanthemata. The bed-clothing should be 
 boiled, the toys destroyed, the carpet and rugs thoroughly beaten, and the floor 
 and furniture scrubbed with soap and water. The neglect of this undoubtedly 
 accounts for the frequent failures to cure this troublesome affection. 
 
 m. T^nia (Tape- worm). 
 
 The common tape-worm is from twenty to fifty feet in length, of a white 
 color, and composed of numerous flattened segments, each of which, except 
 
IXTESTINAL PARASITES. 
 
 533 
 
 those near the so-called head, is a complete hermaphrodite. Nourishment is 
 absorbed through the body-walls from the contents of the intestinal canal, in 
 which the whole worm lies immersed. The "head" is a modified segment 
 about the size of the head of a pin, and it is by this organ with its suckers or 
 hooks that the worm retains its hold on the intestine. The segments near the 
 head are not much broader than a piece of thread, but they rapidly increase in 
 size and become from one-quarter to one-half an inch broad at the other ex- 
 tremity of the worm. 
 
 Varieties. — The two species commonly found in this country are the beef 
 tape-worm, Tcenia mediocanellata, and the pork tape-worm, Tcenia solium. 
 
 Fig. 5. 
 
 Fig. 6. 
 
 Taenia Mediocanellata. Head and Mature Seg- 
 ment, Enlarged (Heller). 
 
 Two other species may be mentioned, as they 
 are sometimes encountered : Tcenia nana and 
 Tcenia cucumerina. Another species, belong- 
 ing to a different genus, Bothriocephalus latus, 
 is found only in certain parts of the continent 
 of Europe. 
 
 The beef and pork tape-worms (Figs. 5 and 
 6) are easily distinguished by their heads, and 
 less readily by the sexually mature segments. 
 The pork tape-worm has a circle of hard chiti- 
 nous hooks on the head, with four sucking 
 disks, and the head itself is somewhat pointed. 
 The head of the beef tape-worm is not pointed, 
 and is provided with four suckers only, being 
 devoid of the circle of hooks. This species may 
 also be distinguished by the sexually mature 
 segments or proglottides which are passed from 
 the anus. In the pork tape-worm the lateral 
 branches of the uterus (Fig. 6, b), are only 
 eight to twelve in number, and quite thick, 
 while in the beef tape-worm the side branches are finer and are much more 
 numerous, being twenty or thirty in number (Fig. 5, b). These can be seen 
 by flattening out the segments between two microscopic slides and holding them 
 up to the light. The addition of glycerin makes them more transparent. 
 
 Tsenia Solium. Head and Mature 
 Segment, Enlarged. (Beneden.) 
 
534 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Tcenia nana has of late years been found to be very numerous in Italy, 
 particularly in Sicily. It has been found in Egypt, and also in England. 
 With so many Italians of the poorer class constantly coming to this country, 
 its occurrence here is to be expected. It especially attacks children, and may 
 occur in great numbers in one individual. It is very small, being only ten to 
 fifteen mm. in length. The head is armed with four suckers and a rostellum 
 with hooks, which can be protruded or entirely withdrawn. Severe nervous 
 symptoms are sometimes caused by this worm. 
 
 Tcenia cucumerina is another rare form of tape-worm which especially 
 infects children, being acquired by them from dogs. 
 
 Life History. — The ova are produced in each segment in great numbers, 
 and those of the two common varieties of taenia are easily distinguished from the 
 eggs of the round and thread-worms by their smaller size and spherical instead 
 of oval shape. The eggs of T. mediocanellata are slightly larger than those 
 of T. solium, which are about y^-g- of an inch in diameter (Fig. 2, a and b). 
 
 The tape-worm lives in the small intestine, firmly attached to the mucous 
 membrane by the suckers and hooks on its head. While the head is attached 
 to the upper part of the jejunum, the other extremity, in the common species, may 
 reach nearly or quite to the ileo-caecal valve. The pork tape-worm is generally 
 found singly, while two or more beef tape-worms may occur in the same indi- 
 vidual. The worm grows by a process of breeding or segmentation from the 
 segments close to the head. As these become farther and farther removed from 
 the head by this process, they become larger and sexually mature. The first 
 sexually mature segment of T. solium is about the four hundred and fiftieth 
 from the head. Some of the ova are extruded from the lower mature seg- 
 ments, and pass off with the faeces, but most of them escape from the anus still 
 contained in the ripe segments, which break off entire. These segments, be- 
 sides passing out in the faecal mass, may slip out of the anus into the under- 
 clothing ; and this happens so frequently that attention is usually called to the 
 presence of the worm in this way. 
 
 For the development of the eggs another host is utilized, this host being the 
 
 hog in the case of T. solium, and cattle in the case of T. mediocanellata. In the 
 
 case of the hog, with its fondness for grubbing around in heaps of offal and 
 
 manure, infection easily takes place. Cattle may be infected in a similar way 
 
 Fig. 7. while cropping grass that has been fertilized with human 
 
 faeces. In the animal's stomach the thick outer coatings of 
 
 the ova are dissolved, the embryos are set free, and proceed 
 
 at once to pierce the stomach-walls, and, carried along in the 
 
 blood-current, bury themselves in the muscles, the liver or 
 
 other viscera. Here they develop into cysticercus cysts, which 
 
 in the pork tape-worm are a little larger than a pea, in the 
 
 beef tape-worm somewhat smaller. Within these cysts the 
 
 larval taenia or scolex grows, the head being formed with a 
 
 short neck and a flask -shaped body (Fig. 7). These cysts 
 
 remain quiescent for from three to six years, after which 
 
 they die and become calcified. If, however, the flesh con- 
 
 Cysticercus^narvai taining living cysts is taken into the human stomach, the 
 
 tape-worm. larval scolex sprouts into the mature tape-worm and the 
 
 cycle of changes is complete. 
 
 It occasionally happens that the eggs of tape- worms are swallowed by men, 
 and cysticerci may develop in various parts of the body, especially in the sub- 
 cutaneous and intermuscular connective tissue, or in the brain or eye. 
 
 Method of Infection. — The consumption of raw or imperfectly cooked 
 
IXTESTINAL PARASITES. 535 
 
 meat, in which the temperature has not been raised to a sufficient point to kill 
 the cysticerci, is the source of infection for taenia. Infants and children are 
 liable to become infected with the beef tape-worm from the use of raw meat, 
 sometimes recommended in intestinal troubles. When the beef is very finely 
 minced or when the juice only is used, the beef being thoroughly pressed 
 and strained, this danger is removed. The consumption of raw sausages is 
 a more common cause of the pork tape-worm among continental nations 
 than in this country; here the beef tape-worm is probably more commonly 
 met with. 
 
 Children, from their uncleanly habits and their custom of sucking the 
 fingers, are more exposed to the danger of swallowing the ova and developing 
 cysticerci. 
 
 Symptoms. — The symptoms caused by tape-worms in the intestine are as 
 obscure as those of round-worms, and, as with these parasites, are often lacking. 
 A child, as well as an adult, may harbor a tape-worm for years, the only indica- 
 tion of this being the passage of segments from time to time per anum. Un- 
 comfortable sensations in the abdomen and pain in the region of the navel, with 
 the various nervous symptoms given under the head of Lumbricoids, such as 
 picking at the nose, disturbed sleep, fitful and at times ravenous appetite, have 
 been observed in these cases. There may be nausea and salivation, and 
 vomiting is at times present. The bowels are often irregular. The movements 
 of the worm in the intestine are sometimes described, but it is doubtful whether 
 this is anything more than a psychical phenomenon. Failure to take on flesh 
 notwithstanding a ravenous appetite is to the laity a characteristic symptom of 
 tape-worm, but its significance is of very doubtful value, for it is a symptom 
 often present without the worm, and is indicative of faulty digestion and imper- 
 fect assimilation. As with the other intestinal worms, chorea and convulsions 
 have been attributed to taeniae. 
 
 The following case came under my care at the Children's Hospital in July, 
 1890: 
 
 Angelina M , four and a half years old, has had a tape-worm for two years. The 
 
 mother has found segments frequently in her under-clothing and in the stools. She has 
 been under treatment by various doctors from time to time, but without permanent relief, 
 as the whole worm has never been expelled. The child was accustomed to eat a great 
 deal of very rare beef. She complains of constantly feeling tired, is peevish and fretful, 
 frequently picking the nose, and is restless at night. Her head perspires a great deal, 
 her appetite is at times ravenous, and she complains of pain about the navel. The 
 bowels are regular. 
 
 Under treatment — which I shall give below — she expelled a beef tape-worm twenty- 
 four feet long, with the head entire. It is extremely interesting to note that a year later, 
 in May, 1891, the patient returned, complaining of exactly the same symptoms, which 
 had never been recovered from, but she never passed any more segments of worm. 
 
 Diagnosis. — There is no difficulty in making the diagnosis of tape-worm, 
 for the mature segments slip from the anus at intervals of every few days 
 or are passed in the stools. Their white color and peculiar shape at once 
 attract attention, so that it is not necessary to make microscopic examinations 
 of the faeces or to resort first to anthelmintic treatment. The distinction 
 between the two common species of taenia is made in the manner detailed in 
 the description of the worms. The fact that patients are apt to mistake 
 shreds of mucus for worms, requires the physician to assure himself of the 
 correctness of the identification before beginning treatment. 
 
 Treatment. — Having made sure that a worm is present, appropriate treat- 
 ment should be at once instituted unless contraindicated by some acute illness ; 
 
536 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 for, although the worm in the intestine may produce no symptoms, there is 
 always danger of cysticerci developing somewhere in the body from the acci- 
 dental ingestion of the ova. 
 
 Half-hearted measures are sure to be failures, consuming time, irritating the 
 child, and wasting its strength. To be successful the entire worm, including 
 the head, should be obtained, although it often happens that if the worm be 
 broken off close to the head and expelled, there is no return of the trouble. This 
 can probably be explained by the fact that the head is in reality expelled, but, 
 being so small, is not found in the faecal debris. This is particularly apt to be 
 the case if the mother or nurse attempt to find the head. It is much better 
 for the physician himself to make the search. This should be done by adding 
 water to the stool and shaking up the faecal mass or stirring it gently with a 
 stick, being careful not to break up the worm ; by decanting the water from 
 time to time and adding fresh, a clear mixture will be obtained in which it is 
 easier to find the parasite. 
 
 Treatment consists, first, in the preparatory dietetic management ; secondly, 
 in the administration of some drug which experience has shown will kill or 
 benumb the worm ; and lastly, in the use of a cathartic to remove the offend- 
 ing body. 
 
 The preparatory treatment is partial starvation, in order to weaken the 
 worm. For this purpose small amounts of such food as can be digested in the 
 stomach are to be preferred, and the colon should be unloaded, so as to make 
 the exit for the worm easy. As children cannot stand much starving, the pre- 
 paratory period should be shorter than in adults, and it loses some of its irk- 
 someness by including the night. After a light dinner the child should be 
 given a bowl of beef-tea with a half slice of white bread for supper ; an 
 enema must be given in the evening and the child put to bed early. The break- 
 fast must consist of beef-tea alone. An hour later, say at 9 A. M., the anthel- 
 mintic can be given, to be followed in one hour by the cathartic. The stools 
 should be carefully preserved and examined as explained above. It sometimes 
 happens that the worm is partially expelled by a movement from the bowels, 
 and is left hanging out of the anus. In this case great care should be used 
 not to break it off, a large injection being given to dilate the rectum and allow 
 the removal of the worm by gentle traction. Dilatation of the anus by a small 
 rectal or nasal speculum will take off the pressure of the sphincter and aid in 
 extraction. 
 
 It only remains to consider the various taenicides recommended. The list 
 is a large one, but I will mention only the important ones. These are — pom- 
 egranate, the bark of the root and its alkaloid pelletierine ; filix mas, the root 
 of the male fern ; kousso ; pumpkin-seed ; turpentine ; and cocoa-nut. 
 
 The first, pomegranate, is one of the most efficient. It can be given in a 
 decoction, which, however, makes a disagreeable draught, and one apt to defeat 
 its own purpose by causing vomiting. A much neater way, and one that I 
 have always employed, is to use the alkaloid pelletierine. The tannate of this 
 alkaloid is made into an elegant but very expensive preparation by Tanret of 
 Paris, and is put up in small bottles containing one adult dose. This can be 
 obtained in all our large cities, and its efficiency makes up for its high price. 
 As pomegranate in full doses causes nausea, giddiness, faintness, and indistinct- 
 ness of vision, it is best for the child to lie down after the dose is given. In 
 the case of tape-worm in the child of four and a half years, related above, the 
 preparation of the tannate of pelletierine was given, one-third of the bottle, which 
 contained five teaspoonfuls, being administered at a dose. The child com- 
 plained of slight dizziness and headache. An hour after the tsenicide a full 
 
INTESTINAL PARASITES. 537 
 
 dose of castor oil was given, and four hours later the worm was expelled 
 entire. 
 
 The oil of male fern, oleoresina aspidii, is ths next most efficient remedy for 
 tope- worm, a teaspoonful being given to a child of five years, shaken up with 
 some agreeable menstruum, as in the following recipe : 
 
 1^. Oleoresinae aspidii 3j. 
 
 Tinct. quillaige f^ss, 
 
 Spts. aurantii dulcis f3J- 
 
 Syr. aurantii q.s. ad f£vij. — M. 
 
 Kousso appears to be used more by European than American physicians 
 and is said to be efficient and free from danger. The freshly-prepared infusion 
 is best used (infusum brayerse, U. S. Ph.), but is very objectionable to children 
 from its disagreeable taste, and is liable to produce vomiting. 
 
 Pumpkin-seed is a perfectly safe and simple remedy, but in my experience 
 is never efficient, a small part of the worm being left behind to reproduce the 
 trouble. The outer shell of the seeds should be removed, and the inside rubbed 
 up with syrup or honey into an agreeable mass. One or two ounces of this can 
 be eaten, followed, as in all cases, by a purgative. 
 
 Another agreeable remedy is the meat of the cocoa-nut. From large quan- 
 tities of this there have been favorable reports lately, but as cocoa-nut is rather 
 indigestible it might have an untoward effect on the child. 
 
 With pelletierine or male fern, preferably the former, properly given with 
 all the details of treatment attended to, success should always finally crown our 
 efforts, and it seems to me better not to waste time with any other remedies. 
 
 IV. — Trichocephalus dispar (Whip-worm). 
 
 This is a small worm, thickened at one end, but tapering out like a whip- 
 lash at the other. It is four or five centimetres long, and lives in the caecum 
 where it is often found in large numbers (Fig. -p g 
 
 8). The eggs (Fig. 2, d) are about the size of 
 the ova of the pin-worm, from which they are 
 easily distinguished by the irregular rounded 
 shape. At each extremity is a break in the 
 egg-walls. Of 16 children examined for this 
 purpose, I found the eggs of this worm in the 
 feces of one. The worm gives rise to no symp- 
 toms, as far as known. Trichocephalns Dispar (Heller). 
 
DISEASES OF THE LIVER 
 
 By JOHN H. MTJSSER, M. D., 
 
 Philadelphia. 
 
 Diseases of the Liver are not of frequent occurrence in childhood. 
 The factors essential for the development of hepatic disorder require the 
 element of time to aid them. This is one reason gall-stones, for instance, do 
 not occur in early life. Moreover, the customary food and drink of early 
 childhood do not influence hepatic function and nutrition deleteriously, and 
 therefore functional derangements, hepatic congestion, and sclerosis are rela- 
 tively infrequent. Other etiological factors of liver disease in adult life are 
 not operative in childhood. The liver is more frequently the seat of secondary 
 disease than possibly any other organ. The primary diseases usually occur in 
 adult life, and hence the secondary effects are only observed at that period. 
 For instance, cancer of the liver and abscess following amoebic dysentery are 
 not of frequent occurrence in childhood. 
 
 While the above applies chiefly to organic disease of the liver, the writer 
 fully believes that functional disorder in late childhood and early adolescence 
 is of more frequent occurrence than we are led to believe from the text-books. 
 If the broad view of Murchison be true, that lithgemia and allied disorders with 
 their long train of functional derangements in the gastro-intestinal tract, the 
 nervous system, and the circulatory apparatus, or their results, terminate 
 in organic disorder of liver, kidney, arteries or nerve-structure, we must 
 believe that the beginnings are found in the errors of diet, the improper 
 clothing, the misguided exercise, the vicious methods of education, and abnor- 
 mal excitements of the nervous system which occur in childhood. It is true 
 the physiological labors of the liver are so closely related to, or rather so 
 markedly an adjunct to, the physiological labors of other organs of the primae 
 vise that it is almost impossible to fix upon the disturbing factor when disorder 
 is observed. Hence a clinical distinction between malnutrition and malassimi- 
 lation cannot be made. Functional disorders, therefore, will not be discussed 
 in this chapter, and for the above reasons are usually excluded in works on 
 diseases of children. 
 
 Diseases of the gall-ducts, save catarrhal inflammation, are due either to 
 gall-stones (not present in childhood) and their consequences or to diseases 
 outside of the duct that do not arise in early life. Hence affections of these 
 passages need not be considered. 
 
 General Etiology. — The causes of liver disease in childhood do not differ 
 from those in adult life, though they are not as frequently operative, or the 
 results of their operation are not seen. Icterus neonatorum and congenital 
 obliteration' of the ducts are the diseases of the liver peculiar to childhood, 
 and therefore have a distinct etiology. Other affections of the liver are com- 
 mon to both periods. Errors of diet, excess in rich food or in stimulants, 
 
 538 
 
DISEASES OF THE LIVER. 539 
 
 cause congestion of the liver in children as in adults. Seasonal changes are 
 factors, although it seems that high temperature does not often tend to cause 
 acute congestion of the liver in children ; at least, writers on tropical diseases 
 do not specifically refer to the occurrence of acute congestion in early life. 
 Malaria causes congestion of the liver at any age ; checking of discharges or 
 chronic constipation are not marked factors in childhood ; but the congestions 
 that arise in the course of infectious diseases are more commonly found at this 
 time. Scarlet fever, measles, and, notably, relapsing and yellow fever, are 
 attended by congestion of the liver. In passive congestion we find the same 
 influences at work in the child and the adult. The effects of obstruction of 
 heart and lungs are similar. 
 
 As in congestion, so in fatty liver, the causes are not peculiar. In chil- 
 dren abnormally obese or the subjects of phthisis or profound anaemia, the 
 disease is liable to occur, just as in adult life. The same is true of amyloid 
 disease; prolonged suppuration alone or in tuberculous bone disease or in 
 tuberculosis of the lungs leads to its frequent occurrence in children. Syphilis 
 is a common associate and rachitis is occasionally observed with amyloid liver. 
 Osier states that amyloid disease is found in prolonged convalescence. 
 
 Syphilitic inflammation of the liver in children is almost always con- 
 genital. In hydatid disease of the viscus we see a common cause at both 
 periods of life, and as hydatids grow slowly, it is possible infection takes place 
 in childhood, but symptoms do not arise until later in life. 
 
 In suppurative hepatitis the etiological factor differs at different ages. In 
 this affection in children we do not find the baneful causative effects of high 
 temperature, nor does it appear to follow amoebic dysentery as frequently as in 
 adults. It is possible this form of dysentery is not common in children. The 
 writer had occasion to analyze all the recorded cases of abscess of the liver 
 up to 1890, and found that portal pyaemia and traumatism were more frequent 
 causes than tropical dysentery (respectively 10 and 8 in 34 cases), and that 
 round worms in the ducts were only slightly less common. 
 
 In cirrhosis of the liver, again, the causes are not dissimilar, although the 
 infectious diseases play a more important part in childhood, while alcoholism 
 is an infrequent causal agency. Klein points out the frequency of scarlatina, 
 and Laure and Honorat, and Siredey, measles, as factors in its production. 
 Tuberculosis is another cause. It is remarkable to find the affection occurring 
 with general arterio-capillary fibrosis. Howard believed that rich, high-seasoned 
 food is likely to produce cirrhosis in childhood, and that we have reason to 
 believe ptomaines are causal agencies. 
 
 But little attention need be paid to the morbid anatomy and pathology 
 of diseases of the liver in childhood. The morbid processes do not differ from 
 similar processes in adults, and, as the scope of this article is limited, the dis- 
 cussion of morbid anatomy and pathological histology will be omitted. 
 
 General Symptomatology. — The subjective and objective symptoms of 
 hepatic disease in childhood usually present the same striking picture of mor- 
 bid change as in adult life. Apart from the symptoms that attend failing 
 health, the subjective sensations of hepatic disorder are few. If we consider 
 functional derangements of the liver to be the primary cause of lithaemia, then 
 indeed the above remark is not correct ; but, as previously noted, such rela- 
 tionship will not be considered. 
 
 Pain is a subjective symptom found only in one or two of the disorders 
 which are to be discussed in this article. It occurs in suppurative hepatitis, 
 in syphilitic inflammation of the liver when the capsule is involved, and 
 in a slight degree in congestion. It may be localized to a small area, or 
 
540 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 the whole organ may be the seat of pain. It is constant, increased by 
 pressure or movement. It may extend to the right shoulder. The patient 
 may be compelled to lie on the affected side with the legs drawn up. The 
 paroxysmal pain that characterizes hepatic colic, and is the most frequent pain 
 of hepatic disease in adults, does not occur. Pain in the region of the liver 
 in childhood must be distinguished from pleurodynia and pleurisy. In pleuro- 
 dynia there is immobility, respiration and other movements are painful, the 
 area is tender on superficial examination by palpation, and other portions 
 of the body may be affected with rheumatism, or there is a distinct history 
 of exposure. In pleurisy the pain is markedly increased by breathing, is 
 associated with a pleural friction, and is sharp and lancinating, attended 
 by cough and increased by it. Pressure at a localized area increases it. It is 
 often difficult, indeed impossible, to distinguish right-sided pleurisy from a 
 perihepatitis. In both friction occurs ; in the former, fluid may soon be 
 detected in the pleural cavity, or the development of pneumonia may aid to 
 distinguish the two. It may be said that the pain that attends liver disease is 
 increased by pressure at any part of the liver, particularly upward along the 
 lower edge of the viscus, or in the epigastrium. 
 
 Pain in simple abscess of the liver is localized ; the locality corresponding 
 to the seat of injury when that is the cause of the abscess. In pylephlebitis 
 the pain is more diffused. In abscess there is localized tenderness ; in peri- 
 hepatitis the parts are exquisitely tender on palpation. Weight and fulness 
 and uneasy sensations are described by the patient when there is enlarge- 
 ment of the liver. They are not of diagnostic value. 
 
 The subjective symptoms referable to gastro-intestinal derangement are 
 many, but are not characteristic. Loss of appetite, a bitter taste, nausea, 
 dyspeptic symptoms, particularly flatulency, with irregular or costive bowels, 
 occur. The objective symptoms — noted by the usual methods of physical 
 examination — are jaundice, ascites, enlargement of the spleen and of the 
 abdominal veins, haemorrhoids, and fever and sweats. 
 
 Physical Examination. — The liver in infancy and childhood is larger in 
 proportion to the weight of the body than in adult life. It therefore presents 
 a relatively greater surface for examination. The left lobe is particularly 
 accessible to physical examination. The upper border of the liver extends to 
 the fifth, sixth, and seventh ribs in the mid-clavicular, axillary, and scapular 
 lines respectively. The lower border extends two inches below the margin 
 of the ribs. In the median line the left lobe extends to within an inch of 
 the umbilicus. 
 
 Inspection. — The decubitus of the patient is not peculiar in hepatic affec- 
 tions except when acute inflammation is present. The recumbent posture is 
 assumed and the legs drawn up. The patient may lie on the right side. If 
 pain be present, it is increased by keeping on the left side. The abdomen is 
 usually distended by flatus, or in certain affections by ascites. If the liver be 
 enlarged, the right lower third of the thorax is distended, as well as the con- 
 tiguous portion of the abdomen. If there is much enlargement or if acute pain 
 is present, the movement of the right lower half of the thorax is limited. 
 The epigastrium is distended. The swelling of the hepatic area may corre- 
 spond to the entire organ or may be localized. In abscess and hydatid disease 
 tumors may be detected in the left lobe of the liver, along the lower border 
 of the right lobe, or as swelling with projection of the ribs at points corre- 
 sponding to the convex surface of the liver. Hence the epigastrium, the right 
 hypochondrium, and right lumbar region, and the mid-clavicular, mid-axillary, 
 and scapular lines along the upper border, are the favorite seats of election 
 
DISEASES OF THE LIVER. 541 
 
 of tumors. In abscess the superimposed skin may be reddened. The appear- 
 ance of the veins over the surface must be noted. 
 
 Palpation. — By palpation the position of the lower border of the liver and 
 the character of its surface are determined. The former is easily ascertained 
 if the abdomen is not too much distended and if the child can be kept quiet 
 during the examination. The normally large left lobe must not be mistaken 
 for a tumor. The liver moves with respiration, and this fact must be ascer- 
 tained in order to exclude the presence of tumors in the abdomen due to other 
 causes. Faeces in the transverse colon must be excluded by the administration 
 of purgatives. The surface of the liver, as well as its edge, may be soft, as 
 in fatty liver, or indurated, as in amyloid disease. In both the edge is smooth ; 
 in cirrhosis it may be sharp, but is invariably hard. Bosses may be detected 
 due to cancer, hydatid disease, or abscess. In hydatid disease they are soft 
 and may fluctuate ; in abscess they are hard at first, then become soft and 
 fluctuating. A friction vibration is sometimes detected by the palpating hand 
 in cases of perihepatitis, and the peculiar fremitus may be elicited in hydatid 
 disease. (Edema of the surface is observed occasionally in abscess. 
 
 Percussion. — By this means the size of the liver, whether diminished or 
 enlarged, can be accurately determined, and the degree of enlargement ascer- 
 tained. Marked deviations from the normal boundaries of percussion, as indi- 
 cated above, serve to distinguish the changes. It must not be forgotten that 
 to define the upper border deep percussion must be employed, and, to define 
 the lower border, light percussion. The colon must be emptied of faeces, and 
 the character of the evacuations noted. Affections of the pleura, particularly 
 effusions, must be excluded. When a pleural effusion is present there is a uni- 
 form bulging of the side, the respiratory movement of the liver is restricted, 
 and a depression is sometimes seen between the effusion and the liver if that 
 organ be pushed down. By percussion it is found that the dulness of effusion 
 is movable, and that its upper limit is S-shaped or horizontal. The rational 
 symptoms of pleurisy aid to distinguish it. When the liver is enlarged the 
 ribs are everted. 
 
 In determining the outline of the liver by percussion it is well to ascertain 
 if it be regular or not. When the liver is enlarged in its entirety the normal 
 shape is not departed from. If the enlargement is due to hydatid disease or 
 abscess, the outline is irregular. The area of dulness may extend out from the 
 normal liver in positions indicated by palpation. Sometimes the enlargement, 
 though uniform, occurs in one direction only ; thus in abscess or hydatid dis- 
 ease of the convexity the increase in dulness is upward and to the right ; in 
 hydatid disease of the centre, downward. Both affections may be limited to 
 the left lobe, and then an increase in size of the corresponding area is noted. 
 
 Diagnosis. — By means of physical examination, with a study of rational 
 symptoms, simulated enlargement of the liver is excluded. Apparent increase 
 in the size of the liver, as determined by palpation and percussion, may 
 depend upon congenital change in the shape of the liver or upon displace- 
 ment of this organ by the deformities of the chest, due to rickets or to caries 
 of the vertebrae. Congenital change in shape is recognized by the fact that 
 it is noted soon after birth, and that, while it is persistent, symptoms of hepatic 
 disease are absent. 
 
 Apparent enlargement of the liver upward — dulness extending to the 
 fourth rib in front — may be due to tumors in the abdomen or to ascites ; or the 
 normal liver dulness may be continuous with the dulness due to sarcoma of the 
 kidney, to tuberculous disease of the omentum, to an ovarian tumor, or to 
 encysted or free fluid in the peritoneal cavity. 
 
542 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 If fluid be present, the dulness may change if the patient turns on the left 
 side ; the lower border can then be defined. If the fluid be encysted, diagno- 
 sis is more difficult. A history of previous peritonitis or a history of tuberculo- 
 sis, with associated development of the disease in other organs, with fever and 
 emaciation, is suggestive of tuberculosis, which is usually the cause of encysted 
 fluid as well as omental disease. A tumor of the right kidney may be dis- 
 tinguished from an enlarged liver if the tumor be rounded, if the fingers can slip 
 between the tumor and the liver, if a tympanitic note, indicating the presence 
 of the intestine, be found to run across the surface of the kidney, if the tumor 
 do not move with respiration, and finally by urinalysis. 
 
 The physical examination is not complete unless the characteristics of the 
 organs adjacent to the liver are observed. Without such examination no 
 diagnosis can be made nor rational treatment conducted. 
 
 Operative exploration of the liver, accomplished by means of the aspirator 
 or hypodermic syringe, properly sterilized, is useful to confirm the diagnosis 
 of hydatid disease or of abscess of the liver. By this means three kinds of 
 liquid may be withdrawn — serum, pus, or hydatid fluid. The former, serum, 
 does not occur in the liver ; either the pleura or the space underneath the dia- 
 phragm yields it ; but its presence does not exclude hepatic disease, for serous 
 inflammation may complicate the liver affection. Cases are recorded in which, 
 after emptying the pleura of serum, deeper exploration through the diaphragm 
 yielded pus. The association of pleurisy or empyema and subdiaphragmatic 
 abscess with hepatic disease must not be forgotten. 
 
 By the aspirator clear laudable pus may be withdrawn. It often contains 
 crystals of leucin and tyrosin, and, it is said, the characteristic liver cells. If 
 such cells can be recognized, it is proof positive that the pus was originally in 
 the liver. The pus may be so mixed with blood as to appear reddish-brown, like 
 anchovy sauce. In this case, on microscopical examination, the amoeba 
 dysenterica is sometimes found in the purulent fluid. The abscess is then 
 secondary to dysentery. 
 
 Hydatid fluid is clear, alkaline, of low specific gravity, contains sugar, 
 a trace of albumin, and a large amount of chloride of sodium. Succinic acid 
 has also been detected. On microscopic examination hooklets, echinococcus 
 membrane, sometimes scolices, and often hsematoidin crystals are found. It is 
 to be remembered that hydatid cysts may suppurate ; pus will then be secured 
 by aspiration, in which the remains of the echinococcus cyst are present. 
 
 In diseases of the liver in childhood an accurate diagnosis can be made 
 only by a consideration of the personal history of the patient, of the previous 
 diseases from which he suffered, of the evolution of the disease the nature of 
 which is to be solved, the subjective symptoms and physical signs of the ail- 
 ment, and the condition of all the organs and structures of the body. A sys- 
 tematic pursuit for all the facts, as embraced above, is necessary in the study 
 of disease of any portion of the body ; but the liver, more than other 
 organs, is subjected to onslaughts of morbid action that primarily develop 
 elsewhere ; hence previous ailments must be investigated and the integrity of all 
 the tissues carefully ascertained. For the differential diagnosis of the various 
 affections this is essential. Of the hepatic affections discussed in this work, 
 congenital disease of the gall-ducts, some forms of congestion, and hydatid 
 disease are the only ones that are not secondary to affections of other organs. 
 
 A diagnosis is facilitated not only by inquiring into the integrity of the 
 various organs of the body, but also by securing definite information regard- 
 ing the occupation, habits, residence, and all other conditions of life of the 
 patient. Illustrations could be advanced in any disease, but it suffices to 
 
DISEASES OF THE LIVER. 543 
 
 point out the value of the knowledge of alcoholism in cirrhosis, of exposure 
 to phosphorus in yellow atrophy, of residence among dogs in hydatid disease. 
 
 . Jaundice. 
 
 Etiology. — As seen most frequently in childhood, jaundice is due to 
 obstruction of the bile-ducts — the hepatogenous form — resulting from pressure 
 upon the ducts, or obstruction within them. 
 
 Pressure upon the Ducts. — Organic disease of structures adjacent to the 
 ducts which might press upon them is very rare in childhood. 
 
 Obstruction within the Ducts. — Affections of the mucous membrane are 
 abnormal processes very liable to occur in infancy. When the lining mem- 
 brane of the ducts, and particularly the portion of the common duct known 
 as the pars intestinalis, is the seat of catarrh, the membrane swells and causes 
 obliteration of the lumen. Jaundice therefore occurs. Congenital obliteration 
 of the ducts is also found to be a cause of jaundice. Gall-stones do not occur 
 in childhood, and the wandering of worms into the duct is rare. It is seen, 
 therefore, that the obstructive or hepatogenous form of jaundice is due in the 
 larger proportion of cases to catarrh of the ducts and sometimes to obstruction 
 of them by round-worms. 
 
 The causes of hcematogenous or non-obstructive jaundice are also few in 
 number. Yellow fever, malaria, epidemic jaundice, and pyaemia may be pos- 
 sible causal factors ; poisoning by phosphorus, the use of ether or chloroform, 
 mercurial poisoning, and snake-bite are rare possibilities. No cases of acute 
 yellow atrophy in childhood have been reported. 
 
 Jaundice is a symptom, not a disease. It is recognized by symptoms and 
 general physical signs. 
 
 Symptoms. — Icterus, or the yellow hue of skin in jaundice, is usually first 
 noticed by the nurse or mother. The color varies from lemon-yellow to olive- 
 green or a bronzed hue. In obliteration of the ducts it is most intense. It 
 develops gradually, usually on the face first. In the obstructive form it is 
 general. The conjunctivae are deeply colored ; the mucous membranes are tinted ; 
 the secretions are bile-tinged ; the sweat stains the linen yellow. The urine is 
 loaded with bile-pigment. It is brownish-yellow or has a greenish tinge. 
 When shaken in a test-tube a yellow froth rises to the surface. By the nitrous 
 acid test the play of colors characteristic of reaction with bile-pigment is seen. 
 While the tissues and secretions are bile-tinged, the faeces are deprived of 
 the pigment. They are pale or slate-gray in color, very offensive and pasty. 
 The temperature is frequently subnormal. Prostration occurs, and anaemia 
 arises. The influence of the bile on the nerve-centres or their peripheral 
 terminations is seen in the character of the pulse, the occurrence of itching, 
 and the grave cerebral phenomena to which the term cholesteraemia has been 
 applied. The pulse-rate is much diminished ; it often falls to two-thirds or 
 one-half of the customary frequency. Itching is a most distressing symptom 
 and is caused by the bile-pigment irritating the peripheral cutaneous nerve- 
 filaments. Often the body, particularly the trunk, is covered with scratch- 
 marks. The skin is liable to eruptions, as erythema and boils. 
 
 Ordinary cases of jaundice frequently show some irritability of temper and 
 mental depression. This may be followed by drowsiness and by stupor ending 
 in coma. In children convulsions are frequently seen. In malignant cases the 
 typhoid state usually closes the scene ; the pulse becomes rapid, fever occurs, 
 the tongue is dry and brown, sordes collect on the teeth, and there is sub- 
 sultus tendinum with low delirium, and sooner or later convulsions and coma. 
 
544 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 Here too haemorrhages occur, the leakage being subcutaneous or into the 
 mucous membranes, and appearing as nose-bleed, haematemesis, or melaena. 
 
 Epidemic jaundice occurs at times in children. Denton reports a small 
 epidemic among children of the same school. The symptoms were sudden 
 vomiting, headache, vague gastric pains, with prostration, and in three or four 
 days intense jaundice. Duration, ten to twelve days. Hennig, after a study 
 of three house-epidemics of infectious icterus, concludes that it is a general 
 acute, specific, infectious, miasmatic, non-contagious disease. It may be spo- 
 radic, epidemic or endemic, and appears to have a relation to typhoid fever 
 and to typhus. The infectious agent arises outside of the human body. The 
 disease runs a favorable course and never relapses. 
 
 Raven believes ordinary catarrhal jaundice may be infectious, and reports 
 an instance in which one child of a family became icteric from exposure, and 
 that four others of the house developed the affection, apparently by contagion. 
 
 Diagnosis. — The diagnosis of jaundice is not difficult. The greenish- 
 yellow hue of chlorosis, with the pearly conjunctivae, would suggest an exam- 
 ination of the blood, the result of which would distinguish chlorosis and 
 jaundice. Similar examination would enable an exact diagnosis of pernicious 
 (idiopathic) anaemia to be made in cases resembling jaundice in the straw- 
 colored skin and the conjunctivae made yellow by the deposition of fat. The 
 rarity of Addison's disease in childhood is such as to preclude the possibility 
 of an error in diagnosis. The same may be said of malignant disease of the 
 abdominal viscera. Malaria, however, occurs at any age ; but the rational 
 symptoms, the plasmodia and pigment in the blood, and the condition of the 
 spleen aid in the diagnosis of the paludal disorder. 
 
 Varieties of Jaundice. — Jaundice in the New-Born. — In the new- 
 born infant jaundice occurs in mild form during the first week of life on 
 account of ligation of the cord and consequent alteration of blood-pressure in 
 the liver, and in malignant form in (1) congenital obliteration of the biliary 
 passages, and (2) pylephlebitis secondary to inflammation of the umbilical 
 vein. 
 
 Simple jaundice in infants rarely produces grave symptoms. The skin, 
 the conjunctiva, and the mucous membranes show a yellow discoloration, vary- 
 ing in degree in different cases. The urine is loaded with bile-pigment. The 
 child sleeps more than in health, and may not arouse when feeding should 
 take place. The bowel movements may be pasty and white. Such jaundice 
 begins twelve or twenty-four hours after birth. It lasts two days to a fort- 
 night. The infant usually remains well -nourished. It is due to low tension 
 in the blood-vessels of the portal circulation (after ligature of the cord), which 
 causes rapid absorption to take place from the bile-capillaries in which the 
 tension is higher. Quincke thinks it is due to patency of the ductus venosus. 
 
 Icterus neonatorum is to be distinguished from the pseudo-jaundice that oc- 
 curs after birth due to a destruction of red corpuscles in excess of the powers 
 of the liver to discharge them from the body in the bile. In this condition 
 the conjunctiva is not injected, the stocls are not clay-colored, and the 
 urine does not contain much pigment. The discoloration fades like a bruise 
 from yellowish red to flesh color. It is said late ligature of the cord allows 
 a portion (one-half) of the blood in the placenta to flow into the infant's 
 body, and therefore this distends the foetal vessels by so much. This fact is 
 of importance if, as Parks states, distended blood-vessels exhibit more intense 
 jaundice. 
 
 The treatment of the mild jaundice of infants is very simple. The bowels 
 should be opened by a mild laxative, such as calomel or gray powder in minute 
 
DISEASES OF THE LIVER. 545 
 
 doses, or a few grains of calcined magnesia. The kidneys should be kept 
 active by nitre or citrate of potassium well diluted. The child should be 
 aroused to be fed, and the effects of the jaundice on the nerve-centres should 
 be carefully watched. Ammonia in the form of the muriate or the aromatic 
 spirits should be given, as in the following prescription : 
 
 Tfy. Ammon. chloridi gr. j. 
 
 Syr. acaciae f §ss. — M, 
 
 Sig. A coffee-spoonful every two hours. 
 Or, 
 
 Ify. Spt. ammon. aromat f^j. 
 
 Syrupi f^vij.— M. 
 
 Sig. One-half teaspoonful every two hours. 
 
 Spirits in the form of whiskey in hot water may be given if there be 
 depression. Hot water, sweetened, can be given with advantage in copious 
 drafts, particularly when fasting, for its effect on the liver and kidneys. 
 
 There does not seem to be any reason against the use of gentle massage 
 and faradism ; both are vaunted in catarrhal jaundice in later life. Exter- 
 nally mild sinapisms, with light friction, must be employed if the circulation 
 fails ; and the extremities must be kept warm. 
 
 Jaundice due to Congenital Obliteration of the Bile-passages. — Four forms 
 of obliteration have been noted : First, that in which no passage exists 
 between the liver and duodenum ; second, in which there is one permeable 
 canal, but no exit from the gall-bladder ; third, in which both cystic and 
 hepatic ducts are obliterated ; and, fourth, in which obliteration has taken 
 place below the junction of the cystic and hepatic ducts. 
 
 Congenital malformation, with narrowing of the lumen of the parts on 
 account of defective development, may exist to such degree that it leads to 
 sluggish discharge of bile, which causes irritation of the ducts. A catarrhal 
 process is set up, and leads to complete obliteration. The process is slow, but 
 the obliteration is finished in some cases during intra-uterine life ; in others 
 not until a few months after birth. In a few cases the inflammation of the 
 ducts and the surrounding parts has led to localized peritonitis. In all cases, 
 "biliary" cirrhosis of the liver has developed secondarily. 
 
 The condition is rare. Dr. John Thomson was able to collect 64 cases. 
 We are indebted to his monograph for the following facts : The parents of 
 the children affected with obliteration of the bile-ducts are usually healthy. 
 Syphilis in the parents is not an important factor. In several instances more 
 than one child of the same family was affected, and in a large number of 
 instances nearly all the children of families in which one case occurred had 
 infantile jaundice or were subject to digestive disturbances. The character of 
 the labor did not seem to influence the occurrence of the disease. At birth 
 the affected child presented no abnormal appearance, except jaundice. In 
 2 out of 60 cases the lesions of congenital syphilis were seen. Boys were 
 affected more frequently than girls. 
 
 Jaundice is the most pronounced symptom. It is most frequently present 
 at birth, but may not develop until one, two, or six days after, and may be 
 delayed beyond a fortnight. It soon becomes of a greenish hue, and it 
 progressively deepens until the final termination. The urine contains bile 
 coloring matter. The meconium may be normal or colorless. When it is 
 normal the obliteration has taken place late in uterine life or not until after 
 birth. The motions are whitish-gray at first or become so immediately after 
 
 35 
 
546 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the meconium is passed. At times green matter is voided with the stools. 
 It may be due to mercury which had been administered or to micro-organisms 
 in the faeces. 
 
 Next to jaundice, the occurrence of spontaneous haemorrhages is the most 
 frequent and characteristic symptom. They occur subcutaneously, from the 
 umbilicus, the bowels, the stomach, the nose, and other portions of the body. 
 The occurrence of haemorrhage is of very bad prognostic omen, death usually 
 occurring a short time afterward. Usually in jaundice the blood-corpuscles 
 are so reduced as to create the haemorrhagic tendency, but Thomson believes 
 haemorrhages occur because of some change in the blood-vessels produced by 
 an excess of ptomaines in the blood, the function of the liver by which these 
 poisonous materials are destroyed being in abeyance. 
 
 With or without haemorrhage, convulsions frequently take place. These 
 phenomena are of frequent occurrence in other forms of jaundice, and are not 
 peculiar to the affection under consideration. 
 
 Progressive and easily recognized enlargement of the liver and spleen 
 takes place, with the development of the grave phenomena indicated. Emacia- 
 tion and exhaustion rapidly progress, and death ensues from slight intercurrent 
 disease, from coma or from exhaustion. 
 
 The diagnosis is not difficult ; the prognosis of a fatal termination is posi- 
 tive. The duration is from one week to four months. Two cases recorded by 
 Thomson lived to the eighth month. Treatment is without curative results. 
 
 Jaundice due to Inflammation of Umbilical Vein. — Icterus may occur in 
 infants because of inflammation of the umbilical vein, with secondary pyle- 
 phlebitis. The stump of the cord is swollen and may exude pus, or the 
 navel is ulcerated and inflamed. Haemorrhage is likely to arise. The skin 
 is discolored around the navel, and the parts are tender. The liver is enlarged, 
 and may be tender over the surface. In rare cases a localized or general 
 peritonitis occurs. The attack may be ushered in with a convulsion, which 
 is apt to recur. The infant is restless and cries very much. The desire to 
 nurse is lost. Vomiting occurs, and often diarrhoea soon sets in. Foci of 
 infection arise in other structures — the joints, the brain, the lungs. The 
 joints become painful on movement and are swollen and red. 
 
 After the convulsion, or perhaps without it, fever sets in with the customary 
 phenomena. The temperature is high and may be intermitting ; the pulse is 
 very rapid, the respiration increased; cough may be present; jaundice is not 
 very intense. As the temperature rises the liability to convulsions increases, 
 and death follows the convulsions, occurs in coma, or may take place from 
 exhaustion. After death a septic pleurisy, pericarditis, peritonitis, or menin- 
 gitis may be found, or similar inflammation of the kidneys observed. 
 
 The fever, the local signs and symptoms, and the jaundice render the 
 diagnosis easy. In a few cases the local signs are not noted, under which 
 circumstances the difficulties are greater. The prognosis is most grave. The 
 treatment is simply symptomatic. Prevention of this fatal illness of the new- 
 born must be sought in strict antiseptic dressings of the cord. Often a cord 
 bleeds after the first ligature. The second tying is most dangerous unless 
 done with proper precautions. The writer had a case of this character in 
 which infection took place from and at the hands of a dirty nurse. Before 
 ligating the cord dirty rags were applied to attempt to control the haemorrhage. 
 
 Jaundice in WinckeVs Disease. — Jaundice is seen in that fatal affection 
 of the new-born known as Winckel's disease, or acute haemoglobinuria. 
 Cyanosis and haemorrhage occur with the haemoglobinuria, but the liver and 
 spleen do not enlarge. 
 
DISEASES OF THE LIVER. 547 
 
 Jaundice in Later Infancy and Childhood. — Icterus occurs at any 
 period of childhood and in both sexes. It is usually of the so-called catarrhal 
 form. Errors of diet, improper food, excesses, irregular meals, improper cloth- 
 ing, exposure and chilling of the extremities, leading first to gastro-intestinal 
 catarrh, are common causes. 
 
 The onset is gradual, being preceded by the symptoms of acute or subacute 
 catarrh of the stomach and duodenum. There is some tenderness in the epi- 
 gastrium and the right hypochondriac region, the liver is enlarged and may 
 extend an inch or two below the normal line, and the characteristic signs 
 and symptoms of jaundice are present. The hue does not change to the green 
 or bronzed yellow of malignant jaundice. Haemorrhages do not often occur. 
 A moderate degree of fever is observed for a short time. The course may 
 extend over three or four months. 
 
 The diagnosis is not generally difficult. A history of long-continued 
 improper feeding or of a sudden attack of vomiting, etc. from improper food 
 or from cold, is usually elicited. The gradual development of the jaundice, 
 with relatively slight constitutional symptoms, with moderate fever only, aids 
 in the recognition of the character of the affection. The causal presence of 
 worms or hydatid cysts in the ducts cannot be distinguished during life. 
 
 The prognosis is good. 
 
 Treatment. — If fever be present, rest in bed must be enjoined. The 
 extremities must be kept warm. Mild counter-irritation over the epigastrium, 
 by means of sinapism or frictions with stimulating liniments, may be em- 
 ployed ; massage is also beneficial. Gerhard advises compression of the gall- 
 bladder or gentle manipulation in that region. Faradism has also been 
 advised. The diet must be bland and free from saccharine or amylaceous 
 articles. Milk diluted with an alkaline or carbonated water or with lime- 
 water and taken hot, koumyss if vomiting be present, junket, and animal 
 broths, such as beef-tea, mutton-broth, and chicken-tea, may be administered. 
 After the acute symptoms have subsided semi-solids may be used. Prepara- 
 tions of milk and eggs, beef-jellies, oyster-broth, and clam-broth are appe- 
 tizing. Light fish may be selected as convalescence proceeds, and sweet- 
 breads, broiled beefsteak, and the white meat of chicken. 
 
 If there be much gastric disturbance, sedatives must be used. Calomel 
 in small doses, calomel and bismuth, effervescing alkaline waters, carbonic- 
 acid water, citrate of potassium in officinal solution favorably made, are of 
 service. If there be pain, minute doses of magnesia may be added to the 
 mercurial powder, or paregoric may be given with the citrate of potassium : 
 
 1^. Liq. potassii citratis f^ij. 
 
 Tr. opii camph f§j. 
 
 Sig. One-half to one teaspoonful every two or three hours. 
 
 Hydrochlorate of cocaine in solution sometimes allays the vomiting. If 
 there be constipation, an enema sufficient thoroughly to evacuate the bowels 
 frequently relieves the vomiting. Afterward, if necessity requires, the bowels 
 should be opened by a mercurial, as calomel or gray powder, in small, fre- 
 quently-repeated doses, or by the citrate of magnesium, or a saline purgative, 
 as Hunyadi, Friedrichshall, Bedford, or Saratoga water. 
 
 When the acute symptoms are ameliorated, it remains to treat the catarrhal 
 inflammation of the duodenum and ducts and the symptoms due to the jaundice. 
 
 In the treatment of catarrh the diet, as indicated above, must be persisted 
 in ; small doses of bismuth may be continued. Nitrate of silver in small dose. 
 
548 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 with opium if pain be present, is a valuable sedative which modifies the 
 catarrhal process. In young children it may be given in solution and should 
 be administered on an empty stomach : 
 
 1^. Argent, nitrat gr. ss. 
 
 Mucilag. acaciae f^ij. — M. 
 
 Sig. Teaspoonful three times daily to a child under two years. 
 
 Oxide of zinc, in doses of one-twelfth of a grain every three hours, is also 
 useful. 
 
 Small doses of ipecacuanha are often, after acute symptoms have subsided, 
 of service. One-fourth to one grain of the powder three times daily is praised 
 highly by many. 
 
 Phosphate of sodium is a most valuable drug in catarrhal jaundice. Ten 
 grains three times a day in milk for an infant or half-drachm to one drachm 
 for a child of ten, in hot water, and taken fasting, proves of inestimable 
 benefit. It may be used with other remedies. 
 
 Chloride of ammonium is much used, particularly in India ; one to five 
 grains of the drug every three hours is frequently followed by surprising 
 results. It may be administered in syrup of licorice or in syrup of orange. 
 It does appear to dissolve toughened mucus, to allay congestion, and to pro- 
 mote secretion from the glands in the tubes. 
 
 Pilocarpine in doses of one-sixteenth of a grain has been recommended. 
 It seems to have been of great benefit to adults. 
 
 After the tongue cleans, or, as is often the case, its epithelium is restored 
 and the papillae assume a normal aspect, the sedative remedies may be dis- 
 continued and a weak bitter or an acidulated bitter may be given : 
 
 Ij*. Acid, hydrochlorici dil TTLxxxij. 
 
 Infus. serpentariae f^ij. — M. 
 
 Sig. Teaspoonful in water before meals. 
 
 For more chronic cases dilute nitric acid internally and the local pack 
 of nitric acid are often serviceable. 
 
 If the jaundice be of malarial or gouty origin, quinine in the former, or 
 colchicine in the latter, has been often prescribed. 
 
 Finally, to treat the catarrhal process, the method of Krull is strongly 
 insisted upon : Two to four pints of water are injected into the colon two or 
 three times daily. The temperature is raised at each enema. The first enema 
 is given with the water at a temperature of 59° F. It is made two or three 
 degrees warmer until enemata at temperature of 72° are given. Krull and 
 others testify warmly to its beneficial effects in children. The writer has seen 
 most surprising results in adults, and, as no harm can result from its use, 
 would not hesitate to use it in children. 
 
 Of the symptoms of jaundice requiring especial attention, itching may be 
 mentioned. Sponging with sedative lotions is of service. Ten drops of car- 
 bolic acid to a pint of water, a solution of the bichloride of mercury, 1 to 3000, 
 hot solutions of alkalies, as bicarbonate of sodium or borax, a drachm of each 
 to the pint, may be employed. 
 
 Pilocarpine is recommended by Goodhart. He preferred to give it hypo- 
 dermatically ; -^ to -gL of a grain should be given to children over four years 
 old. Since it was advised by Goodhart a number of physicians have com- 
 mended its use. Internal diaphoretics of domestic origin at times are of 
 
DISEASES OF THE LIVER. 549 
 
 service. An infusion of sage or hot drinks, with a stimulant, excite perspira- 
 tion and relieve the itching. 
 
 Intestinal dyspepsia with flatulency and painful digestion require some 
 medication. The diet should in a measure prevent the development of these 
 symptoms ; nevertheless, they occur. Preparations of pancreatin given an 
 hour after meals, with an alkali, will aid much in digestion. If they are not 
 of service, such drugs as correct fermentation in the intestines must be adminis- 
 tered. Of these, salol, naphthalin, and thymol are of great service, while 
 creasote, carbolic acid, and charcoal may be given with advantage. Salol may 
 be administered in powder or compressed pill. Naphthalin and beta-naphthol 
 should be given in gelatin-coated pill or capsule. The coating does not dis- 
 solve until the drug reaches the intestine, and hence is of great advantage. 
 Creasote or carbolic acid may also be given in pill or in emulsion with syrup 
 of acacia. A prescription like the following generally overcomes the disagree- 
 able symptoms : 
 
 IJ*. Creasoti gr. 
 
 Carbonis lig gr. j. 
 
 Pancreatin : . . . . gr. j. 
 
 Bismuthi subnitrat gr. iij. — M. 
 
 Ft. chart. No. i. 
 Sig. Take after meals. 
 
 0r > 
 
 1^. Acidi carbolici . . gtt. iv. 
 
 Sodii bicarb 3j. 
 
 Spiritus chloroformi feij. 
 
 Pulv. acaciae 
 
 Sacchari albi da gr. xx. 
 
 Aquae q. s. ad ffiij. — M. 
 
 Sig. A teaspoonful after meals or every three hours. 
 
 In selecting creasote the drug made from the beechwood must be used, 
 and willow charcoal is preferable to the animal form. 
 
 The cerebral symptoms of jaundice can only be overcome by hastening 
 the elimination of bile and at the same time supporting the patient. Stimu- 
 lants must be used ; preparations of ammonia, alcohol, and caffeine are to be 
 selected. The preparations of ammonia are probably the best. Of course 
 the patient must be nourished, and, if necessary, caffeine and cocaine may be 
 resorted to. Both are advantageous stimulants, because they cause increased 
 secretion from the kidneys, which are chiefly concerned in eliminating the bile. 
 The poison without doubt sets up nephritis. It is necessary to guard against 
 this complication if possible. Creating diaphoresis by jaborandi or the hot 
 vapor-bath brings about this result. The kidneys may be relieved also by local 
 applications, and particularly by the use of dry cups. In the case of more 
 or less persistent jaundice these organs should be relieved quite frequently 
 in the manner just suggested. The alkaline waters that may be selected for 
 their beneficial effects upon the liver should also have diuretic properties. If 
 they are not sufficient, the citrate of potassium or cream of tartar lemonade 
 may be given. 
 
 The slow pulse, the subnormal temperature, and the prostration that ensues 
 in jaundice are to be treated in accordance with the general principles of the 
 management of these conditions. If haemorrhages occur, turpentine or erigeron 
 may be administered internally. Sulphuric acid and the acetate of lead are 
 
550 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 also valuable astringents. The blood is always reduced in jaundice, the red 
 corpuscles diminished in number. It is possible the systematic inhalation of 
 oxygen may prevent this diminution, or at least combat symptoms depending 
 upon it. It certainly is worthy of trial. 
 
 Congestion of the Liver. 
 
 Both the active and passive forms are seen. Active congestion is acute, 
 and is induced by an exaggeration of all circumstances which increase the 
 physiological congestion that takes place under the stimulus of food. Over- 
 eating, the eating of rich food, the abuse of stimulants, are liable to cause an 
 acute attack of hepatic congestion. Excess of heat may superinduce an 
 attack in hot climates. 
 
 The symptoms are much like those of catarrhal jaundice, with the physical 
 signs of enlargement of the liver. The jaundice is not intense. The face 
 becomes sallow and cachectic if jaundice be absent. The patient loses in 
 health and strength. Some pain is complained of in the hepatic region, 
 which is tender on palpation. The liver is enlarged uniformly in all direc- 
 tions, often extending two inches beyond the normal boundaries ; the edge 
 can be felt and is smooth and rounded ; the surfaces also are smooth. In a 
 few cases the gall-bladder is enlarged, and can be detected in the right hypo- 
 chondriac region to the left of the midclavicular line in a line drawn from the 
 acromion process of the right shoulder to the umbilicus. 
 
 With the removal of the cause the symptoms disappear, and by the end 
 of a month the functions of the gastro-intestinal tract are restored and the liver 
 is reduced in size. In some cases enlargement of the organ and the peculiar 
 complexion of the patient continue for a longer period. 
 
 Passive Congestion. — The passive form of congestion is associated with 
 disease of the heart and lungs and chronic malarial poisoning. The pro- 
 nounced symptoms are due to the disturbance of these organs ; along with 
 congestion in other organs the liver becomes engorged with blood, and hence 
 gradually enlarges. The shape of the enlargement is similar to that in active 
 congestion. The edge of the liver is likely to be sharper and more indurated. 
 No nodules can be detected on the surface. In the right midclavicular line the 
 lower border may extend to the level of the umbilicus, and in the median line 
 the left lobe may extend three-fourths the distance. Frequently the upper 
 border cannot be so readily made out, because of the occurrence of effusion 
 into the right pleura. The rational symptoms are those of mild gastro-intes- 
 tinal catarrh. The tongue is furred ; there are nausea, loss of appetite, 
 and intestinal dyspepsia ; vomiting and constipation may occur, or there may 
 be diarrhoea. A slight form of jaundice is developed. Albuminuria is 
 observed, and the urine presents the appearance of congestion of the kid- 
 neys. On account of the interest centred in the condition of the heart and 
 lungs passive congestion of the liver is frequently overlooked. 
 
 Diagnosis. — The diagnosis of active and passive congestion of the liver 
 is made without difficulty. The presence of a cause for the congestion, together 
 with the mode of onset, are pronounced factors in the diagnosis. 
 
 Prognosis. — In the acute forms the prognosis is generally favorable. In 
 chronic congestion the prognosis is modified by the knowledge of the cause 
 of the congestion. 
 
 Treatment. — The removal of the cause is essential to the successful man- 
 agement of active congestion of the liver. Correction of errors in diet, in habits 
 of life, or in occupation often suffices to relieve the affection. The gastro- 
 
DISEASES OF THE LIVER. 551 
 
 intestinal symptoms are treated as in catarrhal jaundice. More stress must 
 be laid on the use of purgatives for depletion. The alkaline waters and the 
 mercurials are of benefit. Phosphate of sodium is useful : it may be given 
 in hot solution on an empty stomach either at night or on rising in the 
 morning. The hygienic and dietetic management employed in catarrhal jaun- 
 dice is of use in active congestion of the liver. In hot climates, if such con- 
 gestion occur, two drugs are used and lauded. The chloride of ammonium 
 in 3- to 5-grain doses, every two or three hours, relieves the discomfort and 
 appears to remove the engorgement of the organ. Ipecacuanha is used for a 
 similar purpose. The drug must be given in large doses, administered twice 
 in the twenty-four hours ; 5 grains to children under five years of age is 
 admissible. In order that vomiting should not be caused by the drug, the 
 administration should be preceded by a few drops of the deodorized tincture 
 of opium and a sinapism applied to the epigastrium. Twenty minutes after 
 the application the drug may be given. After the more acute symptoms have 
 subsided bitter tonics should be prescribed. If, however, there is pronounced 
 gastric catarrh, small doses of calomel or bismuth or nitrate of silver, as 
 advised in catarrhal jaundice, may be administered. One of the mineral acids, 
 especially dilute nitric acid, in small doses, is given after the subsidence of 
 the acute symptoms, particularly if the liver does not diminish in size. 
 
 Passive congestion of the liver is treated by alleviating the symptoms due 
 to the engorgement, and by the employment of measures and remedies to relieve 
 the primary cause of the disease. 
 
 Fatty Liver. 
 
 Enlargement of the liver due to fatty infiltration or degeneration occurs in 
 the course of other diseases or on account of improper habits of the patient. 
 In children it is always an intercurrent affection. Tuberculosis and wasting 
 diseases generally are associated with fatty infiltration. The wasting that 
 attends gastro-intestinal catarrh is associated with fatty liver. This is par- 
 ticularly the case if the catarrh results from the excessive use of sugar and 
 starchy food. The enlargement is due to an accumulation of fat in the liver, 
 and not to degeneration of the structures. It is said that children who are 
 closely confined and have become anaemic are liable to this disease. 
 
 Symptoms. — The subjective symptoms are negative. Enlargement of 
 the liver, which is uniform in all directions, is observed. The organ is of 
 doughy consistency and the edge is rounded. The surface is smooth and pain- 
 less on palpation. Jaundice, ascites, and other symptoms due to hepatic dis- 
 order do not occur. 
 
 Treatment. — The treatment depends upon the cause. If enlargement from 
 fat accumulation is found in children who tend to be obese, and who have 
 been indiscreet, strict hygienic and dietetic management must be invoked. 
 The carbohydrates must be excluded from the diet ; out-door exercise must be 
 carefully planned, and if it cannot be indulged in, massage and Swedish move- 
 ments must be directed. Sea-air has been advised in cases of this character. 
 
 Amyloid Disease of the Liver. 
 
 In this form of liver disease the organ is enlarged and but few hepatic 
 symptoms of a subjective character are observed. The affection is associated 
 with amyloid disease in the spleen, kidneys and intestines. The degenera- 
 tion occurs in the course of phthisis, chronic bone disease, prolonged suppura- 
 tion, and rickets. It may occur at any age throughout childhood. 
 
552 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Symptoms. — Anaemia is a prominent general symptom, and the pallor of 
 the face is striking. The liver is enlarged in all directions ; undue prominence 
 of the abdomen in the course of any of the above-named affections should 
 lead to an examination of this viscus. In addition to the enlargement of the 
 liver, the spleen is also found to be enlarged. The liver sometimes attains 
 a very large size ; it may be twice or three times the normal weight. The 
 surface is smooth, the edges hard and rounded. No pain attends palpation. 
 The external veins may be distended ; but jaundice does not occur, and ascites 
 only results from diseases in other parts of the body, generally from the con- 
 dition of the kidneys. Diarrhoea is usual, and haemorrhage from the bowels 
 may also take place. 
 
 Diagnosis. — The nature of enlarged liver occurring in the course of the 
 diseases previously indicated can usually be determined without much dif- 
 ficulty. The diagnosis is rendered more positive by the detection of similar 
 disease in the spleen and by the occurrence of albuminuria and polyuria 
 due to amyloid disease of the kidney. The recognition of amyloid disease 
 should be attempted in all cases in which operative measures for the relief 
 of bone disease or suppuration is contemplated. Any grave operation will be 
 contraindicated by the presence of this complication. 
 
 Treatment. — Notwithstanding the frequent suggestion by prominent 
 authorities of the use of alkalies and the preparations of iodine in the treat- 
 ment of this affection, there does not seem to be any drug which modifies or 
 changes the course of the disease. The removal of the cause, if possible, is 
 the most rational method of treatment. The few symptoms that are caused 
 by the functional derangement or enlargement of the liver are to be treated. 
 It must not be forgotten that in some cases it is almost impossible to say how 
 much amyloid disease is present or to what extent the enlargement of the 
 major organs within the abdomen is due to congestion; The symptoms and 
 etiology may point with certainty to the presence of amyloid disease. If in 
 such cases the heart be weak or there be organic disease, venous congestions 
 of the viscera may also take place ; and apparently hopeless amyloid disease 
 may be cured by recognition of this pathological fact, and hence by resorting 
 to removal of the cause by the administration of digitalis, strophanthus, and 
 other heart-tonics. 
 
 Syphilitic Inflammation of the Liver. 
 
 The morbid process above indicated due to the special specific poison is 
 seen in the congenital forms of the disease in childhood. Two forms of inflam- 
 mation occur — one in which the disease is limited or in large part confined to 
 the capsule ; the second, in which the connective tissue of Glisson's capsule 
 is the seat of inflammation. 
 
 Symptoms. — The symptoms are generally seen in children who have the 
 characteristic appearance of face, trunk, and extremities of congenital syphilis, 
 elsewhere described in this book. The skin eruptions, coryza and other 
 mucous inflammations, anaemia, emaciation, and malnutrition, and, later in 
 life, the appearance of the teeth, complexion, and shape of head, render the 
 recognition of congenital syphilis comparatively easy. In perihepatitis there 
 is much pain over the liver, breathing is difficult, and there is fever. The 
 temperature rises to 100° or 101°, the pulse is frequent, the countenance 
 distressed. Relief to the pain takes place when the patient assumes the 
 upright position and crouches forward, or when he lies on his back with 
 the legs drawn up. The marked tenderness interferes with palpation and 
 
DISEASES OF THE LIVER. 553 
 
 percussion. When the pain subsides the organ is found enlarged and the 
 edges hard. After a week or ten days the more severe symptoms abate and 
 convalescence is rapid unless the patient be broken down by previous bad 
 health. Recurrence takes place on exposure or fatigue or without apparent 
 cause. 
 
 In another group of cases the shrinking of new-made connective tissue 
 begins, and soon the organ is grasped in the toils of fibroid overgrowth, con- 
 traction takes place, and all the symptoms of portal obstruction arise. 
 
 Jaundice may be the only manifestation of infantile hepatic syphilis. It is 
 in all probability due to perihepatitis, with compression of the gall-duct, or to 
 enlarged glands, which likewise compress it, or, most frequently, to adhesive 
 inflammation of the portal vein. 
 
 Syphilis may be the cause of cirrhosis of the liver. The symptoms are 
 twofold — one due to the congenital taint with possible associated lesions in 
 other structures ; the other, to portal obstruction. The latter symptoms do not 
 differ from those of portal obstruction in cirrhosis of the liver of alcoholic 
 origin. 
 
 Diagnosis. — The diagnosis of syphilitic disease of the liver is determined 
 largely by the association of the lesions and well-known appearances of congen- 
 ital syphilis, with symptoms indicating inflammation and functional disorder of 
 the liver. Often the symptoms, and particularly the objective ones, are not 
 obvious. The apparent alteration in size of the liver is not demonstrable ; 
 there is little if any pain, and features of portal obstruction are not observed. 
 Jaundice may be the only symptom present. It is well to bear in mind that 
 persistent jaundice in childhood without apparent cause, certainly if the gastro- 
 intestinal tract be free from catarrh, may be of syphilitic origin. The thera- 
 peutic test often aids in making a diagnosis. 
 
 Treatment. — The treatment is largely that of the cause, the remedies 
 applied for the relief of congenital syphilis being indicated. In addition 
 to the constitutional treatment the pain, jaundice, ascites, and other symptoms 
 are to be relieved by methods previously indicated in this paper. 
 
 Suppurative Hepatitis. 
 
 Two varieties are seen. In one the abscess is single, and in the other 
 multiple ; in the former the suppuration in nearly all the cases is secondary 
 to trauma ; in the latter suppurative pylephlebitis has occurred on account of 
 suppuration in the portal area. 
 
 Symptoms. — The symptoms in the two forms differ entirely. In traumatic 
 abscess, after the injury there is much pain in the hepatic region and symp- 
 toms of perihepatitis. The parts about the seat of injury are swollen, and 
 the external surface may show the signs of a blow. After the injury the pain 
 may diminish and the child be apparently well, when a recurrence of the local 
 symptoms will arise ; or the effects of the injury may not subside in the usual 
 time. Pain in the region of the liver will be complained of, and on examina- 
 tion the organ is found to be enlarged. The enlargement is not uniform. It 
 may be upward only, or, as is most frequently the case, be indicated by exten- 
 sion of the lower border of dulness downward. On palpation the hepatic 
 region is painful ; oedema over the most painful part or over the hepatic area 
 or the area of enlargement may be observed. If the abscess be developing in 
 the right or left lobe, an undue prominence may be seen in the right hypo- 
 chondriac or in the epigastric regions respectively. It will be noted to move 
 with respiration and to be continuous with liver dulness on percussion. 
 
554 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 With the development of the local signs of enlargement and inflammation gen- 
 eral symptoms arise. The fever, which may have been due to trauma, does not 
 disappear, and indeed becomes more pronounced. It assumes a remittent or even 
 distinctly intermittent type, and may be preceded by daily rigors and followed by 
 exhaustive sweats ; prostration ensues, and there may be a loss of flesh. The 
 tongue is furred, appetite lost, vomiting may occur, and diarrhoea is frequently 
 present. If the inflammation be seated on the convex surface of the liver, 
 breathing is interfered with and cough may be present ; both respiratory acts 
 will in all probability be attended with pain. The pain is then noted in the 
 sixth or seventh interspace in front or the seventh or eighth interspace behind. 
 It may extend to the right shoulder, and in some cases pain in this position alone 
 is complained of. 
 
 As previously intimated, sometimes the symptoms of suppuration, with 
 local signs of inflammation, do not develop until a long time has elapsed after 
 the injury. The general symptoms may arise before local signs of inflamma- 
 tion are evident. Between the injury and the development of the symptoms 
 the child is not in good health. Loss of appetite, languor, inability to exert 
 himself as was his former habit, with loss of flesh and strength, are very likely 
 to be present. 
 
 Multiple abscess of the liver is usually preceded by a history of suppura- 
 tion, and therefore a point of infection somewhere in the portal area. An 
 appendicitis is one of the most frequent affections w T hich precede this form of 
 suppuration. It is thus seen that active abdominal symptoms may be present 
 prior to the development of symptoms indicating involvement of the liver. 
 If in the course of such symptoms jaundice arises and the liver becomes 
 enlarged and painful, we may well suspect that the inflammation has spread 
 to the portal vein. The type of the fever may also change. It becomes dis- 
 tinctly intermittent, and daily chills attend it. The onset of jaundice is 
 characterized not only by the discoloration of the skin, but by the develop- 
 ment of symptoms of the typhoid state. Delirium of a low muttering character 
 soon occurs, deepening into stupor. The tongue becomes dry and brown, 
 sordes collect about the teeth and lips, and subsultus is seen. In some 
 instances convulsions occur; in others death takes place from exhaustion. 
 Diarrhoea, if not previously present, is sure to arise. The stools are offensive 
 and watery, and contain light-colored fcecal matter. The urine contains bile- 
 pigment, soon becomes scanty and high-colored, and is found to contain albu- 
 min and to have blood, epithelial, and granular casts. The nephritis may 
 become so marked as to be a serious, indeed fatal, complication. 
 
 The patient usually lies on the right side, and when he assumes the opposite 
 position complains of a heavy, dragging sensation. The skin is sallow, the 
 complexion muddy. The facies is quite characteristic. Waring describes the 
 appearance as follows : Countenance expressive of anxiety, shrunk, collapsed, 
 pale, livid, or parchment-like. 
 
 Diagnosis. — If the symptoms of suppuration just indicated arise after 
 trauma or the occurrence of suppuration of the portal area, diagnosis is not 
 difficult. The cases of suppuration secondary to worms in the hepatic duct, 
 or to suppurative inflammation of the ducts, extremely rare in childhood, are 
 recognized with difficulty. The absence of a focus of suppuration in any other 
 portion of the body when hectic symptoms are present should determine the 
 necessity of careful examination of the liver. Enlargement, either general or 
 local, may be made out by careful percussion. The exploratory needle may 
 render positive a suspicion of hepatic suppuration, but the negative results of 
 puncture do not exclude abscess. Friction-sound at the base of the right 
 
DISEASES OF THE LIVER. 555 
 
 lung, with diminished expansion of that side, may call attention to possible 
 hepatic suppuration. 
 
 Reference has not been made to abscess of the liver occurring in the 
 course of dysentery. The writer has not been able to find any recorded cases 
 of this association in childhood, though there is no special reason why it 
 should not occur. In cases of dysentery it is important to interrogate as to 
 the condition of the liver, and, on the other hand, in acute liver affections the 
 presence or absence of dysentery is to be ascertained. Amoebae in the stools, 
 in pus from an abscess, or in expectoration would confirm the diagnosis of this 
 form of abscess of the liver. 
 
 Prognosis. — In multiple abscess of the liver the prognosis is very grave, 
 such cases terminating fatally. In single abscess, if the pus can be reached 
 by aspiration or by the knife, the prognosis is much more favorable. If the 
 abscess be beneath the diaphragm in the upper portion of the right lobe, the 
 issue is much more doubtful than when superficial. 
 
 Treatment. — The management of a case falls entirely into the hands of 
 the surgeon. In multiple abscess of the liver no measures are of avail. In 
 single abscess or where the number is limited to three, free incision must be 
 made and may result favorably. If the abscess be situated along the margin 
 of the ribs or in the epigastric region, the operation is simple and reparation 
 takes place rapidly. The writer has seen two such cases recently in the Phila- 
 delphia Hospital. An abscess of the convexity of the right lobe must be 
 reached through the pleural cavity. Excision of the ribs is necessary, and 
 isolation of the pleural cavity quite essential. After pus is secured and the 
 cavity drained and irrigated, a drainage-tube must be inserted and the case 
 treated by the usual surgical methods. Recently the writer reported a case 
 under his care in which Dr. Willard performed the operation above indicated 
 most successfully. 
 
 Hydatid Disease. 
 
 This is a comparatively rare affection in this country. It seems, however, 
 to be on the increase ; within the last two years the writer has seen six cases, 
 and knows it to have been more common in the experience of others. In 
 children it is even more rare than in adults. With the exception of a child 
 under twelve at the University clinic, no cases have come under the writer's 
 observation. In the literature of the disease few if any cases are reported 
 under two years of age. The liver is one of the organs most frequently 
 affected. In childhood it appears to be the organ selected in 70 per cent, 
 of the cases. In the recent exhaustive work of Graham a few cases only are 
 recorded. He states that within a period of one year he observed hydatids 
 in ten children, their ages varying from five to eight years. The youngest 
 case that he refers to is one operated on by Thomas, a boy aged two years and 
 one month. This disproves the statement of Leuckart, Avho at the time of his 
 publication believed the youngest cases recorded to have been four and six 
 years of age respectively. 
 
 There is, therefore, no immunity for children if their associations are such 
 as to cause infection. The infection may occur very early in life, but the slow 
 growth of the cyst makes it possible that they are not recognized for years. 
 Moreover, in childhood, as Graham remarks, " the organs in which the cysts 
 are situated are less likely to be so completely affected as is the case in the 
 adult subject where the pressure changes are more permanent." 
 
 Space will not permit a discussion of the mode of development or infection 
 of the human species. The growth in the child and the manner of its infec- 
 
556 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tion do not differ from the same in adults (for description of which recent text- 
 books on pathology contain sufficient information). 
 
 Symptoms. — The cyst in the liver may develop and reach a large size 
 without recognition. Attention is first called to its presence by the occurrence 
 of mechanical symptoms ; the abdomen enlarges or there are enlargement and 
 swelling of the liver region. On examination, if the liver be the seat of the 
 disease, it is found to be enlarged. The enlargement may be uniform ; usually, 
 however, it takes place in a particular direction. If the growth springs from 
 the convex surface of the liver, the area of dulness extends higher in the 
 axillary region and behind in the scapular line. If it begins in the right lobe, 
 and the lower portion thereof particularly, the extent of dulness is increased 
 downward toward the umbilicus. Sometimes the tumor is confined to the left 
 lobe of the liver, and hence is recognized in the epigastric region. The prom- 
 inence in the epigastric region or below the ribs in the mammary line is 
 smooth and tense on palpation ; sometimes fluctuation can be detected. In a 
 moderate proportion of cases the so-called hydatid fremitus is elicited, if the 
 left hand be placed over the tumor and another portion tapped quickly and 
 forcibly with the right. 
 
 The tumor is painless, and there is no tenderness on pressure. The patient 
 suffers from distention. There is interference with respiration, so that fre- 
 quently he is compelled to sit up in bed in order to alleviate the dyspnoea. 
 The general health is usually unaffected. 
 
 In some cases the cyst is in such relation to the hepatic duct as to cause 
 compression jaundice. The jaundice usually develops gradually. In rare cases 
 the cyst breaks into the hepatic duct ; some pain follows this accident, and on 
 account of the obstruction by the cystic contents jaundice develops. If the 
 patient comes under observation after rupture of the cyst has taken place, the 
 diagnosis is rendered more obscure. The enlarged cyst has been dispersed, 
 and therefore most of the signs of tumor disappear. 
 
 Suppuration of the cyst sometimes takes place, and- in addition to the 
 symptoms due to hepatic pressure those of pyaemia arise, — rigors, periodical 
 elevations of temperature, sweats, and great prostration. Jaundice occurs 
 either because of the pyaemia, or, if it be intense, because of obstruction of 
 the ducts and probably suppurative cholangitis. 
 
 The outcome of cases of hydatid disease varies. The liability to rupture 
 is the same at all periods of life ; perforation may take place into the stomach, 
 the colon, the pleura and bronchi, or in some cases externally. It has been 
 said that in a few cases where this accident has occurred recovery has taken 
 place. The perforation may also take place into the pericardium or the vena 
 cava ; when this accident occurs death takes place suddenly. 
 
 Diagnosis. — A diagnosis is not usually difficult. Irregular enlargement 
 of the liver, the surface of which is smooth and painless, or the presence of a 
 tumor of the same character connected with the liver, probably fluctuating, in 
 an individual otherwise in good health, usually indicates the presence of this 
 disease. If the cysts are multiple, and the surface of the tumor, therefore, 
 irregular, the diagnosis is more difficult. The health is usually retained, and the 
 benign nature of the enlargement thus inferred. Syphilitic disease of the liver 
 and carcinoma must be excluded in adults. The rarity of the latter affection 
 in childhood and the absence of a primary focus of malignant disease, with 
 retention of health and strength, exclude cancer. In syphilis the enlargement of 
 the liver may be irregular and a distinct boss recognizable. This usually 
 occurs in tertiary syphilis, a form not seen in childhood. In congenital syphilis 
 involving the liver large prominences are not seen. Nevertheless, in both 
 
DISEASES OF THE LIVER. 557 
 
 instances it is well to resort to exploratory puncture, and, if syphilis be sus- 
 pected, to the treatment as a test in diagnosis. If suppuration takes place in 
 the cyst, it cannot be distinguished from abscess unless it be known before the 
 accident that there was a painless enlargement of the liver without fever. In 
 adults dilatation of the gall-bladder has been mistaken for hydatid. This con- 
 dition does not occur in childhood, and hence need not be considered. Hydro- 
 nephrosis has also been mistaken for hydatid disease. The condition is not 
 common in children, but can be distinguished by the results of exploratory 
 puncture. When the cyst extends upward, it is often difficult to distinguish 
 it from a pleural effusion. The same physical signs in the lower part of the 
 right chest may be present as in effusion. Frehrichs believed that the direc- 
 tion of the upper line of dulness is significant in hydatid disease of the 
 liver. It does not take the S curve, as in effusions, but reaches the highest 
 point at the angle of the scapula. Sometimes empyema complicates a hydatid 
 cyst, as in cases reported by Murchison. The cases that are most difficult of 
 diagnosis are those which have ruptured into the lungs before coming under 
 observation. The appearance of hooklets in the sputum is characteristic. 
 
 Reference has been made in the beginning of this article to results of 
 exploratory puncture in cases of suspected hydatid disease. The fluid with- 
 drawn has special properties which render the recognition of the disease abso- 
 lute. 
 
 Prognosis. — From results of observation at the post-mortem table we see 
 that a number of cases of hydatid disease of the liver undergo spontaneous 
 cure. These cases, of course, are not recognized during life. If the disease 
 is recognized and the tumor is accessible, the prognosis is very good. The 
 results of treatment are generally quite favorable. 
 
 Treatment. — Internal medication is of no avail and need not be discussed. 
 Surgical procedures are necessary. Electrolysis has been used, but since the 
 advent of antiseptic surgery has fallen into disuse. Medicated injections are 
 not in high favor. Iodine, carbolic acid, solution of bichloride of mercury, 
 and permanganate of potassium have been used, but the treatment is open to 
 objections. Indeed, at the present time all methods except free incision are 
 discarded as more or less dangerous. The uncertainty that attends the intro- 
 duction of the trocar and the possibility of infection render such methods 
 more or less hazardous, while the difficulty of completely emptying the cyst 
 renders it liable to recur after the fluid is withdrawn. Recamier's method of 
 opening into the cyst by caustics or the thermo-cautery has been employed. 
 The method is tedious and painful, and not without danger. 
 
 The treatment by direct incision and evacuation of the contents of the 
 cyst has been rendered possible by the developments of abdominal surgery. 
 Incision should be made over the most prominent part of the tumor in the 
 manner of performance of a laparotomy. After the cyst is exposed it should 
 be attached to the edges of the abdominal incision ; it is then opened by the 
 knife and its contents evacuated. The daughter-cysts may be evacuated by 
 forceps. Too much force must not be used. In order to secure complete 
 evacuation irrigation of the cyst-cavity must be employed. A drainage-tube 
 is then inserted and the patient dressed as in an abdominal operation. If the 
 cyst grows from the upper surface of the liver, it must be evacuated by pass- 
 ing through the diaphragm. One or two ribs should be resected, the pleura 
 stitched to the diaphragm, and evacuation then brought about by the previous 
 method. 
 
 In oases that have been operated upon a form of urticaria known as the 
 hydatid rash is sometimes seen. It is said that the fluid of a hydatid cyst 
 
558 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 will not cause peritonitis. Any portions of the cyst-wall that are left behind 
 or any of the daughter-cysts will cause suppuration. 
 
 Cirrhosis of the Liver. 
 
 Through the writings of Palmer Howard, of Edwards, of Hatfield, and 
 others we have learned that in its etiology, clinical course, and mode of termina- 
 tion cirrhosis of the liver in childhood does not differ from that in adult life. 
 
 Etiology. — Alcoholism is a very constant factor in its causation. The 
 habit is usually fostered because of the delicate state of the child in early 
 infancy, coupled with the belief of ignorant parents that rum contributes to 
 its development. It is true some children from their swaddling-clothes have 
 an appetite for liquor, and when not discouraged are likely to develop all the 
 lesions of alcoholism. Syphilis, as already mentioned, is another prominent 
 cause. In Howard's cases an adhesive pylephlebitis took place primarily, 
 followed by secondary cirrhosis. In some of the recorded cases chronic heart 
 disease was the causal factor. The infectious fevers, as scarlatina and measles, 
 play an important part. Tuberculosis is attended by a form of cirrhosis both 
 when the liver is involved in the tuberculous disease and independently of it. 
 Howard and others believe that ptomaines and products of imperfect digestion 
 may be productive of this affection. In rickets there is often found enlarge- 
 ment of the liver which is due to an overgrowth of connective tissue. 
 
 Hypertrophic or biliary cirrhosis is rarely seen in childhood. It is due to 
 chronic obstruction of the biliary passages, and hence is present in congenital 
 obliteration of the ducts. 
 
 From the recorded cases collected by the above-mentioned authors, cirrhosis 
 of the liver has been found to occur more frequently in males than in females 
 in the proportion of two to one. The largest number of cases occur between 
 the ninth and thirteenth years. It is found, however, at birth, and may occur 
 at any period subsequently. 
 
 Symptoms. — In the early stages of the disease capillary congestion is 
 noted in the face. This may increase. As the disease advances the face 
 becomes drawn, the parts free from stigmata are pale, or a sallow, muddy com- 
 plexion is seen. The symptoms due to obstruction are usually most prominent. 
 Grastro-intestinal catarrh is observed. Morning nausea and retching with 
 discharge of mucus take place, the appetite is poor, the bowels irregular, 
 alternating attacks of diarrhoea and constipation take place, and the bowel 
 movements usually contain considerable mucus. Haemorrhages from the lower 
 end of the oesophagus, the stomach, or the intestinal tract may occur, and are 
 very characteristic symptoms of cirrhosis. In gastric haemorrhage the vomiting 
 has no relation to food, and is not associated with symptoms of gastric ulcer. 
 In the later stages of the disease haemorrhages occur from the nose or the 
 mouth, and purpuric spots develop. They are due to the state of the blood. 
 Haemorrhoids are frequently present. 
 
 Jaundice occurs in about the same degree of frequency as in the cases of 
 adults. It is usually slight, and may disappear and recur two or three times 
 in the course of the disease. Slight fever is seen in many cases. The temper- 
 ature rises to 101° and 102° in the evening. It may'be present for a long 
 period of time, and as the end approaches disappear entirely. 
 
 The urine is high-colored, of high specific gravity, and contains an excess 
 of urates and uric acid. Frequently nephritis develops in the course of the 
 affection. Albumin is then found, and the urine contains hyaline and granular 
 casts. The specific gravity always remains high, and there is an excess of 
 
DISEASES OF THE LIVER. 559 
 
 lithates. From time to time sugar may be detected, but a persistent glycosuria 
 is not likely to arise. 
 
 On physical examination, when the disease is someAvhat advanced, further 
 evidences of portal obstruction and attempts at compensatory circulation are 
 seen. The venules along the base of the thorax, extending across the chest 
 in an arc, following the attachment of the diaphragm, are very distinct. The 
 external veins, particularly the epigastric and mammary, are particularly dis- 
 tinct. If compensation does not take place, ascites develops, and after its 
 development the feet may swell. The spleen is frequently enlarged, but its 
 size often cannot be determined when ascites is present. The liver is found 
 to be enlarged if the case is seen in the early stage, and it may be slightly 
 tender on palpation. Subsequently it diminishes in size, or the small size is 
 at once noted. The diminution of the left lobe is particularly noticeable. With 
 the walls relaxed the edge and surface can sometimes be felt rough and gran- 
 ular. Some cases are not attended by atrophy. Thus there may be much fat 
 in the liver, and, notwithstanding the connective-tissue overgrowth, the organ 
 remains enlarged. Fatty atrophy of the liver is the name applied to this 
 form. In " biliary cirrhosis " the liver is enlarged and smooth. Jaundice is 
 permanent, and the other symptoms of cirrhosis are present. 
 
 On account of the organic disease of the liver auto-intoxication takes place 
 with ptomaines or products of imperfect digestion. Low delirium, deepening 
 into stupor, with the ocurrence of frequent convulsions, or noisy delirium fol- 
 lowed by convulsions, show the effect of the toxine on the nervous system. 
 Jaundice is not necessarily present when these symptoms develop. 
 
 Diagnosis. — The disease may be far advanced, and not recognized because 
 of the absence of symptoms or signs. A boy aged fifteen years died in the 
 Presbyterian Hospital of typhoid fever. He had been under the observation 
 of the writer for nine years. Acute rheumatic fever with endopericarditis was 
 the reason of the first consultation ; valvular disease continued. The patient 
 had been in poor health, and the parents were wont to give him spirits. This 
 had been continued more or less until the fatal illness occurred. At the 
 autopsy cirrhosis of the liver in an advanced degree was discovered. 
 
 The appearance of the face, the symptoms of portal obstruction, and the 
 physical signs of atrophied liver are points on which the diagnosis is based. 
 
 The occurrence of subacute gastritis with morning vomiting, of haernat- 
 emesis, and of mabena, without the physical signs of a small liver, are never- 
 theless most suggestive, particularly if the patient be poorly nourished, with 
 a drawn, pallid countenance, and especially congestion of the cheeks — venous 
 stigmata. If ascites, enlargement of the spleen, and jaundice supervene, the 
 diagnosis is absolute. 
 
 Treatment. — We can never tell whether the enlarged liver of the early 
 stage of cirrhosis is one in which congestion predominates, or, on the other 
 hand, one in which the overgrowth of connective tissue is in excess. If the 
 former, we know that there are measures which markedly influence the engorge- 
 ment. If the latter, it is possible a further increase may be averted by proper 
 hygienic and prophylactic measures. It is our duty, notwithstanding the 
 uncertainty, to relieve engorgement. External depletion by cups and leeches, 
 purgatives in quantity to ensure three to six liquid stools a day, Rochelle salts, 
 citrate of magnesium, and saline waters, are to be used. The waters of such 
 springs as Saratoga and Bedford in this country, and Carlsbad in Germany, 
 are beneficial. Counter-irritation in mild degree is likewise of value. If 
 leeches or cups are inadvisable, stimulating liniments may be employed. The 
 diet is to be carefully selected. A milk diet is for a time the most satisfactory. 
 
560 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Stimulants and rich, stimulating articles of food, fats, sugars, and starches are 
 to be avoided. Waters are to be used abundantly ; they may be taken hot 
 in large bulk (a glassful) when the patient is fasting to flush the liver. 
 
 Phosphate of sodium may be advantageously added to waters to produce 
 a depurative effect. At first small doses of calomel or mercury with chalk 
 should be given for a few days. A furred tongue, nausea, constipation, with 
 pasty stools, indicate its use. From time to time it should be repeated. 
 Iodide of potassium has been said to relieve the engorged liver in the early 
 stage of cirrhosis, but the chloride of ammonium is a better drug, in doses of 
 five to ten grains in syrup of licorice or in emulsion, given every four hours. 
 
 The treatment of the second stage is entirely symptomatic. Gastro- 
 intestinal catarrh, haemorrhages, ascites, jaundice with its resulting phenomena, 
 and finally the distressing symptoms of the cirrhotic cachexia, require in 
 turn, or too frequently at the same time, careful therapeutic and dietetic 
 management. 
 
 Whatsoever the symptoms may be, the diet plays a most important part. 
 The class of food referred to above is to be selected ; from time to time a 
 strict course of milk diet may be instituted. Again, with the ascites most 
 prominent, a dry diet should be advised. The condition of the stomach and 
 Dowels very largely determines the character of diet. If there be much 
 intestinal dyspepsia, albuminoid food should be administered. Meats chopped 
 fine and made into a pulp can be given for a long period of time. In order 
 to create free discharge of the products of digestion, large quantities of water 
 should be taken once or twice a day. The disadvantage of a continuous meat 
 diet arises in the possible development of scurvy. This may be counteracted 
 by the use of lemon-juice once or twice in twenty-four hours. The gastro- 
 intestinal catarrh is treated by the same class of remedies as are indicated and 
 have already been detailed in the management of catarrhal jaundice. 
 
 Haemorrhage from the stomach is to be treated by rest, the use of cracked 
 ice, the external application of the ice-bag, the administration of food by the 
 rectum, and the use of astringents. An opiate should always be given to quiet 
 the agitated patient. Morphine hypodermatically or dry on the tongue may be 
 selected, or the deodorized tincture of opium combined with the chosen astringents 
 used. Gallic acid is one of the preferable astringents ; aromatic sulphuric acid 
 may also be employed. Both should be given well diluted in iced water : 
 
 ^. Tr. opii deodorat 
 
 Acid, sulphuric, aromat da f^j. — M. 
 
 Sig. Eight to ten drops every two, three, or four hours, well diluted. 
 
 The acetate of lead alone or with bismuth is a valuable astringent. 
 Hamamelis may be given in the form of the fluid extract well diluted ; twenty 
 drops is a sufficient dose, and may be given every one or two hours to a child of 
 ten. Astringent preparations of iron usually are advised — the sulphate, the 
 chloride, and the pernitrate. They should be given in small doses frequently 
 repeated. If nausea and vomiting are not present, ergot might be used ; the 
 writer, however, has never had any benefit from its use ; indeed, gallic acid 
 and the aromatic sulphuric acid have been sufficient to control the bleeding. 
 Intestinal haemorrhage may be treated by astringents by the mouth or by 
 enemata. If bleeding be from the rectum or the lower portion of the colon, 
 weak solutions of alum or of salts of iron by enema are of special value. 
 The solution should be cold if the bleeding is from haemorrhoids. One-half 
 drachm of Monsel's solution to three ounces of water are the proper propor- 
 
DISEASES OF THE LIVER. 561 
 
 tions for enemata of this character. Ice may be used in the rectum, as well 
 as ice-water. By the mouth the astringents advised for gastric haemorrhage 
 can be used. It" is best to administer them in such form that they will be 
 dissolved in the intestine ; a one-grain pill of Monsel's salt may be given 
 every half hour or hour. The pill should be hard. Acetate of lead in pill 
 mayalso be given. In this class of cases aromatic sulphuric acid has been 
 sufficient in the writers experience. Turpentine has been advised by com- 
 petent authorities, and may be given in capsule in doses of two or three 
 drops every two hours. The oil of erigeron is also considered to be a valu- 
 able styptic. 
 
 If the ascites be not too great or of too long standing, it may be removed 
 by dry diet and diuretics. Alkaline diuretics are particularly of service. 
 Cream-of-tartar lemonade and infusion of scoparius are excellent diuretics. 
 Saline waters which act on the kidneys and the bowels are of great service. 
 Gentle catharsis may be maintained without fear of exhaustion if salines be 
 used. On account of the tendency to intestinal catarrh, irritating cathartics 
 should not be employed. At times the effusion seems to come to a standstill ; 
 the bowels have been sluggish, and the internal viscera apparently loaded with 
 stagnated blood from passive congestion. A brisk cathartic often relieves 
 engorgement and starts up absorption of the exuded fluid. In children the 
 compound jalap powder is the best of the class. It should be given in doses 
 of twenty grains ; the amount may be increased if necessary. If the simple 
 diuretics and cathartics are of no avail, four measures are to be considered and 
 may be tried : 
 
 1st. The use of calomel with diuretics, as in the well-known pill of calomel, 
 digitalis, and squills. It may be given in accordance with the following 
 formula : 
 
 Jfy. Hydrarg. chlorid. mit gr. -^. 
 
 Pulv. digitalis gr. J-. 
 
 Pulv. scillae gr. J. — M. 
 
 Ft. pil. No. i. 
 
 Sig. To be taken every three hours. 
 
 After this combination is administered for ten days it should be withdrawn 
 and squills and digitalis given alone. It then may be resorted to again, the 
 frequency of its use depending upon the effect of calomel on the bowels. 
 
 2d. Caffeine is a valuable diuretic, particularly if stimulating effects are 
 desirable. Dose 1 to 3 grains to a child under ten. The hydrochlorate of 
 cocaine is another drug of the same class, and seems to have been of service. 
 
 3d. Copaiba. This is a most valuable drug in ascites. Its diuretic effect 
 is decisive and usually permanent ; it is to be given in capsule ; three minims 
 is sufficient for a child, to be taken every four hours. 
 
 4th. Paracentesis. Paracentesis should be employed early and frequently, 
 if after a short trial the remedies above indicated do not lessen the amount 
 of effusion. No hesitancy should arise on account of danger, as no accidents or 
 complications are likely to occur. A number of cases have been reported in 
 which frequent tapping has cured the ascites, and thereby arrested for a time 
 at least the progress of the hepatic disease. 
 
 The treatment of jaundice need not require further consideration, for it 
 has been discussed fully in a previous portion of this article. The symptoms 
 of the cirrhotic cachexia which ensue in the latter stages of this malady are 
 alleviated by careful nursing, attention in detail to diet, and the administra- 
 
562 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tion of remedies which secure full functional activity of the various organs 
 of the economy. This particularly applies to the circulation. Cardiac tonics 
 are indicated. Stimulants should not be withheld, and now are of service to 
 counteract prostration, aid digestion, and increase the strength of the heart 
 and circulation. All measures that can be invoked to relieve exhaustion, 
 improve anaemia, and aid nutrition should be resorted to. The administration 
 of concentrated food — animal broths, meat extracts, etc. ; the inhalation of 
 oxygen ; the use of stimulating baths and lotions ; measures to prevent the 
 development of bed-sores, — each or all may be used as indications demand. 
 Proper clothing, in order that the extremities and abdomen may be kept 
 warm, must be insisted upon. At this stage multiple haemorrhages and pur- 
 pura are liable to ensue. The internal administration of astringents, but more 
 particularly of turpentine, or the oil of erigeron, appears to check their devel- 
 opment. 
 
PERITONITIS; TUMORS OF THE PERITONEUM 
 AND OMENTUM; AND ASCITES. 
 
 By J. HENRY FRUITNIGHT, A. M., M. D., 
 
 New York. 
 
 I. Acute Peritonitis. 
 
 This affection is an acute inflammation of the serous membrane lining the 
 abdominal cavity and covering the abdominal viscera. It is characterized by 
 a tendency to effusion, by adhesions through coagulable lymph, and by the 
 deposition of purulent or sero-purulent fluid. Such an inflammation may be 
 confined to a portion of the membrane, when it is said to be circumscribed or 
 local, or it may involve the whole surface of the peritoneum, and thus become 
 general. At the onset only will it be circumscribed or limited, for, unless 
 checked, it quickly manifests a disposition to extend over the whole of the 
 inner surface of the peritoneal sac. 
 
 Etiology. — Peritonitis may occur during intra-uterine life, in the new- 
 born, and during infancy and childhood. In early life idiopathic peritonitis is 
 not a very frequent disease, since at this period the peritoneum is not so sus- 
 ceptible to inflammation as the serous membranes of the thoracic and cranial 
 cavities. When it occurs during intra-uterine life, it is always traceable to 
 syphilis in the parents. It may cause the death of the foetus in utero, or the 
 child may be born suffering from the disease or its consequences. So far as 
 is known, no symptoms in the mother serve to indicate the existence of peri- 
 tonitis in the foetus. If it be not fatal before birth, the resulting adhesions are 
 very apt to interfere with the development of the intestines or to cause a con- 
 striction of a portion of the bowel. 
 
 In the new-born, acute peritonitis is most frequently the result of septic 
 or pyaeniic processes. It is usually caused by an unhealthy inflammation of 
 the umbilicus or by the absorption of septic matter at that point. (See 
 Diseases of the New-born.) 
 
 In infancy and childhood an attack may be traced to exposure to wet and 
 cold. Thus, wetting and chilling of the feet, damp beds, chilly winds, sudden 
 alterations of temperature, rapid cooling of the heated body, and excessive 
 fatigue may be enumerated under this head as causes of acute peritonitis, just 
 as they may act in the production of inflammation in other structures. Very 
 often traumatism may serve as the exciting cause, and here may be enumerated 
 contusions, direct blows upon the abdomen, and the wounds of cutting or blunt 
 instruments produced accidentally or surgically, as in paracentesis abdominis. 
 Again, various mechanical causes (which are in reality traumatic in their 
 nature) may operate in its production, such as intestinal invagination, stran- 
 gulated hernia, displacements of some of the internal organs, or laceration or 
 unusual stretching of the peritoneal membrane. In like manner, peritonitis 
 
 503 
 
564 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 may be caused by the extrusion of foreign matters into the serous cavity, as 
 in ruptured hepatic or splenic abscess, rupture or perforation of the stomach, 
 bile-ducts, spleen, uterus, urinary bladder, ureters, or some part of the intes- 
 tines. It may follow or accompany acute disease of some organ by contiguity 
 of structure ; and here may be mentioned gastritis, splenitis, hepatitis, dysen- 
 tery, ulcerations in typhoid fever, and ulcerations of the vermiform appendix, 
 appendicitis, and the like. Numerous instances have been encountered where 
 an empyema perforating the diaphragm has set up acute peritonitis ; and this 
 result has been observed even in the absence of perforation, the lymphatics 
 acting as the channel of communication. In girls purulent vulvo-vaginitis has 
 frequently caused acute peritonitis by an extension of the inflammation through 
 the uterus and Fallopian tubes. At times also it may result from pressure 
 and ulcerative absorption caused by tumors and malignant growths. The 
 sudden retrocession of a cutaneous eruption has sometimes been closely fol- 
 lowed by an attack of peritonitis, and it is on record that lumbricoid worms 
 have penetrated the bowel and thus acted as an exciting cause. 
 
 Finally, it may occur as a complication of, or a sequel to, rheumatism, 
 erysipelas, pernicious intermittent fever, and the various exanthemata. 
 
 It has been quite well established that in the development of peritonitis 
 micro-organisms, rendered operative by any of the before-mentioned local 
 disturbances, must be regarded as the essential causes. When, experimentally, 
 non-pathogenic microbes, even when combined with small amounts of chemical 
 irritants, are injected into the peritoneal sac, purulent peritonitis is not pro- 
 duced, but only a serous inflammation. On the other hand, when pathogenic 
 micro-organisms are introduced even in very small quantities, severe fibrino- 
 purulent peritonitis ensues. The micro-organisms which produce peritonitis 
 are those found in pus, the staphylococcus, and the streptococcus. Before 
 they can increase in number a preceding or accompanying change in the peri- 
 tonuem is necessary. If the absorptive powers of the peritoneum be greatly 
 changed, the microbes will effect a putrefaction of the intraperitoneal fluids, 
 and as a consequence will produce a general putrid infection of the whole 
 system. 
 
 Pathological Anatomy. — The transparent and shining appearance of the 
 membrane is lost. This is accompanied by a diminution of the lubricating 
 secretion, rendering the serous membrane less moist. The subperitoneal ves- 
 sels become turgid with blood, are visible through the thin membrane as an 
 interlacing network, and when they are greatly distended the peritoneum pre- 
 sents a velvety appearance. At times the blood exudes through the coats of 
 the vessels, when puncta or plaques of sanguineous effusion are seen. Later, 
 if the disease progresses, the serous secretion is increased in quantity and altered 
 in character, being composed of liquid serum and a more solid or glutinous 
 material known as coagulable lymph. It may happen, however, that the effu- 
 sion is entirely composed of serum ; or, on the other hand, serum may be alto- 
 gether absent. In metastatic peritonitis or in attacks of asthenic character the 
 effusion may be puriform or distinctly purulent, while in sthenic cases the deposit 
 of lymph may vary from a very thin layer to a thickness of several lines, and it 
 is usually of a yellowish color. When abundant, it may be found in layers, 
 smooth or corrugated, or it may exist as bands of adhesion uniting the vis- 
 cera with each other or with the parietal peritoneum. At first villous in appear- 
 ance, it afterward becomes smooth and denser, and finally assumes a structure 
 similar to true peritoneal membrane. When once formed, plastic lymph acts as 
 an irritant to the serous surfaces with which it may come in contact — a fact 
 which serves to explain how inflammation is so apt to be diffused over the entire 
 
PERITONITIS. 565 
 
 peritoneal surface. When health is restored these bands of adhesion may 
 partly or entirely disappear. If they continue they may cause little inconve- 
 nience, though it may happen that, by their topographical relations, they 
 may interfere with the functions of the organs to which they adhere. In chil- 
 dren the effusion is most commonly purulent ; it may be merely puriform, 
 decidedly purulent, or simply sanious. Ulceration may occur through the 
 abdominal walls or through the diaphragm into the lung or bronchi, or again 
 through the digestive tract, the bladder, the vagina, or through the psoas muscle, 
 permitting pus to escape from the peritoneal cavity by one of these various 
 channels. 
 
 "When peritonitis exists as a sequel to scarlet fever, measles, rheumatism, 
 or other fever, the serous fluid is in excess, whilst the plastic lymph is incon- 
 siderable in amount or nearly absent. The results of an attack, while at times 
 causative of further disease, may in other cases be protective against more 
 serious accidents : adhesions may supervene which will seriously interfere with 
 the functions of the organs or parts which are bound down or united by these 
 bands ; on the other hand, as in some cases of perforation, this same inclina- 
 tion to plastic exudation may be conservative of life, the deposit being a means 
 by which nature seeks to effect reparation. 
 
 Symptoms. — The earliest and most pronounced symptom of peritonitis is 
 pain. At first the area of pain may be limited ; afterward it will extend over 
 the whole abdomen. The pain is accompanied by high fever and decided con- 
 stitutional disturbances, such as rigors and general malaise. Pressure over the 
 abdomen and augmented action of the abdominal muscles, as in deep inspira- 
 tions, coughing, sneezing, expectoration, and the like, will aggravate the pain. 
 The lightest weight cannot be borne upon the abdomen ; hence the little patient 
 assumes a position which will relax the abdominal walls as much as possible, 
 and lies quietly on his back with his knees bent and thighs flexed. The belly 
 is hot, rounded, and tense, almost invariably swollen and tympanitic from 
 accumulation of flatus due to paralysis of the muscular coat of the. intestines. 
 Sometimes flatus may be readily passed per anum, at others not ; and in this case 
 symptoms of intestinal obstruction are simulated. The bowels are usually con- 
 stipated, though diarrhoea is occasionally met with. Vomiting is nearly always 
 present from beginning to end, and is aggravated whenever food is taken, 
 until the presence of bile and faecal matter in the ejecta may be almost sug- 
 gestive of some mechanical bowel obstruction. 
 
 The skin is hot and dry ; the temperature, as a rule, is elevated, ranging 
 from 101° to 105° F., but it becomes subnormal if the attack terminates in 
 collapse. Inflammation of the peritoneum, however, may coexist with a nor- 
 mal or subnormal temperature, and this very frequently happens in the puru- 
 lent cases. The pulse is small, feeble, rapid, and wiry. The respirations are 
 accelerated, short, incomplete, and jerky, and are costal in type, the abdominal 
 wall remaining motionless. The tongue is coated and the breath is foul. The 
 face is expressive of great suffering and anxiety, and when the attack is very 
 severe, the alee of the nose are drawn upward, the nostrils are dilated, and the 
 lips are parted, so as to expose the teeth, producing the expression known as 
 risus sardonicus. The urine is scanty and high-colored, and often contains 
 albumin. 
 
 When the attack is to terminate in recovery all these symptoms gradually 
 diminish in intensity, whilst the countenance, which has been so truthful an 
 exponent of the patient's condition, once more becomes placid and natural. If 
 the attack is to eventuate in death, the pulse becomes quicker and more thready. 
 the general surface cold and clammy, the extremities chilled, and the breathing 
 
566 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 shallower and more rapid, until life goes out from failure of the general vital 
 forces. In a few cases incoherency of speech or active delirium is present 
 toward the end, but most generally the mind remains clear and logical to the 
 last. The fatal issue of an attack may take place in two or three days, though 
 frequently the patient may live until the sixth, seventh, or eighth day. 
 
 Diagnosis. — Peritonitis in its severer forms is readily recognized, but when 
 subacute or circumscribed, or when it is secondary or exists as a complication, 
 it is not so easy of diagnosis. In young children it is especially difficult to 
 determine its presence because of the uncertainty of exact localization of pain. 
 In erratic cases also pain may be absent, and thus we will be hampered in diag- 
 nosis. The diseases simulating acute peritonitis are gastritis, enteritis, colic, 
 rheumatism, neuralgia, renal calculus, and lead-poisoning. The diagnosis must 
 depend upon the severity of the symptoms, special attention having been paid 
 to the history of the case. If there be persistent vomiting of all fluids and 
 solids, with the presence of sharp paroxysmal pain, accompanied by tenderness 
 on pressure upon the abdomen, with cessation of the abdominal respiratory 
 movements, a frequent, wiry pulse, and fever, the diagnosis of acute peritonitis 
 may be made with reasonable certainty. 
 
 Prognosis. — In the generalized form prognosis is always grave. It has 
 been said that there is no more fatal disease, recovery taking place in rare 
 cases only. The more pronounced the symptoms are, the more doubtful will 
 be the prospect of recovery; and if the patient shall have passed into the 
 stage of collapse, a fatal termination is usually to be expected. An acute 
 peritonitis which is metastatic in origin or which is due to perforation is gen- 
 erally fatal. Diarrhoea is of evil portent, and constant vomiting with complete 
 obstruction of the bowels is a very grave symptom. 
 
 Although the general prospects of recovery are so slight, yet patients 
 apparently moribund have been known to get well. The attack may last but 
 a few days, or even only from thirty-six to forty-eight hours, and very rarely 
 indeed longer than a week. 
 
 Treatment. — The cause of the attack will determine the treatment to be 
 followed in a given case. Unfortunately, however, the physician will not 
 always be in a position to know accurately what this may be or what exact 
 anatomical lesions may exist. The patient must be confined absolutely to bed. 
 All food and drink must be stopped, only cracked ice or iced water to moisten 
 the mouth being permitted. This interdiction of all ingesta must be impera- 
 tive, in order to avoid the harassing and painful vomiting. Nutrition can be 
 maintained until the cessation of vomiting by the use of enemata or supposi- 
 tories containing appropriate substances, as broth, milk, egg-albumin, stimu- 
 lants; later, when the vomiting shall have been overcome, the food should be 
 limited to twelve or fifteen ounces (best predigested) per diem. Ice pills may 
 be given to control the vomiting, also iced champagne in small doses fre- 
 quently repeated, as well to soothe the feeble stomach as for its stimulating 
 effects. Locally, various remedies have been employed. Soft flannel cloths 
 saturated in a solution of tincture of iodine in castor oil and applied over the 
 belly have been highly recommended. Local bloodletting by the application 
 of from four to twelve leeches to the surface of the abdomen is often very 
 valuable in the initial stage. The inunction of mercurial ointment to the abdo- 
 men was formerly much in vogue. Stupes, made by steeping flannels in a pint 
 of hot water containing ten to twenty drops of spirits of turpentine and sprinkled 
 with laudanum, are often of great service. Light flaxseed-meal poultices, 
 dashed with oil of turpentine or laudanum and laid upon the abdomen, have 
 in my hands been of great value. Care should be taken that the poultices be 
 
PERITONITIS. 567 
 
 not too hot, lest the integument be burned. By some physicians cold appli- 
 cations, such as the ice-bag or cold-water coil, are preferred, but children 
 almost always resist their use. 
 
 As to the methods of internal treatment — whether by saline purgatives or 
 by opium — a difference of opinion still exists among physicians of equal skill 
 and eminence. It will be safe to abide by the following conclusion : When an 
 attack of acute peritonitis is recognized almost at the moment of its inception, 
 salines by their rapid and complete depletion may abort an attack. The peri- 
 toneum will be drained of the products of inflammation, the formation of bands 
 and adhesions will be prevented in consequence of the increased peristaltic 
 action of the bowels, whilst, clinically, pain will be relieved as quickly as by 
 the administration of opium. On the other hand, if the case is not seen by 
 the phvsician until some hours after the commencement of the attack, and 
 especially if grave doubts exist as to the cause of the disease, opium and external 
 methods of depletion must be used. It need scarcely be said that in perforative 
 peritonitis the purgative treatment must not be thought of at all. 
 
 In case it has been decided to administer a purgative, either a seidlitz pow- 
 der or some other mild saline or calomel is to be preferred for children. When 
 opium is to be given — which should always be the case when there is intense 
 pain, tenderness, constant vomiting, and a distended and paralyzed condition 
 of the bowels — it should be given in quantity sufficient to relieve pain, to reduce 
 the frequency of the pulse and respiration (the latter to about twelve movements 
 per minute), and to make the little patient slightly drowsy. Two to five 
 minims of the deodorized tincture of opium, or one to four grains of Dover's 
 powder, may be given every four hours, according to indications, at the age of 
 six years. The effects of the opium must, of course, be narrowly watched, for, 
 as is well known, children are very susceptible to its action. In older children 
 morphine may be given either per orem or by hypodermatic injection in doses of 
 from one-twelfth to one-sixth of a grain. The tincture of belladonna is frequently 
 combined with the opium. Excessive tympany can be relieved by the use of 
 laxative enemata in which spirits of turpentine or tincture of asafoetida has 
 been suspended ; or, in case of their failure, the long rectal tube may be used. 
 Free stimulation must be resorted to early, and such alcoholics as brandy, whis- 
 key, and champagne are to be preferred. To these may be added, to assist in 
 keeping active a flagging circulation, such cardiac stimulants as sparteine, 
 strophanthus, and digitalis ; these, if vomited, must be given by the rectum or 
 under the skin. Later, when the attack promises to terminate favorably, every 
 effort must be made to build up the system and to increase nutrition by 
 the exhibition of tonics and easily-assimilated, nourishing food. 
 
 As soon as the diagnosis of acute peritonitis has been made, the question 
 of opening and draining the peritoneal cavity will present itself. Here, again, 
 differences of opinion are encountered. Some advocate an early and immediate 
 operation, whilst others claim that, as cases recover without operation, it is 
 better not to risk the added dangers of surgical interference. It may be con- 
 sidered proper to operate in the following forms of peritonitis : First, in the 
 fulminating forms of the disease, which are characterized by a rapid advance 
 of the symptoms, excessive vomiting and tympanites, feeble pulse, and great 
 restlessness. Secondly, in cases in which collapse seems imminent in spite of 
 treatment, and which present a decreasing temperature and a rapid pulse con- 
 stantly growing feebler. Thirdly, in cases in which pus is present in the 
 abdominal cavity, or in which a tumor is located in, or adjacent to, the abdomen. 
 Fourthly, in cases in which the peritonitis is the result of perforation or ulcer- 
 ation of any of the abdominal viscera. And fifthly, when the peritonitis is 
 
568 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 due to intestinal obstruction. In older children the chances of success are 
 greater than in the younger ones. A certain number of cases will be met with 
 in which the diagnosis will be questionable. It will, at times, be doubtful 
 whether the exudation be purulent or composed only of lymph, and whether 
 the inflammation has been general from the first, or has spread from the caecum 
 or other localized inflammatory area. In such cases it is held to be justifiable 
 :o perform an exploratory operation, which may, under some circumstances, be 
 the means of saving the patient's life. To discuss the method of operation and 
 the questions of drainage and irrigation is not embraced in the scope of this- 
 article, and for such details the reader is referred to the works on operative 
 surgery. 
 
 II. Chronic Peritonitis. 
 
 As a chronic affection peritonitis, with the exception of the tubercular variety, 
 is rare. As early as 1838, Wolff published a study upon chronic peritonitis, 
 and stated it to be an extremely common affection in children ; but as all of his 
 one hundred cases were reported cured, it seems likely that a large proportion 
 were incorrectly diagnosticated. Since then until quite lately the subject has 
 received but little consideration at the hands of medical writers, and the opinion 
 has gained ground that all chronic peritonitis, almost without exception, is tuber- 
 cular (West). This view, however, has been considerably modified by the more 
 recent studies of Baginsky, Yierordt, Henoch, and others, and it is now 
 accepted that the peritoneum, just as well as the pleura, may be the seat of a 
 simple chronic inflammation with serous exudation. 
 
 Chronic peritonitis may sometimes be the sequel of an acute attack of the 
 disease, but it is more frequently an independent affection. 
 
 Etiology. — Most of the patients are females — a fact that suggests a possible 
 connection in some cases between the peritoneal inflammation and a vulvo- 
 vaginitis, which is by no means uncommon in little girls. Rarely a history of 
 traumatism may be elicited, as in a case reported by Henoch, confirmed by 
 post-mortem after a course of six weeks. In another group of cases a preced- 
 ing exanthem may be the apparent etiological factor, as seemed to be likely in 
 two cases — one observed by Fiedler, and the other by Henoch — both occurring 
 after measles. The complete cure, after several tappings, in Henoch's case 
 leaves little doubt of its true character. 
 
 Symptoms. — The symptoms of non-tubercular chronic peritonitis are 
 rather obscure. The abdominal pain is apt to be slight, whilst the con- 
 stitutional symptoms are variable. Usually the health fails gradually ; the 
 appetite becomes capricious ; there is alternate diarrhoea and constipation, the 
 former of which may or may not be accompanied by pain ; sleep is disturbed, 
 and the skin is hot and dry at night. Subsequently, pain or a sensation of 
 tightness in the abdomen is complained of, and after a time effusion of fluid 
 takes place, fluctuation may be discovered on examination, and the cutaneous 
 veins are turgid and well defined. The pain now becomes more marked ; it is 
 usually not localized, but shifts about from one spot to another ; generally there 
 is tenderness on pressure over the abdomen ; still, the appetite may be fairly 
 good, the tongue tolerably clean, and the bowels not particularly irregular. 
 As the effusion accumulates dyspnoea appears ; the pulse is accelerated ; even- 
 ing and morning exacerbations of temperature are observed ; the child 
 rapidly loses strength, becomes much emaciated from profuse diarrhoea, and 
 eventually dies of exhaustion. Yet cases presenting all the symptoms of chronic 
 peritonitis have been known to recover, the effused fluid and other products of 
 inflammation being gradually removed by absorption. 
 
PERITONITIS. 569 
 
 Diagnosis. — When ascites is the only symptom, it will be necessary to dif- 
 ferentiate between an effusion due to simple chronic peritonitis and one caused by 
 obstruction to the portal circulation. The latter condition is comparatively rare 
 in childhood, whether it be due to cirrhosis of the liver or adherent pericardium 
 and mediastinitis ; and the chances are immensely in favor of the presence of a 
 chronic peritonitis. The ascites due to cardiac disease can be eliminated by 
 careful examination of the heart. Since, in the beginning of the disease, the 
 symptoms simulate those of chronic intestinal catarrh, one must be careful to 
 distinguish between this affection and chronic peritonitis. 
 
 The differential diagnosis between chronic and tubercular peritonitis will 
 very often be impossible. The point of greatest value, however, is the general 
 state of the patient : in the simple form the general nutrition and well-being 
 of the child suffer but little as long as digestion is not greatly disturbed nor the 
 effusion overwhelming ; while in the tubercular variety the early emaciation is 
 striking. Search for bacilli in the effusion, even in tubercular cases, is often 
 disappointing, and hence a negative finding does not exclude the more serious 
 disease. 
 
 Prognosis. — This must be guarded, for, while most cases are decidedly 
 unpromising, a certain proportion recover. The history and progress of a given 
 case must give us the cue. 
 
 Treatment. — As the disease usually begins with an intestinal catarrh, our 
 treatment must be directed toward that condition. The child must be placed 
 under the best hygienic surroundings. Plenty of sunlight and, when possible, 
 country air or a sojourn at the seashore, are to be insisted upon. The clothing 
 should be carefully regulated to meet the exigencies of the case, the weather, 
 and other external conditions ; and a flannel bandage must be constantly worn 
 about the abdomen. The patient should be kept at rest, and it is a good plan, 
 in the warm weather, to wheel his couch into the open air as often as possible. 
 
 The diet should be bland, but nutritious. Moderate quantities of under- 
 done chops or steak, fish, fowl, and eggs are all allowable; so also are milk and 
 cream if they do not disagree, but starchy foods are better avoided. 
 
 Abdominal pain may be relieved by hot opium fomentations or inunctions 
 of belladonna ointment; when these fail or in protracted cases, blisters or 
 stimulating liniments, tincture of iodine, compound iodine ointment, and iodide 
 of potassium ointment are useful applications. Frequently in these cases the 
 application to the abdomen of a mild mercurial preparation, such as an oint- 
 ment of the yellow oxide of mercury, about twenty grains to the ounce, will 
 do good service. 
 
 In the way of medicines the mineral acids and preparations of pepsin are 
 useful as aids to gastric digestion ; and to combat the intestinal catarrh, bis- 
 muth, sulpho-carbolate of zinc, the bitter vegetable tonics, and alkalies should 
 be administered. 
 
 The internal use of iodine is also beneficial. This may be administered in 
 the form of iodide of potassium in guarded doses, which must be discontinued 
 on the first indication of disordered digestion ; but a preferable form is the syrup 
 of the iodide of iron, in doses of from five to thirty drops, according to the 
 age and tolerance of the patient, several times daily. I usually order it to be 
 given in cod-liver oil, which is convenient and efficacious. 
 
 If the ascitic effusion shows no tendency to disappear by absorption, tapping 
 by means of a very small trocar and canula should be resorted to, the fluid 
 being allowed to drain away very slowly. It has been advised that during the 
 first few weeks the fluid be drawn off once in twenty-four hours, the amount 
 varying in quantity from one to two pints ; then every two, every three days. 
 
570 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and, finally, once a week. Gradual improvement, it is said, usually takes place 
 under this treatment. When the disease has defied every method of treatment, 
 especially if the fluid returns quickly after repeated tappings, permanent drain- 
 age of the peritoneal cavity has been recommended. If pus be present, incision 
 and drainage should be practised. Recently cceliotomy and washing out of the 
 peritoneal cavity have been advocated by some surgeons as a routine treatment. 
 In some instances it may even be justifiable to perform an exploratory opera- 
 tion. However, in those chrouic cases in which the symptoms are not urgent 
 and the child is not failing, it will be the part of wisdom and prudence not to 
 interfere surgically, but to wait on nature's eiforts, supplemented by medical 
 measures, to effect a restoration to health. 
 
 HE. Tumors of the Peritoneum and Omentum. 
 
 Tumors of the peritoneum and omentum, though rare in children, are occa- 
 sionally met with. 
 
 Carcinoma of the peritoneum has been encountered in early childhood and 
 even in foetal life. It may be primary, and then is often congenital, but it is 
 much more commonly secondary. Scirrhus is the usual variety, and generally 
 occurs in diffused nodules. The primary form is difficult to detect ; the second- 
 ary, much less so, because its presence will be suspected when symptoms refer- 
 able to the peritoneal cavity occur in the course of cancerous invasion of some 
 other portion of the body. 
 
 Sarcoma of the peritoneum has also been met with in childhood, but it is 
 of very rare occurrence. This variety of neoplasm may grow to such an 
 extent as to involve the omentum, mesentery, and other parts in addition to 
 the peritoneum ; in fact, both carcinomatous and sarcomatous growths are apt 
 to involve both peritoneum and omentum. 
 
 Lipomata may also grow from the peritoneum. They are encapsulated, 
 and have no connection with any other organ. 
 
 Serous cystic tumors of the peritoneum also occur. These cysts are com- 
 posed of pseudo-membrane, which during their evolution and organization in- 
 cludes a portion of the fluid exudation and receives an internal serous invest- 
 ment ; they are attached to the peritoneum either by means of a thin neck or 
 by a broad base. Cystic tumors of the peritoneum are difficult to detect, and 
 must be differentiated from cysts of the omentum, from cysts of the various 
 abdominal viscera, and from ascites. 
 
 Tumors of the omentum are quite rare in early life. Omental cancer is 
 usually of the colloid variety, and it may grow to an enormous size. Carci- 
 noma, however, is seldom limited to the omentum, the peritoneum being usually 
 involved simultaneously. Again, when scirrhus invades the peritoneum the 
 omentum usually suffers from the same disease. Cysts and hydatid tumors of 
 the omentum are met with in children, the former not infrequently. The cysts 
 are usually dermoid in nature, though simple serous cysts are encountered. 
 Both varieties, but especially the dermoid, may suppurate. 
 
 Symptoms of all varieties of tumors, whether involving the omentum 
 or the peritoneum, or both, are rather vague, particularly in their incipiency. 
 Later, when they have grown larger, the so-called pressure-symptoms develop 
 and aid us in making a diagnosis. Even then it is very difficult to make a 
 correct differential diagnosis, the pressure-symptoms chiefly aiding in locating 
 the site of the tumor, without throwing light upon its character. 
 
 Cancer of the peritoneum and omentum produces the signs of a diffuse, 
 more or less acute peritonitis with effusion, the so-called cancerous peritonitis. 
 
PERITONEAL TUMORS AND ASCITES. 571 
 
 In the earlier stages of the disease the patient will complain of paroxysmal 
 pain, which later will be more persistent. Lipomata are attended by no spe- 
 cial symptoms beyond the growth of a painless tumor. Growths confined to 
 the omentum are movable and occasion no functional disturbance of the intes- 
 tines. In cystic tumors, either of the omentum or peritoneum, the abdomen is 
 apt to be enlarged; if the tumor be superficial, it will be movable on palpa- 
 tion and give signs of fluctuation, which must be distinguished from the fluctu- 
 ation of ascites. If the patient live long enough and the growth attain the 
 proper size, true ascites will supervene. Pain, of course, will be most promi- 
 nent in the cases of cancerous tumors. In time, whatever may be the nature 
 of the tumor, but particularly in the cases of carcinoma, the general system 
 suffers, nutrition is impaired, the patient is easily fatigued, his appetite fails, 
 and, if the growth cannot be removed, a cachectic condition develops which at 
 last terminates in death. 
 
 Prognosis is most favorable in cystic tumors, less so in lipomatous and 
 hydatid growths, and fatal in the carcinomatous. 
 
 Treatment of cancerous tumors consists mainly of palliation of symp- 
 toms. Anodynes and opiates to control the pain are indicated, and, if the 
 ascites become burdensome, paracentesis is to be performed. Attention to the 
 general condition of the patient, sustaining his strength with good food and 
 tonics, together with the observance of well-established hygienic principles, 
 will embrace all that can be done for these unfortunate sufferers. Operative 
 measures are not to be advised in these cases. 
 
 Operation, cceliotomy, has been more successful in cases of sarcoma, lipoma, 
 hydatid growths, and particularly in cystic tumors. Cystic tumors may be ex- 
 cised or they may be aspirated and drained. As drained cysts are apt to refill, 
 the radical operation, excision, is to be preferred, and it must always be resorted 
 to when suppuration takes place. 
 
 The proper treatment for pressure-symptoms will be suggested by their 
 characters in individual cases. 
 
 IV. Ascites. 
 
 Ascites is an accumulation of fluid — usually serous — within the peritoneal 
 cavity ; occasionally chylous ascites occurs, but in children this variety is 
 extremely rare. Essentially considered, ascites is not a disease. It is a symp- 
 tom of either general dropsy or some local disease of the abdominal viscera, 
 and consists of a transudation of liquid into the peritoneal cavity in conse- 
 quence of disturbed circulation in the liver or of pressure exerted upon some 
 portion of the portal circulatory system. 
 
 Etiology. — The most common cause of ascites in children is cirrhosis of 
 the liver, which, in turn, is most frequently due to syphilis. It may also arise 
 from a simple osmosis of the watery constituents of the blood, in which case 
 it is but a local expression of a general hydraemia superinduced by some 
 cachexia, and it is then often associated with hydrothorax or general anasarca. 
 Again, it may result mechanically from an obstruction to the venous circulation 
 caused by cardiac, pulmonary, or peritoneal disease. Neoplasms of the abdo- 
 minal cavity, whether malignant or benign, and particularly lymphatic tumors 
 situated in the hilum of the liver, will also cause it by mechanical interference 
 with the circulation in the viscera. 
 
 Bright' s disease and acute nephritis ; organic heart disease ; atelectasis pul- 
 monum and emphysema; enlargement of the spleen and profound anaemia 
 caused by malarial poisoning; the pressure of lardaceous lymph-glands upon 
 
572 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the portal vein and inferior cava; and occasionally chronic tubercular perito- 
 nitis, which interferes with the circulation in the peritoneum, — are other etio- 
 logical factors. Interstitial nephritis is not so apt to cause an ascites as a 
 general anasarca. Benign tumors in the abdominal cavity are exceptionally 
 accompanied by ascites, malignant tumors constantly. 
 
 Pathology. — The pathology of ascites is comprehended in the lesions 
 involved in the primary affection. The changes in the peritoneum itself are slight 
 and inconstant. Sometimes this membrane has simply a reddened appearance, 
 but not infrequently it is pale and devoid of any signs of inflammation. 
 
 Symptoms. — The constitutional disturbance attending the formation of an 
 abdominal effusion usually passes unnoticed, but it may be ushered in with chil- 
 liness, nausea, headache, vomiting, colicky pain, or a brief, intermitting diar- 
 rhoea. Pain is absent unless the effusion is caused by peritonitis. When 
 effusion has reached a certain point, the tenseness of the abdominal walls is apt 
 to cause indigestion and irregularity of the bowels ; the skin becomes dry and 
 has an ashen or clayey look ; and the navel protrudes and may be encircled by 
 a plexus of dilated veins, termed " caput Medusae." In very large effusions the 
 skin of the abdomen becomes stretched and glistening, and at times fine white 
 striae, similar to those which are observed upon the abdomen of a pregnant 
 woman, make their appearance. The character of the pulse depends upon the 
 primary disease ; still, it is generally feeble and easily compressed. Provided 
 no inflammatory disease coexists, the temperature is normal. The urine is 
 variable in quantity, though usually diminished ; then it is high in color, and 
 may contain albumin and fibrinous casts. As a result of mechanical interfer- 
 ence with the return circulation from the lower extremities ascites is very fre- 
 quently attended by oedema of the feet and ankles. Large effusions, crowding 
 against the liver, spleen, and kidneys, and forcing the diaphragm up to the 
 second and third ribs, cause anaemia of these organs and collapse of the base of 
 the lungs, with consequent general anasarca. 
 
 Finally, painful and difficult micturition or incontinence of urine, together 
 with difficulty in evacuating the bowels, will ensue. The constant crowding 
 upward of the diaphragm and liver causes dyspnoea, hydrothorax supervenes, 
 and at last the child, unable longer to assume a horizontal position, dies either 
 from asthenia or asphyxia. 
 
 Physical Examination. — Palpation and percussion reveal fluctuation 
 indicative of the presence of fluid, which varies in position according to the 
 posture assumed by the patient. Thus, whilst standing, the abdomen is largest 
 in its lowest part ; when prone it spreads laterally, and if the patient be turned 
 on either side it falls toward the more dependent. In any of these positions 
 percussion practised over the uppermost part of the abdomen, to which the gas- 
 containing intestines always float if entirely free to move, gives a clear tympan- 
 itic note, and by successively altering the patient's posture the tympany readily 
 moves from point to point, while the dulness due to the fluid also changes its 
 place. Wave-like fluctuation is another valuable sign. 
 
 Diagnosis. — The diagnosis of ascites is comparatively easy, yet it must 
 not be forgotten that in children other conditions are often encountered 
 which produce an enlargement of the abdomen. Naturally, the smaller the 
 effusion the more difficult is it to make a diagnosis. When the abdomen is 
 distended by a sufficiently large amount of fluid, wave-like fluctuation and 
 movable dulness can readily be obtained, and leave no doubt of the diagnosis. 
 Small effusions, although always obscure, are most readily detected when the 
 patient sits or lies on one side. 
 
 In addition to detecting the presence of ascites, it is necessary to determine 
 
PERITONEAL TUMORS AND ASCITES. 573 
 
 the nature of the antecedent disease, as upon this prognosis depends. When 
 the fluid is large in amount and movable, atrophic cirrhosis of the liver may be 
 suspected. If the effusion be small and immovable and loculated, the cause is 
 most probably tubercular peritonitis. This disease is characterized by the 
 presence of disseminated nodules, and its symptoms are tenderness upon pres- 
 sure, pain, and fever, possibly conjoined with indications of tubercular disease 
 in some other organ. 
 
 Prognosis. — Though not always a hopeless condition, the prognosis is not 
 very encouraging. Provided the primary cause upon which the ascites depends 
 be removable, as in malaria or alcoholism, and the liver is not completely 
 invaded by the disease, we may hope, by removal of that cause and by proper 
 treatment and hygiene, to effect a cure of the abdominal dropsy. 
 
 Treatment. — In the milder degrees of ascites treatment consists in the 
 administration of diuretics, diaphoretics, and hydragogue cathartics. Acetate 
 of potassium, combined with digitalis and compound spirit of juniper, acts fav- 
 orably. A very efficient combination is the following : 
 
 1^. Magnesii sulphat 
 
 Potassii bitartrat da ^ss. 
 
 Aquae cinnamomi . ." f §iii. — M. 
 
 Sig. A tablespoonful every three or four hours, according to its effect upon 
 the bowels. 
 
 When great general anasarca coexists with the ascites, threatening inter- 
 ference with respiration and circulation, in addition to the free purgation hot 
 vapor baths are to be recommended. These may be applied in the following 
 manner: The patient, completely divested of clothing, is laid upon a blanket, 
 and immediately several bricks, which have been in the mean time thoroughly 
 heated by immersion in pails of hot water, and then enveloped in flannel 
 cloths, are placed at the shoulders and feet. Care must be taken that they be 
 neither too hot nor put too near the body, lest the skin be scorched. Another 
 blanket is then thrown over the patient. The upper corners of the superim- 
 posed blanket are brought over and tucked under the opposite shoulders, while 
 the other end of the upper blanket, with the lower end of the underlying one, 
 are lapped together under the heels of the patient, and the head alone is left 
 to protrude from this improvised sack. This hot pack is maintained for at 
 least twenty minutes, producing profuse diaphoresis and usually greatly amelio- 
 rating the symptoms. The patient and his friends are apt to complain loudly 
 of this heroic treatment, but I can recollect several instances where by its use 
 the child was saved from imminent death ; and often it will accomplish the end 
 sought when all other measures have failed. 
 
 A strict milk diet is to be enjoined as a rule. When, however, hydremia 
 is prominent, iron, tonics, nutritious food, and good air, with a proper obser- 
 vance of all recognized hygienic rules, are indicated. In ascites depending 
 upon atrophic hepatic cirrhosis squills, digitalis, calomel, and iodide of potas- 
 sium will be of service. In this variety, however, the ordinary diuretics usually 
 have but little effect. Here Basham's iron mixture is highly spoken of — viz. : 
 
 ^. Tinct. ferri chlorid 
 
 Acid, acetic, dil. da fjj. 
 
 Liq. ammonii acetat. . f^vi. 
 
 Aqme ...... q. s. ad fsvj. — M. 
 
 Sig. Tablespoonful three times daily for a child of six years. 
 
574 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 If, despite this treatment, the fluid continues to accumulate, paracentesis 
 abdominis must be practised. This operation should not be performed too 
 soon, nor should we delay it to the last moment. The proper time is when 
 remedies fail after a fair trial and when, in spite of treatment, the patient's 
 general health daily deteriorates. Ordinarily this operation is simple and free 
 from danger. Either an aspirator or fine trocar and canula may be used, but 
 I prefer the latter. This tapping can be repeated as often as the exigencies of 
 each particular case may require. If fluid reaccumulates within three or four 
 days, a retapping should be postponed as long as possible ; if, however, a num- 
 ber of w T eeks elapse before the peritoneal cavity is refilled, the operation may 
 be correspondingly deferred to that time. 
 
 Permanent drainage by means of a rubber tube under proper antiseptic 
 precautions has been highly commended by Dr. A. Caille, whenever, after one 
 or two tappings, the ascitic fluid rapidly reaccumulates. When all other meas- 
 ures of treatment are futile, this method of permanent drainage should be 
 utilized. 
 
 While the operation of paracentesis is very trifling, every antiseptic pre- 
 caution should be employed. In order to produce local anaesthesia a hypoder- 
 matic injection of three to five minims of a 2 to 4 per cent, solution of cocaine 
 may be made at the proposed point of operation, or the same result may be 
 obtained by the rhigolene spray or the application of ice and salt. The linea 
 alba, below the umbilicus, is the usual point of election except for loculated 
 effusions. In the latter case, as distended veins ramify extensively over the 
 abdominal wall, caution must be used not to wound any of them with the 
 trocar. As the fluid escapes pressure is kept up by means of a many-tailed 
 bandage : this lessens the risk of syncope and secures a thorough evacuation 
 of the fluid. If the puncture has been made at the side of the abdomen, the 
 patient must lie on the opposite side for some little time, so that the wound 
 may cicatrize properly. This w T ill obviate the occurrence of a fistula, a sequel 
 which will prove a source of great annoyance to the patient, inasmuch as leak- 
 age soils the clothing and provokes cutaneous inflammation. 
 
CONGENITAL INTESTINAL MALFORMATIONS 
 
 DISEASES OF THE ANUS AND RECTUM. 
 
 By HENRY R. WHARTON, M. D., 
 
 Philadelphia. 
 
 I. Congenital Malformations of the Intestines. 
 
 Congenital malformations of the small intestine are met with much less 
 frequently than those of the rectum and anus ; in the Vienna Foundling Hos- 
 pital only 9 anomalies of this nature were found among 150,000 infants. 
 The malformation may consist of a stenosis or atresia of the gut ; or the 
 bowel may terminate in a cul-de-sac at the point of obstruction, and beyond 
 this point again begin in a cul-de-sac, the remaining portion of the intestine 
 being well developed ; or the bowel may have a diverticulum given off which 
 attaches it to the abdominal walls, and this may contain a fistula opening 
 upon some portion of the body ; or, finally, the defect may consist in an 
 abnormal shortness of the intestinal canal. Holmes mentions two cases of 
 congenital occlusion of the small intestine in which the diagnosis was satisfac- 
 torily established, and Dr. W. Craig reports a case of congenital malformation 
 of the small intestine in a child who lived seventy-two hours, and in whom the 
 autopsy showed an obstruction of the small intestine at the upper fifth of the 
 ileum. The intestine in this case was distended above the point of obstruc- 
 tion, and upon opening the bowel it was found that it ended in a cul-de-sac ; 
 further examination of the gut beyond the point of obstruction showed that 
 the intestine began in a cul-de-sac, and the intervening space between these 
 two pouches was occupied by a band of fibrous tissue. The most frequent 
 position of congenital occlusion of the small intestine is the duodenum near the 
 point at which the biliary duct and pancreatic duct open, or at the point where 
 the duodenum becomes jejunum under the transverse mesocolon. Malforma- 
 tions of the ileum are most common near the ileo-csecal valve, or a short 
 distance above it, where the ductus omphalo-mesentericus is given off. Among 
 the congenital malformations of the small intestine may be mentioned that 
 condition known as Meckel's diverticulum, which consists in a c}"lindrical or 
 flask-shaped appendage attached to the ileum a metre or more above the ileo- 
 cecal valve, and is a remnant of the omphalo-mesenteric duct. Another form 
 of this defect consists in the presence at the umbilicus of a reddish tumor 
 covered with mucous membrane, which has been described as a warty tumor 
 of the umbilicus, congenital mucous polypus of the umbilicus, and as adenoma 
 of the umbilicus. 
 
 Congenital malformations of the large intestine are also of infrequent 
 occurrence, but may involve the colon, the sigmoid flexure, or the rectum. 
 The malformations of the large intestine may consist of an occlusion of the 
 
576 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 gut at any portion of its length ; or the gut may exist in a rudimentary condi- 
 tion. The latter defect is most apt to be associated with Meckel's diverticulum, 
 with a faecal fistula between the ileum and the fissure above the umbilicus, or 
 with a faecal fistula between the small intestine and some portion of the abdominal 
 walls. Atkin reports the case of a child who died two days after birth, and in 
 whom, upon autopsy, the rectum and colon were found to be in a rudimentary 
 state, smaller than an ordinary quill ; in this case the parts had remained in 
 the condition in which they exist in the early embryo. 
 
 The various congenital malformations of the small and large intestine are 
 probably largely to be attributed to accidents in development due to a com- 
 plicated disposition of the intestinal tract of the embryo ; and it is also likely 
 that foetal peritonitis plays an important part in the production of these 
 deformities. Theremin is of the opinion that many of these anomalies are 
 due to changes in the peritoneum which have taken place early in foetal life. 
 
 Symptoms. — The symptoms arising from congenital malformations of the 
 large or small intestine are simply those of intestinal obstruction in a more or 
 less marked degree, which depends upon the completeness of the occlusion ; and 
 all observers are agreed as to the absence of any definite symptoms accurately 
 localizing the seat of the lesion. The vomiting of whitish mucus, with ob- 
 struction of the bowels, in the case of a new-born infant, points to an occlu- 
 sion high up in the small intestine, and if the obstruction exists in the 
 jejunum or ileum, this may be replaced by the vomiting of meconium. In 
 such a case the symptoms would in no wise differ from those consequent upon 
 the presence of an occlusion situated in the region of the rectum or anus. If 
 a faecal fistula is present, the symptoms of obstruction will not be so marked, 
 and the position of the fistula may serve as a guide to the situation of an intes- 
 tinal malformation. 
 
 Diagnosis. — As before stated, the localization of the lesion is often most 
 difficult. In a newly-born child who presents swelling of the belly with 
 vomiting and obstruction of the bowels, the anus and rectum should first be 
 examined to exclude the possibility of malformation of these parts; a soft 
 catheter should be passed into the rectum, and if, upon injecting water, 
 meconium is brought away, it can be inferred that the obstruction exists at a 
 higher point of the intestinal canal. 
 
 Prognosis. — The prognosis is always unfavorable : complete occlusions of 
 the duodenum or of the high portion of the jejunum must necessarily prove 
 fatal in a short time ; but when the obstruction is incomplete or occupies 
 a position low down in the small intestine, or if associated with a faecal fistula, 
 the patient may survive for some time, even for years. Complete occlusions are 
 usually fatal within a few days unless relieved by operative treatment. 
 
 Treatment. — In cases of complete obstruction operative treatment must 
 be resorted to promptly. Up to the present time the results obtained have 
 not been encouraging ; but with the improved technique of abdominal opera- 
 tions more favorable results may be looked for in these cases. As before 
 stated, the diagnosis of the seat of the lesion is often impossible ; but as in 
 cases of complete occlusion the result is necessarily speedily fatal, it seems wise 
 to attempt an exploratory operation with the hope of affording relief or bring- 
 ing about a cure. A median laparotomy, unless there is some definite symp- 
 tom present which points to the exact seat of the obstruction, should be the 
 operation selected. If upon opening the abdomen the occlusion is found situ- 
 ated in the duodenum or high up in the jejunum, the case must be abandoned 
 as hopeless, unless it be found possible to excise the occluded portion of the 
 bowel and bring the ends together by sutures (circular enter orraphy), or to make 
 
MALFORMATIONS OF THE RECTUM AND ANUS. 577 
 
 an attempt to establish the continuity by the procedure known as lateral intes- 
 tinal anastomosis. If the occlusion is due to a membranous septum, this may 
 be exposed by incising the gut, and after it has been perforated or cut away 
 the intestinal wound should be united by Lembert's sutures and the abdominal 
 incision closed in the usual manner. If the occlusion exists low down in the 
 small intestine or in the large intestine, circular enterorraphy or lateral anas- 
 tomosis may be employed, or an artificial anus may be made by bringing 
 the gut to the abdominal wound, securing it there, and opening it. This latter 
 procedure would seem to be the wiser one, as it requires much less time to 
 accomplish it, and if the patient survives, after he has attained some age an 
 attempt may be made to establish the continuity of the intestinal canal by 
 lateral anastomosis. If a faecal fistula is present and there are no marked 
 symptoms of intestinal obstruction, no operative treatment should be insti- 
 tuted ; but if the patient exhibits symptoms of intestinal obstruction, the fis- 
 tula should be dilated or incised, and, if relief be obtained, further operative 
 treatment should be postponed until a later period. 
 
 II. Congenital Malformations of the Rectum and Anus. 
 
 Congenital malformations of the rectum or anus occur, according to various 
 observers, in the proportion of 1 case in 10,000 births. 
 
 Pathology. — These malformations result from arrested development of the 
 parts in early foetal life. At its earliest commencement the alimentary canal 
 consists of a simple sac or bag developed from the innermost layer of the blas- 
 toderm, partly within and partly without the body ; and as development pro- 
 ceeds this communication between the two portions of the sac is shut off, and 
 the portion within the abdomen consists of a simple tube, the mesenteron, 
 which terminates at the anterior extremity of the embryo in a blind pouch, 
 w T hile at the posterior extremity a similar pouch is formed. The cul-de-sac at 
 the anterior extremity of the embryo comes in contact and communicates with 
 an invagination of the epiblast, which is called the stomodceum, while a similar 
 depression of the epiblast at the posterior extremity of the embryo, named the 
 proctodeum, forms the anal orifice and communicates with the mesenteron. 
 The majority of malformations of the rectum and anus are due to an interrup- 
 tion in the latter stages of the process just described, or, in other words, to an 
 arrested or irregular development of the proctodeum or mesenteron. The 
 termination of the rectum in the genito-urinary tract is due, in addition to the 
 arrested development just mentioned, to a similar arrested development in the 
 perineal septum, which separates the rectum from the genito-urinary tract, both, 
 in the early life of the embryo, having a common orifice. The failure of devel- 
 opment of the perineal septum explains the frequency of cases of imperforate 
 rectum and anus in which there is a communication between the intestinal tube 
 and the genito-urinary tract. 
 
 The best classification of the malformations of the rectum and anus is that 
 adopted by Bodenhamer, and is as follows : 1. Congenital narrowing of the 
 rectum or anus without complete occlusion ; 2. Complete occlusion of the anus 
 by a membranous diaphragm or well-formed skin ; 3. The anus is absent, and 
 the rectum ends in a blind pouch at a point more or less distant from the peri- 
 neum ; 4. The anus is normal in appearance, but ends in a cul-de-sac, and the 
 rectum ends in a blind pouch at a variable distance above this point ; 5. The 
 anus is absent, and the rectum ends by a fistula at any point of the perineum 
 or sacral region ; 6. The anus is absent, and the rectum ends in the vagina, 
 the bladder, or the urethra ; 7. The anus and rectum are normal, but the 
 
 37 
 
578 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 1. 
 
 Congenital Narrowing of the 
 Rectum and Anus. 
 
 Fig. 2. 
 
 Ureter, vagina, or urethra opens into the rectal cavity ; 8. The rectum is totally 
 absent. 
 
 1. Congenital Narrowing of the Rectum or Anus, without Com- 
 plete Occlusion. — This variety of malformation is probably more common 
 
 than is generally supposed, as it escapes notice if 
 the narrowing is not sufficient to produce marked 
 symptoms of obstruction ; and probably in many 
 cases of this nature, in which the stenosis is not 
 extreme, the efforts of the child in passing the 
 faeces bring about the necessary amount of dila- 
 tation. As the stenosis may not be sufficient to 
 prevent the escape of the semifluid faeces of infant 
 life, the condition may not be detected for some 
 time, and it is only as the child becomes older and 
 the faeces become more consistent that accumula- 
 tion takes place in the rectum and attention is 
 directed to the malformation (Fig. 1). 
 
 Treatment. — The treatment of this variety of 
 congenital stenosis is best conducted by gradual dilatation, which may be carried 
 out by the daily introduction into the bowel of graduated bougies, or by the 
 introduction of the oiled index finger of the mother or the nurse, which is by 
 far the best of all bougies for this purpose. 
 
 2. Complete Occlusion of the Anus by Membranous Diaphragm or by 
 Well-formed Skin. — In this form of malformation closure of the anus may 
 be caused by a diaphragm of mucous membrane or skin, 
 which appears to be due to the adhesion or skinning over 
 of the surface of the anus, the rest of the proctodaeum 
 being normally formed (Fig. 2). 
 
 Treatment. — The treatment consists in making a cru- 
 cial incision at the position of the anus, opening the rectal 
 pouch, and evacuating the faeces and trimming off the edges 
 of the mucous membrane and skin. The wound should be 
 dusted with iodoform and dressed 
 with a pad of antiseptic gauze, and 
 the subsequent management of the 
 case consists in keeping the anus 
 well dilated for some time to prevent 
 cicatricial contraction. 
 
 3. The Anus is Absent, and 
 the Rectum ends in a blind pouch at a point more 
 or less distant from the Perineum. — In this variety of 
 malformation the rectal pouch may terminate near the skin, 
 or it may end high up in the pelvis and the space between 
 it and the perineum be filled with cellular tissue, or in 
 other cases a distinct fibrous cord can be traced from the 
 The Anus is absent, and termination of the rectum to the skin (Fig. 3). 
 Blind Pouch (after Bail). Treatment. — In the treatment of this malformation — 
 and, in fact, of all forms of imperforate rectum in which 
 complete occlusion exists — the duty of the surgeon is very clear ; he should, 
 as soon as possible, attempt to reach the rectal pouch by a perineal incision. 
 The earlier this is attempted the better, for delay in operating certainly con- 
 duces largely to a fatal result. I cannot subscribe to the opinion of those who 
 advise delay until the rectum is distended with faeces and gas, which may make 
 
 Fig. 3. 
 
 Complete Occlusion of 
 the Anus by Membran- 
 ous Diaphragm or Skin 
 rafter Ball). 
 
JIALEOPJIATIONS OF THE RECTUM AND ANUS. 579 
 
 the position of the rectal pouch more apparent, but which is not unattended 
 -with the risk of rupture of the intestine and exhaustion of the patient ; and 
 it has also been shown that by delay the meconium becomes reduced in bulk 
 through the absorption of the fluids. It should be remembered that the rectum 
 in infants descends in the hollow of the sacrum and is close to the bone, and 
 except at its upper portion is uncovered by peritoneum posteriorly ; in front 
 its peritoneal investment descends to a much lower level, and its close relation 
 in this aspect to the genito-urinary tract is an additional reason for the selection 
 of the posterior region for exploratory operation. Various operative measures 
 have been recommended and resorted to in cases of imperforate rectum. 
 
 Puncture with a Trocar Canula. — The introduction through the perineum 
 of a trocar and canula was formerly advised, and by its use I have seen the 
 rectum reached and meconium evacuated ; but subsequently it is usually found 
 necessary to enlarge the wound made by the instrument to secure free exit of 
 faecal matter, so that the procedure possesses no advantage over the perineal 
 incision, and has the disadvantage that the rectal pouch may be entirely missed 
 by the trocar and important structures injured by its blind introduction. 
 
 Perineal Operation. — This is considered the best operation to undertake in 
 these cases, since, if successful, it leaves the patient with an anus in the 
 normal position, and often with fair control of the bowels, for the anal sphincter 
 is frequently well developed in spite of the malformation of the rectum. In per- 
 forming this operation the child should be placed in the lithotomy position, and 
 the incision should be made in the median line of the perineum from the root of 
 the scrotum to the coccyx. The tissues should be divided slowly, any bleeding 
 vessels being secured as they are met with. The surgeon should explore the 
 wound with the finger during the operation, to discover, if possible, the bulg- 
 ing of the rectal pouch, and should be careful to make the deepest incisions 
 posteriorly. In a female infant the finger introduced into the vagina during 
 the operation may give the surgeon some information as to the position of the 
 rectum ; or if the mass of fibrous tissue in which the rectum sometimes ter- 
 minates is seen or felt, it may serve as a guide to the position of the rectal 
 pouch. Nearness of the tuberosities of the ischium is a sign of absence of the 
 rectum ; and if it is found that the vagina or bladder fills up the concavity of 
 the sacrum, it is an indication of a high termination of the rectal pouch. The 
 incisions may be carried with safety to the depth of an inch and a half or two 
 inches, and when the rectal pouch is reached it should be incised. After 
 the meconium has escaped the wound in the rectum should be sufficiently 
 enlarged, and, if possible, its edges should be brought down and sutured 
 to the skin of the perineal wound, care being taken in passing the sutures 
 and in introducing a drainage-tube to leave no pocket around the bowel 
 for the accumulation of discharges. The suturing of the edges of the bowel 
 to the skin is a most important procedure, and one which diminishes largely the 
 amount of contraction in the newly-formed anus ; it may, however, be found 
 impossible to bring down the edges of the rectal wound to the skin in eases 
 where the rectum terminates high up in the pelvis. In such cases a large 
 flexible catheter or a metallic tube may be introduced and held in place by 
 tapes ; but it is difficult to keep it in position, as it is apt to be displaced bv 
 the straining efforts of the child. Verneuil has suggested excision of the 
 coccyx in the early part of the operation, which facilitates the search for the 
 gut, and in case it is found this procedure enables the surgeon more readily to 
 attach the edges of the rectal pouch to the skin. The dressing of the wound 
 should consist in dusting the parts with iodoform and applying a pad of anti- 
 septic cotton, to be held in position by means of a T bandage. 
 
 v 
 
580 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN 
 
 When the surgeon has carried his dissection up into the pelvis as far as he 
 considers it is safe, an inch and a half or two inches, and has failed to reach the 
 rectal pouch, he should then consider the advisability of abandoning the attempt 
 to reach the gut through the perineum, and should endeavor to open the intes- 
 tine either in the left groin (Littre's operation), or in the left loin behind the peri- 
 toneum (Amussat's operation), or in the right groin (Huguier's operation). Of 
 these operations, that in the left groin is to be recommended, as it opens the 
 bowel near its natural termination. If the surgeon decides upon this operation, 
 he should make an incision from one and a half to two inches in length, half an 
 inch above and parallel with Poupart's ligament, beginning at a point opposite 
 the junction of the middle with the outer third of this structure. Or an incision 
 suggested by Ball, following the line of the linea semilunaris, stopping just 
 short of Poupart's ligament, may be substituted for the former incision. The 
 skin and muscular layers being cut through, the fascia transversalis and peri- 
 toneum may be pinched up together, and a small opening made in them, through 
 which a director should be passed, and the two can then be divided with one 
 incision. It is sometimes difficult to determine whether the bowel presenting 
 in the wound is the small or large intestine ; this can be ascertained by gently 
 drawing out a coil : if it be the small intestine, it can be drawn out with ease, 
 and the mesentery will show that it is not the portion of the bowel sought 
 for, and it should be replaced. On the other hand, the large intestine cannot 
 be so readily drawn out, and its mesocolon, if it have one, would be found 
 attached to the left side. The bowel should next be secured to the edges 
 of the wound by several sutures of fine silk or catgut, which should be intro- 
 duced by passing a curved needle through the skin and parietal peritoneum 
 near the edge of the wound, and then transfixing a portion of the bowel ; after 
 which the needle should be made to transfix the peritoneum and skin again, 
 being brought out a short distance from the point of insertion ; the stitches 
 should then be secured. Sutures should be applied in this manner on each side 
 and at the extremities of the incision, after which the gut should be incised to 
 a sufficient extent and the meconium allowed to escape. After the escape of 
 the latter the wound should be carefully cleansed, and the edges of the gut 
 incision may be attached to the skin by a few silk sutures. The surgeon may 
 introduce the finger or a flexible rubber catheter into the opening in the gut to 
 ascertain, if possible, the point of termination of the rectal pouch ; and if it is 
 found to be near the upper portion of the perineal incision, he may deepen the 
 latter on a guide introduced through the artificial anus. It has, however, been 
 found better to rest satisfied with the relief afforded by colotomy, and to post- 
 pone for a time the attempt to form an anus in the perineal region, for the 
 majority of cases in which this has been attempted have been followed by a 
 fatal result. Attempts to accomplish this result some months after the per- 
 formance of colotomy have been more satisfactory, as is seen in cases reported 
 by Byrd and Kronlein. When the patient has attained some age, and an 
 examination through the artificial anus in the left groin shows that the rectal 
 pouch terminates well down in the pelvis, a director or rubber catheter may be 
 introduced through the colotomy wound and made to enter the pouch, and 
 project at the anus, if it be present, or at some point of the perineum. This 
 may then be cut down upon as a guide, and the gut may be opened and sutured 
 to the skin if the edges can be drawn down to that point. 
 
 If the surgeon should prefer to make an attempt to open the bowel in the 
 left lumbar region, the best guide to the position of the colon is a line half an 
 inch posterior to a point midway between the two superior spinous processes of 
 the ilium ; if he fails to find the large intestine, and distended small intestine 
 
MALFORMATIONS OF THE RECTUM AND ANUS. 581 
 
 Fig. 4. 
 
 shows itself in the wound, it is better to open this and stitch it to the wound, 
 rather than to abandon the case and allow the patient to perish by intestinal 
 obstruction. 
 
 The results obtained by the various operations for the relief of the symp- 
 toms due to imperforate rectum show that, in point of safety and as a matter of 
 comfort to the patient, the perineal operation is to be preferred. Cripps has 
 collected 100 cases of the various operations for the relief of imperforate rec- 
 tum ; his table, although exhibiting a high rate of mortality, 50 per cent., 
 shows that the largest number of recoveries followed the perineal operation, 
 and the next in number were those cases in which the colon was opened in the 
 iliac region. The expediency of an operation for the establishment of an arti- 
 ficial anus, either in the perineum or in the groin, in young children with 
 imperforate rectum, is evidenced by a number of well-attested cases in which 
 the patient lived for years afterward in comfort. 
 
 4. The Anus is Normal in Appearance, but Ends in a Cul-de-sac, 
 and the Rectum Ends in a Blind Pouch at a very little Distance 
 above this Point. — In this form the anus and rectum may be separated by 
 a membranous partition of greater or less thickness, or a 
 portion of the bowel may be impervious, or there may be 
 multiple obstructions, or the anal portion may communi- 
 cate with the vagina in the female and the rectum end 
 in a cul-de-sac (Fig. 4). The variety of malformation in 
 which the anus is normal, but is separated from the rectum 
 by a membranous partition of greater or less thickness, is 
 not uncommon. It is apt to escape notice for some time, 
 as the anus is normal in appearance, and it is only when 
 the nurse or mother notices that the child passes no faeces 
 and the belly becomes swollen, or vomiting begins, that the 
 nature of the trouble is suspected. The introduction of the 
 finger or probe into the anus will soon reveal the nature of 
 the trouble. An attempt should at once be made to reach 
 the rectal pouch by an incision through the anus backward 
 toward the coccyx, and if the gut be found it should be 
 brought down and sutured to the edges of the anal wound, 
 much safer than puncture through the anus, which the 
 tempted to employ if the partition between the two cavities did not seem very 
 thick. If it be found impossible, after a careful dissection in the perineal 
 region, to find the rectal pouch, the surgeon should 
 abandon this operation, and attempt to reach the gut by 
 an incision in the left iliac region. 
 
 5. The Anus is Absent, and the Rectum Ends 
 by a Fistula at any point of the Perineum or 
 Sacral Region. — The rectum may open at some portion 
 of the perineum or sacral region, or it may terminate in 
 a narrow channel under the raphe' of the perineum and 
 open at the prepuce or at the symphysis pubis, or may 
 end in several fistulae at different points (Fig. 5). Such 
 patients may have satisfactory evacuations through the 
 fistulae, and may live for months or years without suffer- 
 ing much inconvenience from the deformity. 
 
 Treatment. — If a child so suffering shows evidence 
 of discomfort by reason of the faeces not passing sufficiently freely through the 
 fistula, this should first be dilated or increased in size by incision, and if relief 
 
 Anus ends in a Cul-de-sac, 
 the Rectum ends in a 
 Blind Pouch (after Mol- 
 liere). 
 
 This procedure is 
 surgeon might feel 
 
 Fig. 5. 
 
 Anus is absent : Rectum 
 ends by a fistula at the 
 prepuce (after Ball). 
 
582 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 from the symptoms be obtained, no further operation should be attempted as 
 long as the child remains in comfort. When the patient has attained an age 
 when a more radical operation can be undertaken, the fistula may be explored 
 with a probe or director, and the position of the rectal pouch ascertained if 
 possible ; if it be in a favorable position, a perineal opening should be made 
 to reach the rectum, and when it has been found the bowel should be opened 
 and its edges brought down and sutured to the edges of the perineal wound. 
 The fistulous tract should be laid open or touched with the actual cautery, 
 and allowed to heal by granulation. 
 
 6. The Anus is Absent, and the Rectum Ends in the Vagina, Blad- 
 der, or Urethra. — These malformations, according to the point of termina- 
 tion of the rectum, are classified as atresia ani vaginalis, atresia ani vesiealis y 
 and atresia ani urethralis. Leichtenstern's statistics show that 40 per cent, of 
 rectal malformations are of this nature. This tendency of the rectum to ter- 
 minate in the genito- urinary tract is remarkable when we consider the definite 
 separation which exists between the rectum and the genito-urinary tract in the 
 adult : it is attributed by Ball to the method of development of the proctodeum, 
 or a tendency to reversion to the cloacal type of birds and lower animals. 
 
 Atresia Ani Vaginalis. — In this form the rectum terminates in the posterior 
 walls of the vagina, either by a small or large aperture. The opening may be 
 situated immediately within the fourchette, or may be located high up in the 
 canal (Fig. 6). If the rectal opening is sufficiently large, the patient does not 
 exhibit any symptoms of intestinal obstruction, and the nature of the deformity 
 is only ascertained upon inspection of the parts, when it 
 is found that the anus is absent, and that faecal matter 
 escapes from the vulva. 
 
 Treatment. — If the patient suffers no inconvenience, 
 operative treatment may be postponed until she has attained 
 some age, when the greater development of the parts will 
 conduce to a favorable result. Operations for the relief of 
 this variety are the most satisfactory in their results of all 
 those that have been devised for the cure of congenital 
 malformations of the rectum. When an operation is de- 
 cided upon, the one which is followed by the best results 
 Anus is Absent ; Rec- * s P er f° rme d in the following manner : A director is passed 
 (AfterB^n? the vagiua ' through the vaginal opening into the rectum and is pushed 
 backward, its point being made to project as near as pos- 
 sible to the normal position of the anus ; this is cut down upon from the per- 
 ineum and the rectum is exposed and incised. The rectal wound being then 
 sufficiently enlarged, the gut is dissected loose and its edges are brought down 
 and secured to the skin by sutures. By this dissection of the rectum and bring- 
 ing down of its edges, the opening into the vagina, if it be a low one, is oblit- 
 erated. If a high opening into the vagina remain after the anus has been 
 established in its normal position, an operation may be undertaken later to 
 close this recto-vaginal fistula. An ingenious operation, devised by Rizzoli, 
 for the relief of this malformation is performed as follows : An incision is car- 
 ried from the lower margin of the vaginal anus backward through the perineum 
 toward the coccyx, care being taken not to open the intestine ; the termination 
 of the rectum with its vaginal orifice is now carefully dissected out, and the 
 abnormal anus is transplanted to its natural situation and secured in that posi- 
 tion by a few sutures, after which the perineal and vaginal wounds are brought 
 together by deep sutures. 
 
 Atresia Ani Vesicalis. — In this variety the rectum communicates with the 
 
MALFORMATIONS OF THE RECTUM AND ANUS. 583 
 
 Fig. 7. 
 
 Anus absent; the Rec- 
 tum ends in the Blad- 
 der. (After Ball.) 
 
 Fig. 8. 
 
 bladder, either by a narrow orifice near the base of the organ or by an open- 
 ing near its fundus (Fig. 7). The absence of the anus 
 and the escape of faecal matter intimately mixed with urine 
 at the time of urination would point to the nature of this 
 very serious malformation. 
 
 Treatment. — In the treatment a staff may be intro- 
 duced through the urethra into the bladder, and an incis- 
 ion made through the perineum into the neck of the 
 bladder, as in lithotomy, and continued into the rectum. 
 As the result of this operation the immediate symptoms 
 of obstruction may be relieved, but the patient is left with 
 a urinary and faecal fistula. Ball suggests a laparo-colot- 
 omy, and, when the colon has been found, its complete 
 division, with closure of the lower portion and the bring- 
 ing out of the upper portion at the wound, and securing 
 it in that position to establish an artificial anus. This 
 operation, although attended with greater immediate risk, has the advantage of 
 leaving the patient with control over his urinary excretion. 
 Atresia Ani Urethralis. — In this form the rectum com- 
 municates with some portion of the urethra, allowing the 
 escape of a small amount of faecal matter, which passes 
 more or less in the intervals between urination. The 
 urethral opening is usually so small that faeces cannot 
 escape in sufficient quantity, and the symptoms of intes- 
 tinal obstruction are soon developed (Fig. 8). 
 
 Treatment. — The treatment consists in attempting to 
 find the rectum by means of perineal incision, opening it, 
 and bringing down the edges of the gut and suturing them 
 to the skin. 
 
 7. The Anus and Rectum are Normal, but the 
 Ureters, Vagina, and Uterus Open into the Rectal 
 Cavity. — As this is a malformation in which occlusion of 
 the bowel does not exist and life is not endangered by its 
 presence, no immediate operation is called for. Where the ureters open into 
 the rectum, no operative interference could be of any avail, but in that form in 
 which the vagina or uterus opens into the rectum, and the child has attained 
 some age, an operation to close the fistula and replace the organs may be 
 attempted. 
 
 8. The Rectum is totally Absent. — This differs from the third variety 
 of malformation only in the amount of rectum which is wanting, and its exist- 
 ence may be suspected in those cases in which an exploration of the pelvis by 
 perineal incision fails to reveal the presence of the rectal pouch. This con- 
 dition is to be treated by laparo-colotomy, in the left inguinal region, and the 
 formation of an artificial anus. 
 
 9. The Large Intestine is totally Absent. — This condition is often 
 associated with a faecal fistula at the umbilicus or some other portion of the 
 body, and its treatment consists in securing a free exit of faeces from this fistula 
 by dilatation or careful incision, or by the formation of an artificial anus if no 
 fistula be present. 
 
 The Anus is absent ; the 
 Rectum ends in the 
 Urethra. (After Ball.) 
 
584 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 TTT Diseases of the Anus. 
 Pruritus Ani. 
 
 This affection is occasionally seen in childhood, and is characterized by a 
 painful itching in the region of the anus, which causes the child constantly to 
 scratch the part, so that the skin in the vicinity becomes thickened, eczema- 
 tous, and moist from exudation as a result of the constant irritation. Pruritus 
 ani may result from various causes — from the presence of oxyuris vermic- 
 ularis in the rectum, from eczema of the anus, from pediculi or scabies, or 
 from the presence of a vegetable parasite, as is the case in eczema margina- 
 tum. In other cases in which the itching is not attributable to any of the 
 above-named causes it can often be traced to improper diet or chronic 
 constipation. 
 
 Treatment. — Where the condition can be traced to the presence of eczema, 
 the parts should be frequently bathed with hot water and washed carefully 
 with green soap, and one of the following lotions may be used : 
 
 ly. Acidi carbolici TTtxx. 
 
 Liquor, calcis f.^vj. — M. 
 
 Or, 
 
 1^. Acidi carbolici f^ss. 
 
 Glycerini fgj. 
 
 Aquae q. s. adf^vj. — M. 
 
 Or the following ointment may be applied : 
 
 1^. Ung. picis liquids 3j. 
 
 Ung. zinci oxidi 3iij. 
 
 Ung. aquae rosae 3iv. — M. 
 
 When the itching can be traced to the presence of parasites, either animal 
 or vegetable, the use of some of the antiparasitic lotions or ointments appro- 
 priate for the individual case will rapidly effect a cure. Where the condition 
 is dependent upon errors in diet, a change of diet will often be followed by 
 satisfactory results. Where the trouble arises from chronic constipation, a 
 change of diet should be made and laxatives should be administered, or ene- 
 mata or suppositories of glycerin should be employed. 
 
 Syphilitic Affections of the Anus. 
 
 Mucous patches and moist papules occur with comparative frequency in 
 the region of the anus as the result of congenital syphilis. Allingham speaks 
 of numerous cracks or fissures of the mucous membrane of the anus in chil- 
 dren suffering from hereditary syphilis. Condylomata may appear upon these 
 syphilitic lesions: they are acuminated and spring from previously existing 
 papules or mucous patches, and are accompanied by discharges of a charac- 
 teristic fetid odor. These growths are to be distinguished from the simple 
 forms of vegetation which frequently occur in this region, and are not depend- 
 ent upon the presence of inherited syphilis. 
 
 Treatment. — The treatment should be both constitutional and local. The 
 constitutional effects of mercury can best be obtained in young children by 
 the use of a binder spread with mercurial ointment applied around the abdo- 
 men. The local treatment of the anal lesions consists in the application of the 
 
DISEASES OF THE ANUS. 585 
 
 solid stick of nitrate of silver, or, better, the acid nitrate of mercury, or in dust- 
 ing them with a powder consisting of equal parts of calomel and oxide of zinc. 
 
 Vegetations or Warts of the Anus. 
 
 Vegetations of the anus are not infrequent in childhood, and the growths 
 may attain great size. They are similar in structure to warts situated in other 
 parts of the body, and are papillary overgrowths covered with squamous 
 epithelium. From their situation they are apt to be kept in a moist condition, 
 and as a result there is often present a certain amount of offensive discharge. 
 
 Treatment. — If the parts can be kept perfectly dry, a cure will usually 
 rapidly result : with this end in view, when the growths are not large, dusting 
 with lycopodium or powdered oxide of zinc will often be followed by their 
 disappearance. If the growths are large, they may be touched with the solid 
 stick of nitrate of silver or a saturated solution of chromic acid ; or they may 
 be destroyed by the application of the actual cautery, or trimmed away with 
 scissors. The objection to the latter mode of removing them is the profuse 
 haemorrhage which may result, but this can generally be controlled by the 
 application of a firm compress to the bleeding surface. 
 
 Fistula in Ano. 
 
 Fistula in ano is an affection in which there is a communication between 
 the mucous surface of the rectum or anus and the skin in its immediate neigh- 
 borhood. A complete rectal fistula is one in which there is a sinus leading 
 from the rectum to some point of the skin in the region of the anus ; an 
 incomplete fistula or an internal rectal sinus is one in which there is a sinus 
 passing from the rectum into the perirectal cellular tissue ; another form of 
 incomplete fistula is known as the external rectal sinus, and is one in which 
 there is an opening on the skin passing into the cellular tissue around the 
 rectum, but not perforating the wall of the gut. Fistula in ano is certainly a 
 rare affection in infants and children. Allingham mentions the fact of its 
 occurrence in. children of a very tender age. I have myself seen a few 
 cases in children, and recall a case of complete fistula in a child a few months 
 of age. The affection may result from perforating ulceration of the mucous 
 membrane of the rectum, or from an ischio-rectal abscess opening into the 
 rectum or through the skin in the vicinity of the anus, and also from wounds 
 involving the rectum or anus. 
 
 Diagnosis. — This affection is usually not difficult to diagnose if the finger 
 be introduced into the rectum and a probe passed into the external opening, 
 when, by a little careful manipulation, the probe may be made to enter the 
 bowel if the fistula be a complete one. In the incomplete form of fistula 
 Inown as internal rectal sinus, careful palpation of the tissues surrounding 
 the anus will often reveal an indurated mass of tissue which indicates the posi- 
 tion, of the internal fistula, and the finger introduced into the rectum may also 
 feel the orifice of the internal opening; while the discharge of pus with the 
 stool points to the existence of this affection. In the form of incomplete 
 fistula known as external rectal sinus, if the finger be introduced into the 
 rectum and a probe passed into the external opening, it can be felt at some 
 point to come near the wall of the bowel. In children it should be remem- 
 bered that, in certain cases of disease of the bones of the spine, of the sacrum, 
 or of the pelvis, the purulent matter passing through the connective tissue 
 about the rectum may find its way to the surface and perforate the skin in the 
 neighborhood of the anus ; or it may open into the rectum and escape by the 
 
586 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 anus. A careful examination of the patient, however, will reveal the origin 
 of the pus and show that it is not a case of ordinary fistula in ano. 
 
 Treatment. — The treatment of this affection consists in the free division of 
 all the tissues between the internal and external opening of the fistula, and is 
 accomplished as follows : A director having been passed into the external open- 
 ing of the fistula, the finger is introduced into the rectum, and when the 
 point of the director is felt it is passed through the internal opening and 
 brought out at the anus ; the superimposed tissues are then divided with 
 a bistoury. The track of the fistula should next be carefully explored to 
 discover the presence of any branching sinuses running off from it, and if 
 these be found they should be freely laid open. The wound resulting should 
 next be touched with the solid stick of nitrate of silver, or curetted, irri- 
 gated with a solution of bichloride of mercury, and packed with strips of 
 iodoform gauze ; this dressing should be changed at intervals of a few days, 
 and the wound is to be allowed to heal by granulation. In cases of incomplete 
 external fistula the director should be introduced into the external opening, 
 and where its point comes in contact with the gut, guided by the finger in 
 the rectum, it should be made to perforate, and its point brought out at the 
 anus. The superimposed tissues are then divided, as in the operation for 
 complete fistula. In the variety of incomplete fistula known as internal rectal 
 sinus, the position of the fistula being located as before described, an incision 
 should be made through the skin at this point, and a director introduced and 
 made to enter the rectum, its end being brought out of the anus. The sub- 
 sequent treatment of the case differs in no wise from that of the complete fistula. 
 Another method of treatment in incomplete fistula of either variety is to lay 
 the sinus freely open down to the bowel without dividing the sphincter, and to 
 pack the wound with iodoform gauze : in this way a cure may often be 
 brought about. In any case of fistula in which the internal communication is 
 very high up in the rectum, and its division by the knife is considered unsafe 
 by reason of the haemorrhage which may result, an elastic ligature may bo 
 introduced through the external opening by means of an eyed probe and brought 
 out at the anus, after which the ligature is tied and allowed to cut its way out, 
 and the wound resulting is treated like that following division of the tissues by 
 the knife. 
 
 Fissure of the Anus. 
 
 Fissure of the anus is an affection in which there exists at some portion of the 
 mucous membrane of the anus a small linear ulcer, which causes great pain at 
 stool or after the bowels have been moved. This affection is considered infre- 
 quent in childhood, but I am of the opinion that its presence is not so unusual as 
 is generally supposed, and feel sure that a careful inspection of the anal region 
 in children who complain of pain at or after stool will often show its presence. 
 Allingham and Curling mention cases which they have met with in quite young 
 patients, and I have myself seen cases of this affection in children. Kjellberg 
 of Stockholm among 9098 children found 128 cases of fissure of the anus. The 
 majority of these children were less than one year of age, and in 73 cases the 
 patients were less than four months old. Jacobi thinks fissure of the anus a 
 much more common affection in children than is generally supposed, and 
 believes that many of the fretful children who sleep badly and cry constantly, 
 and often present symptoms similar to those of vesical calculus, suffer from 
 fissure of the anus. 
 
 Diagnosis. — Fissure of the anus should be suspected in cases where pain 
 is experienced during or after stool and where the stool contains a few drops of 
 
DISEASES OF THE RECTUM. 587 
 
 blood. In such cases a careful inspection of the part will usually reveal the 
 presence of a fissure. The rectum should at the same time be examined with 
 the finger for the presence of polypus, which frequently coexists with fissure of 
 the anus. 
 
 Treatment. — The treatment of this affection in children can generally be 
 successfully accomplished by an application of a 20-grain solution of nitrate 
 of silver to the ulcer, or by lightly touching the surface with the solid stick of 
 nitrate of silver, and afterward keeping the parts well covered with an ointment 
 composed of thirty grains of iodoform or aristol to the ounce of vaseline, the 
 bowels being kept in a soluble condition. In cases which are found intractable 
 division or stretching of the sphincter may be resorted to. 
 
 Stricture of the Anus. 
 
 This affection may be congenital or may result from an operation in the 
 vicinity of the anus. The treatment of stricture of the anus consists largely 
 in gradual dilatation of the contracted orifice, either instrumental or digital ; 
 if this fails to relieve the condition, a careful incision of the contracted parts 
 should be practised, and subsequent dilatation should be employed for some 
 time. 
 
 Marginal Abscess. 
 
 This affection consists in circumscribed suppuration starting in the mucous 
 follicles of the anus, or from a fissure of the anal margin, and is a much more 
 common and less serious affection in childhood than ischio-rectal abscess. 
 Although painful, it is not apt to result in the formation of a fistula in ano. 
 
 The treatment consists in making a free opening with a bistoury, and to 
 accomplish this the tip of the finger should be passed into the rectum to steady 
 the abscess-cavity and make it more prominent before it is incised ; the wound 
 should then be dressed with iodoform gauze or with lint saturated with car- 
 bolized oil, and usually heals promptly. 
 
 Diphtheria of the Anus. 
 
 This affection is occasionally seen in children suffering from diphtheria of 
 the pharynx, and usually develops late in the disease and in cases in which the 
 system has been profoundly impressed. The deposit of diphtheritic membrane 
 may involve the anus and extend on to the buttocks, and to the mucous mem- 
 brane of the vulva in female children. 
 
 The prognosis is extremely unfavorable, and the cases which have come 
 under my personal observation have all terminated fatally in spite of treat- 
 ment. 
 
 The treatment consists in the employment of such constitutional remedies 
 as are appropriate for diphtheria, and the local application to the affected sur- 
 face of a solution of bichloride of mercury, 1 : 2000 or 1 : 4000, followed by 
 the use of an ointment of iodoform. 
 
 IV. Diseases of the Rectum. 
 
 Proctitis. 
 
 Inflammation of the rectum, or proctitis, is an affection frequently seen in 
 childhood. It may result from injury to the mucous membrane by the feces or 
 by materials contained in the faeces, or it may follow from traumatism received 
 
588 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 from without. It is recognized in two forms — acute catarrhal and chronic 
 catarrhal proctitis. 
 
 Acute Catarrhal Proctitis. — In this affection the inflammatory symptoms 
 are limited to the rectum, and the disease is characterized by great tenes- 
 mus and the frequent passing of bloody mucus, at first mixed with faeces. 
 In addition to these symptoms there are usually present oedema of the mucous 
 membrane of the anus and of the lower portion of the rectum, and vesical 
 irritation ; and as a result of this condition and the constant straining there 
 is often observed a partial prolapsus of the rectum. Many of the symptoms 
 presented are those of acute dysentery, but the abdominal pain and the consti- 
 tutional features of the latter affection are generally wanting. 
 
 Treatment. — The patient should be kept in a recumbent posture, and 
 small doses of castor oil or one of the saline cathartics, either sulphate of 
 sodium or of magnesium, or one of the natural mineral waters, should be 
 administered to secure free evacuation of the bowels. The diet should 
 be restricted to milk, animal broth, and eggs. If, after the bowels have 
 moved, tenesmus continues, an enema consisting of a few drops of tincture 
 of opium and starch-water should be injected into the rectum ; or a rectal sup- 
 pository containing powdered opium grain J, extract of belladonna grain J, 
 iodoform grain 1, should be administered, and if the patient shows signs 
 of exhaustion stimulants should be employed. The disease is usually of short 
 duration, and under treatment the symptoms generally subside in a few days. 
 
 Chronic Catarrhal Proctitis. — This disease usually results from the acute 
 affection, and is characterized by the absence of pain and tenesmus, although 
 in some cases in which ulceration of the mucous membrane of the rectum exists 
 there may be discharged a small quantity of blood and muco-purulent matter. 
 
 Treatment. — The diet should be regulated as in acute proctitis, and if the 
 evacuations are not sufficiently free the bowels should be moved by the adminis- 
 tration of a saline cathartic. The local treatment should consist in the use of 
 enemata of nitrate of silver, \ to 1 grain to an ounce of water, which should be 
 gradually increased in strength until they begin to cause pain ; suppositories of 
 iodoform and extract of belladonna may also be employed with advantage. 
 
 Pekipkoctitis. 
 
 Periproctitis is an inflammatory condition involving the connective tissue 
 surrounding the rectum. It may result from septic causes or direct injury, 
 or may arise from the introduction of foreign matter through ulceration or per- 
 foration of the rectum. Abscess or gangrene of the cellular tissue may result, 
 with subsequent involvement of the skin ; erysipelas also may attack this 
 region, giving rise to erysipelatous periproctitis. 
 
 Treatment. — In this affection, as soon as the swelling and induration can 
 be detected, free incision should be made through the skin and into the cellu- 
 lar tissue outside of the margin of the anus, and the wounds thus produced 
 irrigated with a solution of bichloride of mercury, 1 : 1000 or 1; 4000, or 
 touched with a solution of chloride of zinc, 15 grains to the ounce. The sur- 
 faces then should be dusted with iodoform, and covered with a bichloride-gauze 
 and cotton dressing. If the parts are found to be gangrenous, a charcoal 
 or an antiseptic poultice should be applied, and the patient should be given 
 alcohol and tonics with a liberal diet. 
 
 ISCHIO-RECTAL ABSCESS. 
 
 Ischio-rectal abscess consists of a purulent collection in the loose cellular 
 tissue surrounding the rectum. It is a most painful and serious affection, and 
 
DISEASES OF THE RECTUM. 589 
 
 is the most frequent cause of fistula in ano. It may arise from injuries of the 
 rectum, either from within or from without, from phlebitis or periphlebitis of 
 the hemorrhoidal veins, or from the escape of faecal matter into the cellular 
 tissue through ulcers perforating the rectum. The most characteristic symp- 
 tom of ischio-rectal abscess is a sense of fulness in the lower portion of the 
 rectum, with throbbing pain, which is increased at the time of stool. Where 
 this affection is suspected a careful examination of the rectum with the finger 
 will often disclose a bulging of the rectal wall at some point, and this is often 
 accompanied by swelling and oedema of the skin near the anus ; the presence 
 of fluctuation in this region will often be revealed upon palpation. 
 
 Treatment. — This form of abscess demands prompt and free opening, and 
 by this treatment alone is the pain relieved and the risk of the formation of a 
 fistula in ano avoided. In opening these abscesses I usually follow the practice 
 of Allingham, who recommends that the patient should be etherized and placed 
 in the lithotomy position. An incision should be made at a little distance from 
 the anus parallel with the sphincter, the abscess-cavity laid freely open, and the 
 finger introduced into the wound to break down any secondary cavities or loculi. 
 If it is found that there has been much undermining of the tissues, incisions 
 should be made at right angles to lay all cavities freely open. The abscess- 
 cavity should then be irrigated with a solution of bichloride of mercury, 1 : 2000 
 or 1 : 4000, or with a 1 : 40 solution of carbolic acid ; and the wound should 
 next be carefully packed with lint saturated with carbolized oil, 1 : 30, or, as 
 I prefer, with iodoform gauze. An external dressing of iodoform or bichloride 
 gauze and a pad of bichloride cotton is then applied to the wound and held in 
 position by a T bandage. This dressing need not be disturbed, unless it become 
 loose or soiled, for several days, when the cavity should be irrigated and a 
 few strips of gauze laid lightly in it. The wound should be allowed to heal 
 by granulation. If the bowels do not move in one or two days, a gentle lax- 
 ative may be administered. By this method of treatment the cavity of the 
 abscess rapidly heals, and a cure results without the formation of a fistula in 
 ano. 
 
 Ulceration of the Rectum. 
 
 Ulceration of the rectum is not a common affection in childhood, but it 
 sometimes results from chronic dysentery or chronic catarrhal proctitis. 
 
 The treatment consists in the local use of injections of nitrate of silver, grain 
 \ to 1 to the ounce of water, and in the use of suppositories of iodoform. A 
 restricted diet should also be enjoined, and the bowels should be regulated. 
 
 Stricture of the Rectum. 
 
 This affection may result from the presence of new growths, from the con- 
 traction following wounds of this organ, the result either of accident or opera- 
 tion, and also from congenital malformations of the rectum ; inherited syphilis 
 is mentioned as occasionally causing congenital stricture of the rectum. 
 
 The treatment consists in gradual dilatation of the rectum, either instru- 
 mental or digital ; if the condition be due to the presence of growths, their 
 removal should be accomplished if possible ; and if due to inherited syphilis, 
 antisyphilitic treatment is indicated, in addition to the local measures. 
 
 Syphilis of the Rectum. 
 
 Lesions of the rectum, due to inherited syphilis, are occasionally seen in 
 childhood. A case of gummatous infiltration of the coats of the rectum in a 
 child ten years of age, at the same time exhibiting well-marked symptoms of 
 
590 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 inherited syphilis, has been described by Ball ; and Oser of Cracow has re- 
 ported two cases of gummatous infiltration of the intestines in children suffer- 
 ing from congenital syphilis. 
 
 The treatment of syphilitic lesions of the rectum consists in the adminis- 
 tration of mercury or iodide of potassium, as in the treatment of corresponding 
 syphilitic lesions in other parts of the body. 
 
 Fig. 9. 
 
 Prolapsus of the Rectum. 
 
 Prolapsus of the rectum consists in the protrusion of a portion of the rectum 
 through the anus, and occurs in three varieties: 1. A portion of mucous mem- 
 brane protrudes from the anus (partial prolapsus) ; 2. The entire thickness of 
 the walls of the rectum is included in the prolapse (complete prolapsus) ; 3. 
 There exists an invagination as well as a prolapsus of the rectum. This affec- 
 tion in some one of its varieties is very common in childhood, and the frequency 
 of its occurrence may be accounted for on both anatomical and pathological 
 grounds. The looseness of the attachment of the submucous connective tissues 
 of the walls of the rectum is a well-recognized anatomical fact; and this con- 
 dition is an important factor in the production of prolapsus. The straightness 
 of the coccyx in children is also said to favor its production. In infants and 
 young children the great amount of straining that seems to be required to bring 
 about satisfactory evacuations is also productive of this affection ; this straining 
 
 has been ascribed by Jacobi to the anatomical 
 fact that in children it is not uncommon to find 
 two or three angular flexures in the lower part of 
 the colon. The habit so common with mothers 
 and nurses of placing children upon the chamber 
 utensil and allowing them to spend a large por- 
 tion of time in that position is certainly, to my 
 mind, a frequent cause of the development of 
 prolapsus, and is a custom which cannot be too 
 severely condemned. In many cases the constant 
 straining due to the presence of vesical calculus 
 or rectal polypus, or to a contracted prepuce, may 
 be an important factor in the production of this 
 affection. Improper diet, or the custom of allow- 
 ing children to eat at all hours during the day 
 — and as a result of this over-feeding the pro- 
 duction of a large number of passages — may also be mentioned as a cause. 
 That improper diet and over-feeding produce prolapsus of the rectum is, in my 
 mind, very clearly proved by the fact that at the Children's Hospital of Phila- 
 delphia we often have children admitted to the wards for operation who have 
 suffered from this affection for months : under the use of tonics, proper diet, 
 and regulation of the bowels they fail to further present prolapsus, and are 
 thus soon relieved of the condition without operative interference. Mr. Holmes 
 of London makes a similar observation as to his experience in this affection. 
 
 Symptoms. —The characteristic symptom is the protrusion, during defeca- 
 tion, of a reddish-purple mass covered with mucous membrane : it is unac- 
 companied by pain, and usually undergoes spontaneous reduction as soon as 
 the straining efforts cease. In the partial variety of prolapsus of the rectum 
 little inconvenience is experienced, unless the prolapsed portion of the bowel 
 is allowed to remain out for some time, when it may become congested or 
 ulcerated ; the latter condition is more likely to occur in cases of complete pro- 
 
 Prolapsus of the Rectum. 
 Bryant.) 
 
 (After 
 
DISEASES OF THE RECTUM. 591 
 
 lapsus. When the prolapsus is of the third variety and is accompanied by 
 invagination of the rectum, the symptoms of obstruction of the bowel exist, 
 and gangrene of the protruded mass may occur. Death has resulted in such 
 eases from obstruction as well as from peritonitis. 
 
 Diagnosis. — Prolapsus of the rectum is likely to be confounded only with 
 hemorrhoids, which is an extremely rare affection in childhood, or with poly- 
 pus of the rectum. The appearance of the prolapse is very characteristic: 
 the annular fold of tissue surrounding the whole anus with its depressed central 
 orifice, and the fact that after reduction of the mass no tumor can be found 
 in the rectum, would exclude the presence of polypus. The cases most 
 likely to give rise to error are those of intussusception in children where the 
 intussusceptum protrudes from the rectum, and resembles in appearance a 
 prolapsus. Such cases have been found with prolapsus of the rectum ; but 
 if the surgeon makes a careful examination of the protruded mass, and takes 
 into consideration the previous history of the case, such as sudden pain and 
 collapse or the occurrence of more or less obstruction of the bowels, with the 
 passing of blood and mucus preceding the appearance of the tumor through 
 the anus, he will not be likely to confound the two affections. 
 
 Treatment. — The palliative treatment of this condition consists in return- 
 ing the mass through the anus as soon as possible. This is best accomplished 
 by placing the patient across the knees and making gentle pressure with the 
 fingers over the whole mass of the tumor for a few moments, to return the 
 contents of the bowels and the fluids effused in the tunics, and then pushing 
 up the central portion first with the finger. Little difficulty is experienced 
 in effecting this reduction in recent cases, but where the prolapsus has been 
 down for some time and inflammatory effusion has taken place, it may be 
 necessary to administer an anaesthetic before the reduction can be satisfactorily 
 accomplished. The preventive treatment consists in not allowing the child 
 to make prolonged straining efforts on the chamber-utensil or to have the 
 bowels moved in a sitting posture. A child who is subject to prolapsus of 
 the rectum should have the bowels moved while in the recumbent position on 
 the bed-pan, or on the side, or in a standing posture ; and the nurse should 
 support the perineum and anus by two fingers placed one on each side of 
 the anus, or by forcibly drawing the skin of the buttock to one side while the 
 child is passing the stool. When the affection depends upon the presence 
 of a vesical calculus, a contracted prepuce, or a rectal polypus or parasites, 
 producing great straining efforts, the removal of the cause will usually effect a 
 oure promptly. The importance of carefully regulating the diet has been pre- 
 viously mentioned, and care in this respect alone may bring about a cure. 
 Enemata of astringent solutions, such as decoction of oak bark, a solution 
 of alum, or cold water, or suppositories containing extract of nux vomica and 
 orgot, have been employed ; and of these the enemata of decoction of oak 
 bark, or of cold water, are most satisfactory. In cases where these various 
 palliative measures have failed to relieve the condition, I think the safest and, 
 in my experience, the surest method of treatment is that recommended by 
 Allingham. This consists in the application of nitric acid to the mucous mem- 
 brane of the protruded gut. The child's bowels having been previously opened 
 oy the administration of a small dose of castor oil or by the use of an enema, he 
 is etherized, and the surface of the prolapsed bowel is carefully cleansed and 
 dried of mucus by wiping it with absorbent cotton ; the whole surface of the 
 mucous membrane is next painted with nitric acid applied with a swab, care 
 being taken not to allow the acid to come in contact with the adjacent skin. 
 A pledget of oiled cotton or lint is next introduced into the central depression 
 
592 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 of the prolapsed mass, and by pressing it upward with the finger the mass is 
 reduced. Finally, a pad is placed over the anus and held in position by bring- 
 ing the buttocks together over it by means of broad strips of adhesive plaster. 
 The bowels should be kept quiet for two or three days by the administration 
 of a small amount of opium ; and at the end of that time they should be 
 opened by a laxative. The introduction of the oiled cotton or lint I have 
 found in practice unnecessary, as it is apt to be passed by straining when the 
 patient recovers from the anaesthetic; hence I generally omit its use, and 
 merely coat the cauterized surface of the bowel with olive oil or vaseline 
 before reducing it. The recurrence of the prolapsus may take place with the 
 first few passages, but a permanent cure generally results from one application 
 of the nitric acid. Should this, however, not be the case, cauterization may 
 be repeated in a few weeks. The ligature and the clamp and cautery or actual 
 cautery have been employed in the treatment of this affection, but as their use 
 is attended with danger in cases of complete prolapsus of the rectum, and as I 
 have never seen a case in a child in which the simpler and safer procedure, 
 cauterization by nitric acid, has failed to give satisfactory results, I do not 
 think their employment is to be recommended. In cases of prolapsus of the 
 rectum in which invagination has occurred and the patient is suffering from 
 obstruction of the bowels, if the mass cannot be returned under ether an arti- 
 ficial anus should be made in the left inguinal region ; and if the child survives 
 after the invaginated portion of the gut, has been removed by sloughing or 
 other means, an attempt may be made to close the faecal fistula in the inguinal 
 region, and thus allow the faeces to escape through their natural channel. 
 
 HEMORRHOIDS. 
 
 Haemorrhoids are vascular tumors which occupy the lower portion of the 
 rectum, and arise from dilatation or proliferation of the blood-vessels. They 
 may be either internal or external, and are covered either by mucous mem- 
 brane or skin. Haemorrhoids are uncommon in childhood, but are occasionally 
 seen, and may consist either of dilated veins or well-marked venous tumors. 
 Allingham records a case of well-marked haemorrhoids which he saw in a 
 child three years of age. I have myself seen several cases in quite young 
 children, and have seen recently with Dr. Starr a child three years of age 
 who suffered from well-marked venous haemorrhoids, which protruded and bled 
 at stool, and presented symptoms severe enough to call for operative interference. 
 Ball also has observed several cases in young children. The symptoms presented 
 by haemorrhoids in children are similar to those in adults, and consist in pro- 
 trusion of the tumors and bleeding at the time of defecation. 
 
 Treatment. — As haemorrhoids are apt to occur in strumous children, the 
 administration of iron and cod-liver oil is often followed by decided benefit, 
 and locally the use of astringent ointments and the regulation of the action of 
 the bowels may be followed by marked amelioration in the condition. If, 
 however, the tumors continue to bleed and to be protruded at stool, operative 
 treatment is indicated, and the masses may be removed either by the use of 
 the ligature or, as I prefer, by the clamp and cautery. 
 
 Polypus of the Rectum. 
 
 Polypus of the rectum is a much more common disease in childhood than 
 haemorrhoids, and is characterized by the presence of a follicular tumor 
 springing from the mucous membrane of the rectum at a point an inch or an 
 inch and a half above the anus ; it is attached by a pedicle. The form of 
 
DISEASES OF THE RECTUM. 
 
 593 
 
 Polypi of 
 
 Rectum with 
 (After Ball.) 
 
 Prolapsus. 
 
 polypus most commonly seen in childhood is of the follicular or adenoid 
 variety, and resembles in structure the normal mucous membrane of the 
 rectum, from which it originates ; but fibrous and cystic polypi have also 
 been observed. Mr. Thomas Smith has recorded three cases of disseminated 
 polypi of the adenoid variety occurring in young persons, and Cripps also 
 reports cases of multiple polypi springing from 
 the surface of the rectum and colon. Fig. 10. 
 
 A rectal polypus is of a bright-red color 
 when first extruded, but becomes darker and 
 more venous in appearance after it has been 
 protruded for some time and its circulation has 
 been interfered with by constriction of the 
 sphincter. The growths may be either single 
 or multiple, and have pedicles varying from J 
 to 2 or 3 inches in length. Polypus of the rec- 
 tum is comparatively rare in children : Bokai 
 found 25 cases of this growth in 65,970 pa- 
 tients, and Jacobi says that he sees from 1 to 3 
 cases annually among 500 children. A rectal 
 polypus is apt to produce expulsive eiforts with 
 tenesmus, and give rise to a sense of fulness or 
 distress in the lower part of the rectum, and to be accompanied by the escape 
 of glairy or bloody mucus or of blood. 
 
 Diagnosis. — The diagnosis is usually not difficult, as the growth is apt 
 to present at the anus or to protrude from it during defecation, and a 
 careful examination with the finger will disclose the presence of a pedicle to 
 which the growth is attached. Polypus of the rectum is likely to be con- 
 founded with haemorrhoids or prolapsus of the rectum, but a careful inspec- 
 tion and examination of the parts will disclose the nature of the trouble. Before 
 examining a case of suspected polypus of the rectum it is well to give an enema, 
 and when this is passed the growth is apt to be brought to the lower portion of 
 the rectum or may present at the anus. In examining for polypus it is well to 
 introduce the finger as far as possible into the rectum, and, as it is withdrawn, 
 to make the examination of the walls with a sweeping motion, by which mani- 
 pulation the pedicle of the polypus may be hooked upon the finger. 
 
 Treatment. — A polypus of the rectum may be seized with the fingers or 
 forceps and twisted off, and the stump may be touched with nitrate of silver or 
 with nitric acid; but I think the better method of treatment is to grasp the 
 polypus and draw it out of the anus, so as to expose its pedicle, and to sur- 
 round this with a ligature close to the mucous membrane, care being taken not 
 to make sufficient traction to invert the wall of the rectum, which might thus 
 be included in the grasp of the ligature. The ligature should next be firmly 
 tied, and the tumor removed by dividing the pedicle in advance of the ligature. 
 If a number of polypi exist, the same procedure should be repeated for each 
 growth. 
 
 Angeioma or N^ivus op the Rectum. 
 
 This is also a rare affection. Mr. Howard Marsh has reported the case of a 
 girl ten years of age who suffered from rectal hemorrhage, in whom an exami- 
 nation revealed a nsevoid growth in the lower portion of the rectum ; ami Mr. 
 Barker has also published a case of this nature. 
 
 Treatment. — The treatment of nsevus of the rectum consists in the use of 
 
 38 
 
594 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the ligature to strangulate the growth, or the application of nitric acid or Paque- 
 lin's cautery. 
 
 Malignant Disease of the Rectum. 
 
 Malignant disease of the rectum is very rarely met with in childhood, but 
 may occur either in the form of cylindrical-celled carcinoma or of sarcoma. 
 Allingham, Quain, Cripps, and other observers have reported a few cases occur- 
 ring in childhood. 
 
 Treatment, — The treatment consists in the excision of the growth if its 
 situation be favorable for such a procedure ; or linear rectotomy, which consists 
 in freely dividing the growth together with the lower portion of the rectum, 
 including the sphincter, may be practised with benefit, if obstructive symptoms 
 are present. If the growth involves the high portion of the rectum and excision 
 is not possible, colotomy should be performed. 
 
 Wounds of the Rectum. 
 
 Wounds of the rectum may be caused by substances which reach the 
 rectum through the alimentary canal, or by bodies introduced through the 
 perineum or the anus ; these wounds may be lacerated, incised, or punctured. 
 Lacerated or punctured wounds may result from patients falling upon sharp 
 bodies which enter through the perineum or anus, or from fragments of broken 
 bones of the pelvis, causing in many cases extensive laceration of the parts 
 about the rectum as well as of the rectum itself; they may be complicated by 
 injuries of the bladder, vagina, or peritoneum. Lacerated wounds of the rectum 
 may also result from the careless or forcible introduction of the nozzle of an 
 enema-syringe ; and laceration of this organ in children who have been sub- 
 jected to unnatural intercourse should also be mentioned. Incised wounds 
 of the rectum may result from operations upon this organ or from its acci- 
 dental incision in the operation of lithotomy. 
 
 Treatment. — The treatment of incised or external lacerated wounds which 
 involve only the lower portion of the rectum consists in controlling bleeding by 
 the application of ligatures to the bleeding vessels; in washing the wound 
 thoroughly with a solution of bichloride of mercury, 1 : 4000 ; in dusting the 
 wound with powdered iodoform ; and in providing for the escape of discharge by 
 the introduction of a drainage-tube or catgut drain, and in bringing the edges 
 together with catgut sutures. A gauze dressing should then be applied, and 
 the bowels kept quiet for a few days. 
 
 In punctured or internal lacerated wounds of the rectum which do not 
 extend high enough to involve the bladder or peritoneum it is better, in order 
 to secure free drainage, to convert the internal punctured or lacerated wound 
 into an open wound by the division of all the tissues, including the external 
 sphincter and the skin. The wounds should then be washed with a solution 
 of bichloride of mercury, packed lightly with iodoform gauze, and allowed 
 to heal by granulation, the dressing being changed as often as it becomes 
 soiled. 
 
 In a case of lacerated wound of the rectum complicated by wound of the 
 bladder, perineal cystotomy should be performed to provide for the free escape 
 of urine, and free drainage secured by division of the anal sphincter and the 
 introduction of drainage-tubes if necessary. If a punctured wound of the 
 rectum involves the peritoneum, with injury to the contained viscera, laparot- 
 omy should be performed, the wounds of the viscera should be sutured, and 
 the peritoneal cavity irrigated, drained, and closed. 
 
DISEASES OF THE JRECTUM. 595 
 
 Foreign Bodies in the Rectum. 
 
 Foreign bodies may enter the rectum from the alimentary canal or may be 
 introduced through the anus. A great variety of foreign bodies have been 
 thus introduced either by accident or design. Patients suffering from foreign 
 body impacted in the rectum will have ineffectual attempts at defecation, with 
 the passage of mucus, which is often blood-stained. In a case presenting these 
 svmptoms a careful exploration with the finger will enable the surgeon to ascer- 
 tain the presence, the exact location, and the character of the foreign body. 
 
 Treatment. — -The removal of the foreign body should be accomplished 
 with the least possible injury to the walls of the rectum. It is well first to 
 anaesthetize the patient, and then inject into the rectum a few ounces of olive 
 oil. When the character and position of the foreign body have been ascer- 
 tained, it may be dislodged with the finger and removed by forceps. Where 
 the body is irregular in shape or possesses sharp edges or angles which may 
 cause injury to the surrounding parts, retractors or a bivalve speculum should 
 be introduced to secure free dilatation of the anus and lower portion of the rec- 
 tum and facilitate removal without injury to the rectal walls. Where the foreign 
 body consists of a large mass of inspissated material, fragmentation should be 
 resorted to in order to secure its satisfactory removal. If the foreign body has 
 remained in position for some time and ulceration has resulted from its presence, 
 a solution of nitrate of silver, 10 grains to the ounce of water, should be applied to 
 the ulcerated surface, and suppositories of iodoform should also be introduced 
 into the rectum. Extensive ulceration of the rectum following the long-con- 
 tinued presence of a foreign body may be followed by stricture, and the pos- 
 sibility of this condition should be guarded against by judicious dilatation by 
 the finger or bougies. 
 
PART VII. 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 SIMPLE CEREBRAL MENINGITIS 
 
 By THOMAS S. LATIMER, M. D., 
 
 Baltimore. 
 
 By simple meningitis, leptomeningitis, or purulent meningitis, is usually 
 meant inflammation of the arachnoid and pia mater. Writers distinguish an 
 arachnitis, but as this probably never occurs apart from inflammation of the pia 
 or dura it may be considered an unnecessary refinement. Varieties are men- 
 tioned dependent on the situation, grade, or nature of the inflammation, and 
 whether primary or secondary, or according to the character of the exciting 
 cause. All practical purposes are subserved by dividing simple meningitis 
 into acute, subacute, and chronic forms, whilst considering in their appropriate 
 places those peculiarities in each form incident to locality and origin. 
 
 All forms of meningitis have much in common, and a description of any one 
 form is in great part a description of all ; more especially is this the case in the 
 clinical history and in the treatment ; it is therefore expedient, to avoid need- 
 less repetition, which the space allotted to this article does not permit, to dis- 
 cuss the pathology and etiology of the different forms, and subsequently the 
 clinical history and treatment, which are essentially the same in all. 
 
 Simple cerebral meningitis may be defined as inflammation of the arach- 
 noid and pia mater of non- tubercular origin. 
 
 Etiology. — Simple meningitis is said to occur in utero (Guersant) and 
 to be quite frequent in the new-born. According to Ramskill, its period of 
 greatest frequency is prior to the second year, becoming less so from that time 
 until after fourteen, when it again becomes more common, especially between 
 sixteen and forty-five. Gowers places the period of greatest frequency between 
 the ages of one and ten years, including, however the tubercular form. It is 
 essentially a disease of early childhood, and is more common than is admitted 
 by those who refer all basilar inflammations to a tubercular origin. In the 
 post-mortem observations of Drs. Gee and Barlow, recorded in St. Bartho- 
 lomew's Hospital Reports for 1878, are 6 cases of non-tubercular meningitis, 
 and in 41 post-mortem examinations by Dr. Goodhart, in cases which he says 
 without examination would have been set down as tuberculous, 8 were non- 
 tubercular. 
 
 Sex may be admitted among the predisposing causes, since Par ent-Du chat e- 
 let and Martinet found it to be three times as frequent in males as in females. 
 The occupations peculiar to men and the sports of boys, involving exposure to 
 vicissitudes of weather and to mechanical violence, may account in great part 
 
 596 
 
SIMPLE CEREBRAL MENINGITIS, 597 
 
 for this difference, "without assuming that there exists any liability or immunity 
 due to sex per se. 
 
 Injuries to the head, extension of middle-ear inflammation or of any adjacent 
 disease, the special cause of many specific diseases, like pneumonia, scarlatina, 
 erysipelas, and measles, ordinary pus-producing organisms, emboli and thrombi 
 — may all be exciting causes. An inherited or acquired predisposition is per- 
 haps not uncommonly present, but less often than in the tubercular form. 
 Rheumatism has been supposed to be a frequent cause, but its importance has 
 doubtless been over-estimated. Symptoms closely simulating those of mening- 
 itis often arise in the course of acute rheumatism when post-mortem examina- 
 tion reveals no trace of inflammation. Trousseau absolutely denied the inflam- 
 matory nature of these cases, which he called neuroses. Two of the most 
 characteristic symptoms of meningitis, vomiting and headache, are also com- 
 monly absent. Doubtless rheumatism is sometimes a cause of true simple 
 meningitis, but all the symptoms may arise from hyperpyrexia alone. Sup- 
 purative endocarditis or any other septic trouble may occasion it, as in the 
 cases following operation for imperforate anus referred to under Pathological 
 Anatomy. Those cases arising from adjacent disease may be limited to the 
 convexity, while those occurring in the course of acute specific diseases may 
 affect the base also, though a preference for the convexity is recognized in 
 all non-tubercular forms. 
 
 Pneumonia is frequently associated with simple meningitis and the pneumo- 
 coccus is found in the inflammatory exudate. Huguenin states that at Zurich 
 it is a frequent complication of pneumonia, and Chvostek found it four times in 
 220 cases in Vienna. 
 
 The most common cause of this affection is extension from some local adja- 
 cent disease ; middle-ear inflammation is a frequent antecedent. Cases have 
 occurred in which suppuration of the eyeball was primary, the inflammation 
 extending along the sheath of the optic nerve. In some instances no imme- 
 diately exciting cause is apparent. Fagge relates several cases occurring in 
 Guy's Hospital in which a diseased temporal bone was found post-mortem, but 
 the meningeal inflammation appeared to start in one instance from a blow with 
 a bolster, and in another an attack of sunstroke preceded the cerebral symp- 
 toms about seven days. Moxon gives a prominent place to syphilis as causa- 
 tive of meningitis, and Fagge says 5 cases, in which it occurred without other 
 syphilitic lesions within the calvaria, were found among the records of Guy's 
 Hospital. This writer appears to approve the notion that the direct rays 
 of the sun may produce simple meningitis, or that even its reflection from the 
 pages of a book while reading is a sufficient cause ; but this is scarcely 
 credible. 
 
 Pathological Anatomy. — When death occurs in the early stage of lepto- 
 meningitis, intense hyperemia with extreme dryness and opacity of the mem- 
 branes — from distention of the lymphatic sheaths of the vessels — over the 
 whole or part of the brain may be the only lesion. If death occur after a few 
 days' duration, effusion of fluid admixed with cellular elements will be found on 
 the arachnoid, in its sac and infiltrating the pia mater. Abercrombie relates a 
 case in which it was so abundant between the dura and arachnoid as to distend 
 the anterior fontanelle. Usually, however, the quantity of fluid exudate is not 
 large. When life has been prolonged to the fifth or sixth day, the quantity of 
 fluid is sensibly diminished, and a little later disappears. A membrane-like 
 deposit of yellowish hue is found on the arachnoid ; the pia in greater or less 
 partis covered and infiltrated with " concrete pus," which is also found around 
 the vessels and in the sulci of the convolutions (Ramskill). The nerve- 
 
598 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 sheaths may be reddened and bathed in semi-purulent lymph, which at times is 
 punctiform and resembles tubercular granulations. In long-standing cases this 
 may undergo caseation or induration. The nerve-trunks may be in different 
 stages of hyperemia, softening, and disintegration. The dura and arachnoid 
 may be firmly adherent, the arachnoid and pia almost always. 
 
 The ventricles may be invaded, their lining membrane inflamed, the orifices 
 of communication occluded, and the chambers distended with serum or pus, 
 sometimes to the extent of producing a true hydrocephalus. In rare cases 
 they may contain false membrane. More frequently they contain a flocculent 
 fluid of variable quantity, sometimes sufficient to distend the ventricle and 
 compress the cortex. The subjacent brain-substance may be oedematous and 
 softened. This condition is not always associated with unmistakable evidence 
 of inflammation of their lining membrane ; indeed, the inflammatory changes 
 in the ventricles are rarely, if ever, well marked. In those cases where inflam- 
 mation is most pronounced the effusion is seldom limited to the ventricles, but 
 may invade the cord and escape into the brain-space. Great distention of all 
 the ventricles may occur without inflammation, from simple occlusion of the 
 channels of communication with the space around the brain (Gowers). Rilliet 
 relates a case in which the convexity of one side was covered with false mem- 
 brane, whilst the pia of the opposite side was simply oedematous. 
 
 Cases of pneumonic origin are usually bilateral and limited to the cortex ; 
 those extending from local foci — purulent otitis, caries, etc. — are unilateral, 
 and may be associated with thrombi of the sinuses or with abscess (Osier). 
 Septic cases and those associated with specific diseases are apt to be bilateral. 
 The base is often involved in the inflammatory process. An interesting case 
 of basilar meningitis following an operation for imperforate anus, reported by 
 W. T. Howard, Jr., in a child of three months, is related in Osier's Practice 
 of Medicine, in which the ventricles were distended with pus containing a 
 coccus and the bacterium coli commune ; the ependyma was softened and 
 infiltrated with pus. Dr. Hilton Fagge also reports a case, occuring in Guy's 
 Hospital, of a meningeal inflammation following six days after an operation for 
 imperforate anus, attributed to sepsis, though the meningitis was the only evi- 
 dence of pyaemia. Dr. Fagge says the presence of subdural pus may usually 
 be taken as an evidence of extension from without, though in many cases no 
 subdural pus is found. The pia is usually swollen and oedematous, filling the 
 sulci ; the inflammation may extend along the vessels to the cortex, which 
 becomes infiltrated, softened, and so adherent at times that the pia cannot be 
 removed without cortical laceration. The whole surface of the cortex may be 
 bathed in pus or deeply infiltrated with leucocytes, and Huguenin says " sup- 
 puration of the brain-substance may reach such a point as to give rise to a 
 diffused yellow-gray maceration visible to the naked eye " (quoted from Fagge's 
 Practice). The amount of blood in the vessels may be greatly diminished 
 from pressure of the exudate and thickening of their walls. 
 
 Symptoms. — Simple meningitis of childhood usually begins abruptly with 
 well-marked rigors. Prodromic symptoms are much less frequent than in the 
 tubercular form. The patient is petulant and irritable when disturbed, but 
 inclined to apathy at other times, more especially in later stages and when the 
 convexity is especially involved. Violent delirium with or without convulsions 
 may be an early symptom. When convulsions occur early, they are apt to 
 recur often during the progress of the trouble. The delirium may be quiet and 
 the convulsions slight or absent. Pyrexia quickly supervenes, and is usually 
 high : a temperature of 103°-105° F. is not uncommon in the first week. It 
 is sometimes very slight, occasionally scarcely appreciable, and in the last stage 
 
SIMPLE CEREBRAL MENINGITIS. 599 
 
 the temperature may be subnormal. The pre-mortal temperature is sometimes 
 as high as 106°-108° F. 
 
 The pulse may be frequent and tense, usually so in the beginning, or slow 
 and irregular, sometimes as slow as 60, 50, or 40 per minute, or just before 
 death it may rise to 160-180 per minute. Henoch considers an intermittent 
 pulse characteristic of meningitis. It is of more significance in childhood than 
 in infancy, but at no time has it the diagnostic value imputed to it. The 
 extreme variation in frequency and quality of the pulse is probably its most 
 significant character. 
 
 Respiration is usually but little disturbed, but is sometimes sighing, may 
 be quickened at first and subsequently irregular and slow, and toward the 
 close the Cheyne- Stokes rhythm may be present. When the lesion is in the 
 posterior fossa, respiration is slow, labored, accompanied by cyanosis, and may 
 stop suddenly. 
 
 Headache is perhaps the most constant symptom, and is seldom lacking. It 
 is often associated with great tenderness of the scalp and subjacent region, and 
 is sometimes circumscribed, but the localization bears no constant relation to 
 the site of the inflammation. The meninges of one side may be inflamed and 
 the pain and tenderness be on the other ; but when the pain persists in a circum- 
 scribed area it commonly indicates the site of the inflammation. Cases of 
 simple meningitis sometimes run their entire course without pain, and when 
 pain is present it seems to have no constant relation to the intensity or extent 
 of the inflammation. 
 
 Hyperesthesia of the nerves of the special senses of sight and hearing, 
 indicated by extreme aversion to light and noise, is almost invariably present. 
 This may be associated with acute general hyperesthesia. The pupils are at 
 first contracted ; as the photophobia diminishes they become irregular ; one 
 may be contracted and the other dilated, or at times contracted, at times 
 dilated ; finally, both become dilated and vision is impaired or lost ; optic 
 neuritis is present in many cases, especially when the base is involved. Noises 
 at first greatly disturb the patient. This sensitiveness to sound is at times so 
 great that the most softly modulated speech occasions signs of petulance and 
 distress. As the end approaches this gradually passes away, and deafness may 
 ensue. 
 
 The intelligence is sooner or later affected ; the patient is irritable and 
 petulant when questioned or otherwise annoyed ; incoherent speech and 
 delirium are often early symptoms. Other nervous symptoms present at this 
 time are subsultus, carphologia, inco-ordinate efforts at locomotion if this be 
 attempted, and projectile vomiting. 
 
 The tache cerebrale is well marked, but is without diagnostic significance. 
 Occasionally the patient emits short, sharp cries that do not always appear to 
 be due to pain, though in older children they often seem to increase the 
 headache. 
 
 General convulsions may occur independently of the site (Gowers), and 
 eventually give place to coma. Rigidity of the muscles of the neck, with 
 retraction of the head, is an early symptom of diagnostic value : it is more 
 frequent in inflammation of the base than of the convexity. When the base is 
 the site of the lesion, local spasm may occur in simple as well as in tubercular 
 meningitis. Rolling up of the eyes, oscillations of the globes, strabismus, 
 most marked when the eyes are moved, are frequently present in the first 
 stage; later they may give place to paralysis, sometimes limited to the face 
 or a small part of it, sometimes to a single extremity ; or complete hemiplegia 
 is present. 
 
600 AMEBIC AX TEXT-BOOK OF DISEASES OF CHILDBEX. 
 
 Vomiting is so commonly present and of such distinctive character as to 
 possess diagnostic significance. It is projectile, unaccompanied by gastric pain 
 or tenderness, nausea, or retching. It may persist throughout the disease, but 
 is most characteristic in the early stage. It occurs independently of the site, 
 but is more common in inflammation of the base. It is not present in all 
 cases. The tongue is usually somewhat furred, but presents nothing character- 
 istic. The bowels are constipated in a large proportion of cases, and the 
 abdomen is retracted or boat-shaped. 
 
 Finally, all the active symptoms subside ; the headache, photophobia, 
 acoustic sensibility, general and local hyperesthesia, and active delirium, all 
 give place to coma and general collapse. The pupils are dilated, the pulse 
 weak and irregular and the skin cold and clammy. Cheyne-Stokes respiration 
 is established, the sphincters are relaxed, the faeces and urine are voided 
 involuntarily, and death speedily ensues. 
 
 Subacute Leptomeningitis is peculiar only in the relative mildness of the 
 lesions and the slowness with which it develops. It sometimes, though rarely, 
 succeeds to the acute form, but more commonly is subacute from the beginning. 
 The same lesions of milder grade are present, and are due to the same exciting 
 and predisposing causes. 
 
 Hydrocephalus is perhaps more frequent and extensive; active delirium 
 is frequently substituted by a more quiet form and a condition of mental 
 torpor. The patient is less irritable, the photophobia and acoustic sensibility 
 is less, and paralyses are slower to appear. There is but little propriety, how- 
 ever, in recognizing a subacute form ; it is merged by such insensible grada- 
 tions, on the one hand, into the acute, and on the other, into the chronic form, 
 that there is little to distinguish it. 
 
 A latent form is also described, but in the judgment of the writer it has 
 no well-established claim to recognition, and will not therefore receive further 
 consideration. 
 
 Chronic Leptomeningitis. — Chronic leptomeningitis may succeed the 
 acute form, but is of extreme rarity except as a result of syphilis or chronic 
 alcoholism, causes not likely to occasion it in childhood except through inher- 
 itance. 
 
 The symptoms are less clearly distinctive, and the difficulty in diagnosis 
 therefore greater, than in the acute form ; consequently it may often be over- 
 looked and the frequency of its occurrence underestimated. If, as Goodhart 
 has remarked, we accept cervical opisthotonos as evidence of meningitis, it may 
 not only be very chronic, but also intermittent, and, we may add, more fre- 
 quent than commonly supposed. 
 
 Its clinical history is not to be separated by sharply-drawn lines from that 
 of the acute disease. It is essentially the same in character, but of slower 
 development and more protracted stay, and all the more characteristic symp- 
 toms are of less intensity. An apathetic condition with headache and a dis- 
 position to vomit, a pulse at first slow, soon becoming quick and irregular, 
 double vision, strabismus, and irregularity of pupils, may usually be found if 
 sought for. The favorite site of chronic infantile meningitis is the posterior 
 fossa, and the most characteristic symptoms are local and dependent on the seat 
 of the inflammation. Drs. Gee and Barlow observed cervical opisthotonos in 
 most cases. ^ In some cases of rapid development it may be attended or preceded 
 by convulsions, vomiting, pain, and fever ; in others the retraction of the head 
 is slowly induced, unattended by these phenomena. Rigidity of the limbs and 
 epileptic convulsions may occur later, together with oscillations of the globe or 
 strabismus, and occasionally hydrocephalus (Gowers). When the orifices of 
 
SIMPLE CEREBRAL MENINGITIS. 601 
 
 the fourth ventricle are closed with lymph, paralyses, facial and hemiplegic, 
 may complicate the later period. The pia is usually thickened from increase 
 in its connective tissue ; a similar condition is found in the walls of its vessels, 
 and from them may extend to the cortex, inducing such changes as may lead 
 to insanity and idiocy. The pia and arachnoid may be glued together, cede- 
 matous and opaque, and the sulci be filled with serum or sero-purulent fluid or 
 edematous membrane. The Pachionian bodies are increased in number and 
 size. 
 
 Chronic lepto-meningitis is much more frequently associated with syphilis 
 than is the acute form. A swollen and oedematous optic disk, or optic neu- 
 ritis, may aid the diagnosis, but cannot confirm it. 
 
 One is a little at a loss to understand why the cause of the meningitis should 
 De supposed to determine a difference in the symptoms, except in so far as these 
 are due to associated disease. The extent, intensity, and locality of the menin- 
 geal inflammation, with the nervous susceptibility of the individual, will deter- 
 mine the symptoms, which will be much the same whatever the cause. 
 
 Diagnosis. — The positive indications of simple meningitis are found in the 
 symptoms already mentioned, though they may any or all of them occur with- 
 out meningeal lesion of any kind whatever. The general cerebral symptoms 
 are valuable according to their degree and combination, rather than by their 
 mere presence. "The significance of the headache depends on its intensity; 
 of the delirium, on its coexistence with headache ; of vomiting, on its causeless 
 character and persistence; of general convulsions, on their association with 
 other symptoms; of infrequency of pulse, on its combination with pyrexia 
 that usually accelerates the heart " (Growers). It is not to be distinguished by 
 its symptoms from tubercular meningitis, though in general it may be said to 
 be more frequently dependent on some pre-existing local disease, to be more 
 abrupt in its invasion and rapid in its progress in acute cases, and to be more 
 frequently associated with active delirium. It is probably more dependent on 
 some local lesion or association with specific disease than is the tubercular form. 
 In the latter the presence of the tubercle bacilli or of septic materials from 
 degenerating tubercles, with peculiar susceptibility, is alone sufficient for its 
 development. The presence, therefore, of tubercle in other organs, the detec- 
 tion of tubercle bacilli, and a tubercular family history are of greater value in 
 the differential diagnosis than any supposed difference in symptoms directly 
 due to the meningitis. Though clear evidence of tubercle elsewhere mav be 
 wanting, slow invasion, early childhood, and the absence of distinct local cause 
 make for a tuberculous origin. When the base alone is the site of the inflam- 
 mation, the probabilities are strongly in favor of the tubercular form. Inflam- 
 mation of the middle ear or labyrinth, with or without suppuration, may give 
 rise to symptoms that cannot be distinguished, except by their duration, from 
 meningitis. The detection of an otitis, therefore, may lead us to believe in the 
 existence of meningitis originating from it, or to hope that the symptoms are 
 solely due to it and will end in recovery under proper treatment. And in cases 
 that recover under such circumstances, the diagnosis must remain permanently 
 in doubt, since many cases of simple meningitis have been thought to recover. 
 
 It is also not altogether unlikely that the characteristic symptoms may arise 
 as a reflex result of lesions of the most varied character in remote parts of the 
 body. From the cerebral form of pneumonia simple meningitis may be dis- 
 tinguished by the physical signs of the former and the detection of the pneumo- 
 coccus. But it must be remembered that although pneumonia may exist with- 
 out meningitis, with analogous cerebral symptoms, yet pneumonitis and true 
 meningitis may coexist and be due to the same cause. I know of no way to 
 
602 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 distinguish cerebral symptoms occurring in pneumonia without meningitis and 
 those occurring under like circumstances with it, except by their duration ; and 
 even this in many cases is the same, since pneumonia with marked cerebral 
 symptoms often runs a speedily fatal course. Perhaps, instead of trying to 
 differentiate them, it would be best to consider both as local expressions of the 
 same constitutional state. 
 
 Pyaemia may present symptoms closely resembling meningitis, especially 
 when associated with thrombus of the lateral sinus and jugular vein, as in a 
 case reported by Dr. Frederick Taylor. Dr. Wilson Fox also relates a similar 
 case, and Dr. Andrew two instances of pyaemia with cerebral symptoms not 
 distinguishable from meningitis ; both of these recovered, however, so it can- 
 not be said they were not pases of true meningitis, unless it be assumed that 
 acute simple meningitis never recovers. 
 
 Those cases of typhoid fever likely to occasion difficulty in diagnosis are 
 characterized by the predominance of cerebral symptoms and the absence or 
 slight nature of those peculiar to the alimentary canal ; but in typhoid fever 
 headache precedes delirium, usually ceases with its advent, and is sufficiently 
 accounted for by the pyrexia — not so in leptomeningitis. Photophobia and 
 auditory hypersensibility may occur in either, but they are far more acute in 
 meningitis. In typhoid fever vomiting seldom has the distinctive cerebral 
 character, and rigidity of the neck and local paralyses seldom occur. The 
 invasion of typhoid fever is rarely so abrupt ; the pulse is not so irregular. 
 
 Prognosis. — In all cases of leptomeningitis but little hope can be reason- 
 ably entertained of recovery when no error in diagnosis has been made ;• but 
 errors of this kind happen in the experience of the most astute and well- 
 informed physicians. Moreover, cases apparently free from doubt have recov- 
 ered in sufficient number to warrant hope, but hope only, for nothing in the 
 condition of the patient serves as a reasonable basis for expectation of recovery. 
 The cases which do best are those having their origin in injuries, necrosis, 
 caries, suppurative otitis, and other removable causes, and those that arise in 
 the progress of syphilis. The majority even of these will terminate fatally 
 after the inflammation is well established, but much may be done, by the early 
 removal or correction of such causes, to prevent the establishment of meningitis. 
 Those in which the indications are that both the convexity and base are affected 
 run a rapidly fatal course. Patients in whom no reasonable cause exists may 
 be expected to succumb, more especially if the pulse soon becomes irregular and 
 weak, accompanied by nausea, with convulsive seizures followed by profound 
 hebetude. 
 
 When light and noise no longer disturb ; when the pupils become persist- 
 ently dilated ; the skin cold, pale, and bathed in perspiration ; when involuntary 
 evacuations occur ; paralysis local or general becomes established, and coma or 
 a semicomatose condition supervenes, — all hope may be abandoned. 
 
 Treatment. — The treatment in simple cerebral meningitis and in simple 
 cerebro-spinal meningitis is essentially the same. A much larger proportion 
 of cerebral cases are due to local conditions that may be treated by surgical 
 measures, and whenever they do arise from removable causes surgical treat- 
 ment should be instituted without delay. Suppurative otitis, with or without 
 necrosis or caries of the temporal bone, is so often causally related to meningeal 
 inflammation that these lesions should always receive efficient attention before 
 the induction of the graver evil. It has happened to the writer to witness two- 
 cases of supposed leptomeningitis in adults, with fatal terminations, supervening 
 on chronic suppurative otitis that had followed scarlatina many years before. 
 Had the aural trouble been efficiently treated, the meningeal inflammation 
 
SIMPLE CEREBRAL MENINGITIS. 603 
 
 -would in all probability have been averted. Doubtless many similar cases have 
 existed, and, in view of the great fatality of the secondary affection and the 
 impunity with which surgeons of the present day invade the meninges, and 
 even the substance of the brain, they should in future disappear from our 
 records. All cases of injury to the skull that carry with them even a reason- 
 able suspicion of injury to the meninges or brain should, in the judgment of 
 the writer, be trephined, bone-fragments elevated or extracted, blood-clots 
 removed though the membranes have to be incised for that purpose, and all 
 the parts thoroughly cleansed. Analogous procedures are no less imperatively 
 called for in diseased conditions than after injury. 
 
 Cases of syphilitic origin should receive the specific treatment proper to 
 that disease, with a not unreasonable hope of recovery if the treatment be 
 begun early. 
 
 Apart from these special indications for treatment, there is but little to be 
 expected from any means at our disposal beyond the alleviation of suffering. 
 Drugs appear to exert no influence on the course of the disease, and it may be 
 doubted, even in those cases of supposed leptomeningitis that have recovered, 
 whether the remedies administered have contributed to this result. 
 
 Bleeding, local or general, and blisters are still strongly advocated by 
 German writers and by many others. Apart from relief of hyperemia 
 of the cerebral vessels, one sees but little benefit to be derived from 
 them, and it would seem that this might be better accomplished by such 
 remedies as amyl nitrite, which increase the vascular area and so lower blood- 
 pressure without the same impairment of strength as follows bloodletting. 
 Mercury and the iodide of potassium have been warmly and ably advocated 
 as efficient therapeutic agents in this disease, but they so often appear to be 
 entirely without effect that the writer is sceptical of their value except in cases 
 of syphilitic origin. Nevertheless, excellent results of treatment with these 
 agents have been reported by most competent observers. Ramskill in 
 Reynolds's System of Medicine thus summarizes the treatment : " It resolves 
 itself into three great remedial measures : first, bloodletting ; second, hard 
 purging; third, applications of cold water or ice to the head." 
 
 Abercrombie's cases also give strong support to the efficiency of these 
 measures. Case 69, aged eleven, after an illness of five or six days was in a 
 comatose condition, notwithstanding free purging, blistering, and the use of 
 mercury to salivation ; was immediately relieved and made a good recovery 
 after one bleeding from the arm. Case 72, aged twenty-one years, was 
 reduced to a condition of stupor from which he could scarcely be roused, and 
 continued in this way for eight or ten days notwithstanding repeated bleed- 
 ing, blisters, and cold applications. But, after taking full doses of castor oil 
 every three hours until purgation was induced, he was on the same evening 
 relieved and made a good recovery (quoted in Fagge's Practice). 
 
 A brisk purge in the beginning and from time to time during the progress 
 of the trouble will do much to alleviate suffering, and at times seems to have 
 a decidedly beneficial effect. Cases, not a few, are recorded, especially by the 
 earlier writers, which seem to date improvement, rapidly progressing to recovery, 
 from such measures as free catharsis, bleeding, local or general, blisters applied 
 to head or back of neck. Whilst it is difficult wholly to discredit such state- 
 ments or to deny to the agents employed the remedial potency claimed for 
 them, yet it is equally difficult to conceive how with such means such ends 
 could be attained. When remedies of this class are serviceable at all it must 
 be in the early stage before inflammatory exudation, infiltration, or degenera- 
 tive changes have occurred to any notable extent ; and one cannot wholly 
 
604 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 shake off the doubt that they were cases of erroneous diagnosis, or at least 
 belong to that rare class of cases that would have recovered without medical 
 interference. 
 
 An entirely different class of remedies is found in those drugs of anodyne 
 and hypnotic properties which allay vomiting, soothe pain, subdue or lessen 
 active delirium, procure sleep, and contribute in many ways to make tolerable 
 for patients and friends the last days of those for whom in a large majority of 
 cases we can hope to do no more. And, in the opinion of the writer, relief in 
 these particulars is the extent of the power of drugs to be useful in this disease. 
 First rank in this group of remedies may still be boldly claimed for opium and 
 its derivatives, and especially for morphine, which, because of the small dose 
 required, the facility with which it may be administered hypodermatically, 
 and its almost uniform strength and efficiency, takes precedence of all other 
 drugs. The bromides of sodium and potassium, antipyrin, antifebrin, sul- 
 phonal, and many other similar remedies are at times of great usefulness. The 
 occasional use of chloroform by inhalation when convulsions occur gives prompt 
 relief to some of the most distressing symptoms, and is, I believe, as free from 
 danger as any other remedy when judiciously employed ; but nothing can be 
 so confidently relied on to relieve pain, to procure sleep, to quiet delirium, and 
 to arrest vomiting as morphine ; and this it does at as little cost to a feeble 
 heart as any other drug that may be used ; nor do I think is the tendency to 
 coma materially, if at all, increased by its judicious administration. But more 
 valuable than any of the remedies yet mentioned is repose of body and mind 
 as perfect as may be had by the mere exclusion of disturbing causes. The 
 room should be darkened ; no one not indispensable to the comfort of the 
 patient should be admitted ; no loud talking or other noises should be allowed 
 within hearing ; and no needless questioning by anxious friends. In cerebral 
 cases the head should be shaved as soon as the nature of the trouble is clear. 
 Ice or ice-cold water should be almost continuously applied to the head and — in 
 cerebro-spinal cases — to the back. It should be begun early and continued 
 steadily, and in cases of active delirium this may be supplemented by iced 
 applications to the large arteries — brachials and carotids. 
 
 When coma appears, all depressing remedies should cease, although occa- 
 sional recoveries are recorded even in this stage, as in Abercrombie's cases, 
 already quoted, and in Sir Thomas Watson's case of recovery on the application 
 of a blister to the entire shaven scalp after the appearance of coma. It is 
 certainly more reasonable to expect good from the judicious use of stimulants 
 in this stage or at any time when the heart-beat is feeble or intermittent. 
 Throughout the disease, as far as practicable, the strength of the patient should 
 be maintained with the most nutritious diet. 
 
SIMPLE CEREBROSPINAL MENINGITIS. 
 
 By THOMAS S. LATIMER, M. D., 
 
 Baltimore. 
 
 Simple or Sporadic Cerebro-spinal Meningitis occurs under pre- 
 cisely the same circumstances as simple cerebral meningitis, and is attended by 
 the same lesions, except in so far as the anatomical and physiological character- 
 istics of the part invaded necessitate a difference. Nor can it be maintained 
 in the present state of knowledge that any essential difference exists between 
 this and other forms of cerebro-spinal meningitis. The tendency of recent 
 observations and opinion is to the conclusion that epidemic cerebro-spinal 
 meningitis (cerebro-spinal fever) has its origin in a specific germ, probably the 
 diplococcus lanceolatus, and observations have not yet sufficiently multiplied 
 to enable us to say whether or not this organism is also present in all sporadic 
 cases. However this may be, it is clear that the two forms arise under some- 
 what different circumstances, and present such clinical differences as may be 
 seen in other diseases, such as dysentery, that prevail at times epidemically and 
 at times sporadically — differences chiefly of intensity in the symptoms and in 
 the extent of the lesions, the epidemic prevalence implying a concurrence of 
 suitable conditions in the individual and in the auxiliary associated conditions 
 by which he is surrounded, and not necessarily any difference in the immediate 
 exciting cause. In this restricted sense, then, we may still speak of simple 
 cerebro-spinal meningitis as distinguished from cerebro-spinal fever. There 
 are also cases occurring from injury, from sepsis, from local extension, from 
 tuberculosis or syphilis, that probably have no causal connection with the pneu- 
 mococcus, and may with more propriety be designated "simple" than may 
 sporadic cases that appear to be closely connected with this particular organism. 
 
 Etiology. — The causes of simple cerebro-spinal meningitis are precisely 
 the same as those of simple cerebral meningitis, and need not be again con- 
 sidered. They are injuries, extension from adjacent disease, pyaemia, specific 
 diseases, childhood, sex, season, vicissitudes of temperature, and those general 
 malhygienic conditions that predispose to inflammations in general. Menin- 
 gitis is not, however, limited to any class, and may occur among the rich and 
 poor alike. Efforts have been made to connect it with particular articles of 
 food, but without much success. Fatigue from over-exertion seems to be a 
 favoring condition observed most frequently in the adult. 
 
 Pathological Anatomy. — This disease may be an extension from simple 
 cerebral meningitis, in which case the anatomical changes heretofore described 
 in basilar inflammation will be present, and to them must be added those due 
 to invasion of the meninges of the cord ; or it may originate in the cord and 
 extend up to the cerebral meninges, which would not of course alter the nature 
 of the lesion, only the order of occurrence of its symptoms : or it may occur 
 simultaneously in both regions, the anatomical characters remaining the same. 
 These characters are — great hyperemia in the first stage, to which soon suc- 
 
 805 
 
606 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ceed swelling and hypertrophy of the walls of the vessels of the pia mater, 
 sometimes also of the brain and cord, and with this oedema and cellular infil- 
 tration of adjacent parts may coexist. Sometimes the exudate may be small 
 in amount and consist of serum, white corpuscles, and plastic material, by 
 which in the last stage, if the patient survives, the membranes may be bound 
 together, or the pia and surface of the brain or cord ; or it may be of large 
 quantity and purulent, filling the canal and bathing the pia and underlying 
 structures in a grayish-yellow or distinctly purulent fluid, which may fill the 
 entire space between the dura and arachnoid. The infiltration may occasion 
 opacity of both pia and arachnoid. The spinal meninges are usually exten- 
 sively involved, owing probably to the readiness with which septic elements 
 are diffused in the spinal fluid. The spinal fluid is more or less flocculent 
 from the presence of exudation elements, or it may be, as before said, distinctly 
 purulent. A true myelitis may, and not unfrequently does, coexist, in which 
 case paralyses occur of a more permanent character than when the meninges 
 alone are involved. The arachnoid is probably never affected alone, but it is 
 always involved in the inflammation, which may also extend to the dura and 
 to the spinal nerves, to which latter circumstances some of the most character- 
 istic spinal symptoms are due ; but they by no means always share in the 
 inflammation. According to J. Simon, the meningeal inflammation may 
 usually be looked upon as an index to the more important changes that occur 
 in the cerebral and spinal tissue, " and hence it is that the essential phenomena 
 of the disease during life consist in disturbances, more or less grave, of the 
 functions of these all-important organs." 
 
 Other organs and tissues present little or no pathological change, except 
 perhaps the skin, and the lesions here found are commonly limited to the fulmi- 
 nant cases, which are found almost exclusively in the epidemic form of menin- 
 gitis, and have therefore been fully described in another section. 
 
 Symptoms. — In this affection the convexity is seldom involved, and the 
 symptoms are for the most part those characteristic of inflammation of the base 
 and of the cord, more especially of the cervical region of the latter. The 
 special senses are not affected to the same extent as in cerebral meningitis, 
 although vision is sometimes impaired ; irregularities of the pupil and strabis- 
 mus, with oscillation of the globe, are usually present in minor degree, but 
 intense photophobia is rarely a marked symptom. Deafness is quite common, 
 and may be permanent ; in many cases it is due rather to inflammation 
 extending to the labyrinth and middle ear than to direct lesion of the auditory 
 nerve. 
 
 Optic neuritis is present in most instances when vision is affected, and may 
 terminate in permanent blindness in cases that recover. Keratitis, retinitis, 
 opacity and ulcerations of the cornea, and opacity of the lens may all occur, 
 but are not characteristic. Pain is invariably present, especially in the occipi- 
 tal and cervical regions, and is associated with general cutaneous hyper- 
 esthesia ; all movements of the patient occasion suffering, associated with rigid- 
 ity of the spinal extensor muscles, sometimes affecting also the muscles of the 
 chest, abdomen, and jaws, producing a sense of constriction and slight trismus. 
 This hyperesthesia and muscular contraction is probably due to the involve- 
 ment of the roots of the spinal nerves in the inflammatory process. 
 
 The retracted neck and back, at times amounting to decided opisthotonos, 
 is in part voluntary, due to a disposition to relax, as far as may be, irritable 
 muscles (Radcliffe) ; in part reflex, from irritation of the sensitive fibres of the 
 posterior roots distributed to the pia ; and in part from direct irritation of the 
 anterior nerve-roots, or to all these combined. When the patient is perfectly 
 
SIMPLE CEREBROSPINAL MENINGITIS. 607 
 
 at rest, considerable intervals of almost complete relaxation exist, but all efforts 
 to restore the normal decubitus are commonly attended with recurrence of the 
 abnormal position and rigidity. Most intense pain in the head and cervical 
 region is an early and continuous symptom ; it seldom entirely intermits, but 
 severe exacerbations are of frequent occurrence. Pain in the back and loins 
 is often present — always when the lower segment of the cord is invaded. The 
 thighs are flexed upon the pelvis and the legs upon the thighs. Firm pressure 
 over the spinal column does not occasion pain, a point of distinction between 
 meningitis and spinal irritation. Local paralysis with facial distortion is not 
 infrequently present, and in the later stage the patient may become hemi- 
 plegic, which usually implies the extension of the trouble to the substance of 
 the brain or cord. Active delirium generally exists, sometimes as an early 
 symptom, occasionally associated with convulsions, frequently ending in coma. 
 Reflex irritability is always present in the early stage, but is less marked than 
 in tetanus. 
 
 Vomiting is a troublesome symptom in most cases, and is difficult to con- 
 trol. The vomit consists of ingesta, bile, or a glairy greenish fluid. The 
 bowels are usually constipated and the abdomen retracted, but diarrhoea 
 not infrequently occurs, with tympany. Whilst this paper is in progress 
 the writer is attending a case of well-marked sporadic meningitis in which 
 diarrhoea induced by purgation continues, together with decided tympanites. 
 The tongue presents nothing characteristic. It may be unchanged, slightly 
 furred, or covered with sordes in the last stage. Appetite is no doubt impaired, 
 but the desire for food is controlled in a measure, owing to the trismus and 
 cervical contracture which efforts at swallowing, together with the necessary 
 movements, induce. Thirst is an invariable symptom and is with difficulty 
 appeased. 
 
 Pyrexia is present to a very variable extent ; it may be scarcely appreciable, 
 or it may range as high as 105° and 106° F., and in the last stage is usually 
 highest. 
 
 With pyrexia the usually febrile pulse and respiration are associated, but 
 marked dyspnoea may be superadded from paralysis or rigidity of respiratory 
 muscles when the dorsal region of the cord is included in the inflammation. In 
 cases complicated with pneumonia additional respiratory difficulty may be due 
 to this cause; this is, however, a rare complication except in the epidemic 
 form. The pulse is almost always quickened, ranging from 80 or 90 to 120, 
 and in the first stage may have considerable tension, which is lost at an early 
 period, a diminished arterial tension being one of the characteristic features of 
 the disease. Very much more frequent pulse is recorded, and at times it falls 
 as low as 50, but these instances are altogether exceptional. The kidneys 
 rarely show any distinct lesion, but the urine is often increased in quantity. 
 and occasionally contains a small amount of albumin. Retention of urine 
 from spasm of the sphincters or paralysis of the detrusor muscles is sometimes 
 associated with reflex spasm and irritable attempts to urinate. Involuntary, 
 not necessarily unconscious, voiding of urine and fasces also happens. 
 
 Diagnosis. — The positive indications of simple cerebrospinal meningitis 
 have already been mentioned. Briefly stated, they are headache, pain in neck, 
 back, and loins, with general cutaneous hyperesthesia, exaggerated sensibility 
 to light and sound, irregular pupils, oscillations and distortions of the eyeball, 
 followed at times by blindness and deafness, paralysis of cranial or spinal 
 nerves, delirium, convulsions, and coma; vomiting without apparent gastric 
 cause, obstinately persisting; trismus and cervical contractures which may 
 extend to nearly all the muscles of the body; pyrexia of inconstant degree. 
 
608 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 and respiratory labor of varying and uncertain extent. From the epidemic 
 form it is to be distinguished by its sporadic occurrence, its less rapid progress, 
 its perhaps more extensive involvement of the spinal membranes, its usually 
 less acute course, and the comparatively infrequent cutaneous lesions, espe- 
 cially of purpuric or hemorrhagic character. It probably is more frequently 
 causally related to local troubles of eye and ear, bone lesions, trauma, and 
 sepsis. Perhaps if a clear distinction is to be permanently maintained between 
 the simple and epidemic forms, it will come to rest on the absence of the 
 diplococcus lanceolatus in the former and its presence in the latter. 
 
 With typhoid fever it may be confounded, but the distinction is not diffi- 
 cult. The severe persistent headache and spinal pain, the cutaneous hyperes- 
 thesia, the exaggerated sensibility of special senses, trismus, muscular contrac- 
 tures, uncontrollable vomiting, constipation, — all early symptoms, — are suffi- 
 cient for diagnosis before the later symptoms of each make error impossible. 
 
 With tetanus it has little in common but retraction of the head and slight 
 opisthotonos, trismus, and thoracic constriction. In meningitis the back is 
 less bowed, less rigid, and the contracture less easily induced ; the trismus is 
 seldom severe, often wanting, and rarely persists, whilst in tetanus a touch or 
 a breath of air induces rigid opisthotonos, and trismus is an early, severe, and 
 persistent symptom. In doubtful cases, if any such occur, the detection of the 
 micro-organism of tetanus will resolve the doubt. 
 
 Cases of tubercular origin are to be distinguished alone by the invasion of 
 other organs and by the family history, a more protracted course and an initial 
 period of latency, with a less acute career. 
 
 Prognosis. — This is always grave, but a fair proportion of sporadic cases 
 recover under judicious treatment. When the symptoms relate chiefly to the 
 cord, a reasonable hope may be entertained, but when paralysis of cranial 
 nerves, stupor, Cheyne-Stokes respiration, coma, and collapse occur, the issue 
 is no longer uncertain. In some instances death has ensued in five hours, in 
 from twenty-four to thirty-six hours not infrequently, but this has always been 
 in fulminant cases, which are rare in the simple form. In sporadic cases life 
 may be protracted several weeks, and in subacute cases sometimes many 
 months ; the usual period is about from ten to twenty days. Cases that 
 recover are of longer duration than those that terminate fatally, but even in 
 favorable cases the patient may be maimed for life, blind, deaf, paralytic, or 
 with intelligence permanently impaired. In young children and in adults near 
 middle age the mortality is greater than in youth. 
 
 Death may be due to asthenia from continued suffering, bed-sores, and 
 inability to partake of food; or it may be more rapidly induced by respiratory 
 difficulty from involvement of the respiratory centre, or by associated pneu- 
 monia ; or convulsions may be followed by coma, collapse, and speedy death. 
 
 Treatment. — The same treatment advised in cerebral meningitis is advisa- 
 ble in cerebro-spinal meningitis — i. e. perfect rest, exclusion of light and noise, 
 of visitors, and all causes of disturbance ; removal of the cause when known 
 and practicable ; the occasional use of a brisk mercurial or other purge ; liquid 
 food and stimulants administered per rectum if not retained by the stomach ; 
 free and continued use of cold to the shaven head and back — ice preferred ; 
 the careful but efficient use of anodynes, of which opium and its derivatives 
 are best, and in the early stage such remedies as the iodide and bromide of 
 potassium with ergot. When the affection is chiefly or wholly spinal, B ram well 
 speaks in terms of high commendation of the iodide, and of ergot in the second 
 stage, and also of the use of blisters and of tincture of iodine applied along the 
 spine in the region implicated. Pain, cutaneous hyperesthesia, and muscular 
 
SIMPLE CEREBROSPINAL MENINGITIS. 609 
 
 contractures indicate sufficiently clearly the site of the inflammation by the 
 correspondence of these symptoms with the distribution of the nerves whose 
 roots are affected; attention to the bladder and rectum is of course always 
 requisite. Paralyses may require special measures in accordance with the com- 
 mon rules of treatment, but Bramwell suggests caution in the use of electrical 
 stimulation during the period of meningeal irritability. 
 
 39 
 
TUBERCULOUS MENINGITIS. 
 
 By JAMES HENDRIE LLOYD, A. M., M. D., 
 
 Philadelphia. 
 
 Tuberculous meningitis is an inflammation of the membranes of the 
 brain due to the specific action of the tubercle bacillus. It is characterized 
 by the formation of tubercles in, and an inflammation of, the pia arachnoid, 
 with effusion at the base of the brain ; by some secondary cerebritis, and even 
 softening of the brain-substance ; and by effusion into the ventricles. 
 
 Etiology. — The essential cause of tuberculous meningitis is of course the 
 bacillus of tubercle, first demonstrated by Koch. In the vast majority of 
 instances — probably in all cases, in fact — the infection of the brain-mem- 
 branes is secondary to a primary infection in some other part of the body. 
 This primary infection may be in the mesenteric or bronchial glands, in chronic 
 ear disease, or in some other bone disease, such as spinal caries or tuberculous 
 disease of the hip-joint. It is not uncommon in these cases to find tuber- 
 culous infection also beginning in the lungs, or even in the spleen and kid- 
 neys. In some of these latter instances, however, the infection is possibly not 
 primary, but, as in the case of the meninges, secondary. Thus in a number 
 of cases seen by me at the Home for Crippled Children the patients had had 
 long-standing chronic disease of bone, and the infection of the lung-tissue, as 
 well as of the brain-membranes, was evidently secondary and recent. 
 
 Heredity is a predisposing factor, just as it is in all forms of tuberculous 
 infection. In many cases it is possible to elicit a family history of tubercu- 
 losis, and in cases in which this family history cannot be traced there is 
 always a justifiable suspicion of it. It cannot be denied, however, that tuber- 
 culous infection of the membranes of the brain, as well as of other organs, 
 may occur in rare instances in patients in whom there is no hereditary pre- 
 disposition to it. As the disease is due to the invasion of a bacterium, it 
 might possibly occur in a person whose family history showed no trace of it. 
 
 Among predisposing causes age is undoubtedly the most important. The 
 great majority of cases occur in children. The disease is most frequent be- 
 tween the ages of two and seven years. Its frequency diminishes rapidly 
 after the fifteenth year. It is a comparatively rare disease in adult life, 
 although it is possibly rather more frequent in long-standing cases of pul- 
 monary tuberculosis than is generally supposed. Some of the brain-symp- 
 toms, for instance, occasionally seen in phthisis are no doubt due to infec- 
 tion of the meninges. This complication may readily be overlooked at the 
 autopsy, at which time attention is apt to be directed" too exclusively to the 
 thoracic and abdominal organs. 
 
 Sex is not an important factor in predisposing to tuberculous meningitis. 
 Boys are usually supposed to furnish a rather larger number of cases than 
 girls. Trauma has not been satisfactorily demonstrated to be an exciting 
 cause. ° 
 
 610 
 
TUBERCULOUS MENINGITIS. 611 
 
 This disease is usually supposed to attack by preference weakly and deli- 
 cate children, but this can readily be explained by the fact, already stated, 
 that it rarely if ever occurs except as a secondary infection, and consequently 
 only in those cases in which the health has already been impaired by an 
 infection of some other organ by the tubercle bacillus. 
 
 In searching for a cause of tuberculous meningitis in any given case the 
 utmost care must be exercised to determine, if possible, the existence of a 
 focus of tubercle in some other organ. This may readily be overlooked by a 
 careless observer. A few broken-down bronchial glands, a small unabsorbed 
 patch from a precedent pneumonia, an uncured otitis media, or a small focus 
 of caries in a bone may have been the starting-point for the infection. 
 
 Symptoms. — Tuberculous meningitis is usually described as a disease 
 of progressive stages. This is rather an arbitrary or artificial method of 
 description, and ""will only be utilized here after a full description of the 
 various symptoms in detail. While it is true that the disease does in 
 many instances present more or less characteristic stages, such as onset, 
 progress, and termination, yet cases vary amongst themselves so widely in 
 this respect that it seems better to present the individual symptoms before 
 attempting to group these into anything like a classical type. After these 
 symptoms have been fully described they can be presented as they are usually 
 found associated at the bedside. 
 
 The symptoms of tuberculous meningitis are initial decline in health, 
 headache, vomiting, constipation, convulsions, slow and irregular pulse, a 
 variable temperature, emaciation, mental changes, delirium passing into 
 stupor and coma, optic neuritis, and various palsies, affecting not only the 
 limbs, but also, and most especially, the ocular muscles, and frequently the 
 muscles supplied by other cranial nerves. 
 
 The initial decline in health so frequently seen in tuberculous meningitis 
 may be considered as its only true prodrome. As already explained, it is 
 usually due to the fact that the patient is already suffering from some 
 primary tuberculous infection. This may be present in caseating glands or 
 in a focus of tuberculous bone-disease, such as otitis media or spinal caries. 
 The decline in health, in fact, is probably rather due to this primary infec- 
 tion than to the involvement of the brain-membranes. When this latter 
 occurs the characteristic symptoms, in some form or other, such especially as 
 headache and vomiting, usually soon manifest themselves. Thus the initial 
 impairment of health probably indicates merely that the patient's system is 
 beginning to offer less resistance to the tuberculous invasion, and this dimin- 
 ished resistance is the immediate cause for the determination of the infection 
 to the brain-membranes. In very many cases, however, the onset of tuber- 
 culous meningitis is rather abrupt, a period of initial ill-health being en- 
 tirely absent or so slight as to escape observation. In such instances the 
 true significance of the earlier symptoms, such as headache, vomiting, and 
 slight mental changes, may be entirely overlooked, these symptoms being 
 attributed to some other disorder, especially gastric or intestinal derange- 
 ment. This initial ill-health, when it occurs, varies so much that it is diffi- 
 cult of description. It may consist of fluctuations of temperature, impairment 
 of appetite and assimilation, loss of flesh, asthenia, and slight mental phe- 
 nomena, such especially as irritability, peevishness, and unprovoked explo- 
 sions of ill-temper. The child under these circumstances is noted by the 
 parents and attendants to be losing ground ; the physician's advice is asked, 
 and the cause for the obvious failure of health may be sought for dur- 
 ing a short period in vain. In such cases the onset of the characteristic 
 
612 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 symptoms of tuberculous meningitis may be insidious and deceptive in the 
 extreme. Slight headache may occur, and this in young children is not 
 always easily recognized. Gastro-intestinal symptoms may begin to present 
 themselves, such as occasional vomiting and more or less persistent constipa- 
 tion, and the meaning of these may be entirely misconstrued. In such a 
 case a convulsion may be the first grave symptom to attract the physician's 
 attention and to arouse his suspicions. 
 
 Headache is usually a very early symptom in tuberculous meningitis, and 
 one of the most persistent and characteristic. In very young children, as 
 already said, it may not be easily recognized. Its presence may be suspected 
 from an occasional sharp cry of pain, especially when the child is moved or 
 disturbed. The patient may indicate its presence also by movements of the 
 hands toward the head, by dread of light, and by a disposition to remain 
 abnormally quiet and apathetic. The peculiar cry of the child suffering with 
 tuberculous meningitis has been noted by most authors, and has even been 
 named the hydrocephalic cry. It is probably an expression of severe pain 
 in the head, and is so characteristic that it should ahvays excite suspicion. 
 The child sometimes gives utterance to this cry in the midst of perfect 
 calm and repose. The cry then has a sort of explosive character, and is 
 usually piercing and harassing. In older children complaint of the head- 
 ache is usually an early symptom, and is often urgent and persistent. The 
 patient seeks the dark, dreads to be disturbed, and often begs piteously for 
 relief. In some few cases, however, as I have seen, headache, while pres- 
 ent, is not always so severe and prominent in the early stages. On close 
 questioning, however, the presence of this symptom can usually be deter- 
 mined. The child says that its head aches, and will often raise the hand to 
 the region where the pain is most intense. It is not unusually referred to the 
 frontal region : it may, however, be more generally diffused, the patient being 
 unable to state accurately just where it is most severe. This is partly due, 
 no doubt, to the inability of young children to localize and describe accu- 
 rately their subjective symptoms. The headache of tuberculous meningitis 
 does not manifest itself only during the waking hours : in many cases it is 
 evidently present during sleep, and the nights are disturbed by an occasional 
 loud and agonizing cry, which the patient emits unconsciously. This hydro- 
 cephalic cry, with its peculiar explosive character, occurring during sleep, is 
 especially characteristic and suggestive. Headache, even in cases in which 
 it is not prominent in the early stages, is almost sure to become a marked 
 symptom as the case progresses. It is not always disguised even by the 
 stupor which eventually comes on. 
 
 Vomiting is an important symptom in tuberculous meningitis, but it is 
 one the true significance of which is often overlooked in the early stages. 
 It is frequently unaccompanied with nausea, and may then be propulsive 
 or spontaneous in character. It is one of the most constant symptoms of 
 the disease, and, as a rule, is more marked in the early than in the later 
 stages. Barrier, quoted by Meigs and Pepper, found it absent in only 15 
 out of 80 cases. Sometimes, in fact, the vomiting is the first really well- 
 marked symptom of the disease. In these cases it may be so persistent as 
 to lead to the belief that it is caused by some obstinate gastric or gastro- 
 intestinal disorder. Thus in one case, the history of which I know, the 
 vomiting led to a diagnosis of cholera morbus, which was rendered more 
 plausible by the fact that the boy, aged about eight years, had had a few 
 loose stools and that the case occurred in midsummer. This patient was 
 hurried to the seashore, and a true diagnosis was not made until the onset 
 
TUBERCULOUS MENINGITIS. 613 
 
 of stupor, accompanied by convulsions, indicated clearly the true nature 
 of the disease. In the later stages of tuberculous meningitis the vomiting 
 may gradually disappear. This symptom is supposed to depend upon irrita- 
 tion of the roots or intracranial trunk of the pneumogastric nerve. It is not 
 such a common symptom in meningitis from other causes at the convexity or 
 other regions of the brain where the vagus is not involved. In most cases 
 the vomiting is not continuous, but occurs in paroxysms not more frequently 
 than two or three times a day. It usually takes place without warning and 
 without nausea, and thus has the essential characteristics of cerebral vomit- 
 ing. It occurs independently of the presence of food in the stomach, and the 
 matters vomited are merely such as happen at the time to be in that viscus. 
 Occasionally, indeed, there is little if any food in the stomach, and the 
 material rejected is merely a little fluid or mucus. 
 
 Constipation is very rarely absent in tuberculous meningitis. It is regarded 
 by some observers as even more important than vomiting as a symptom of this 
 disease. It is sometimes so aggravated and obstinate that the wonder is that 
 its significance should be mistaken. In combination with the early headache 
 and vomiting it forms a group of symptoms that should be unmistakable. 
 This association of vomiting with obstinate constipation gives a peculiar 
 aspect to these cases, which is entirely different from what would be seen 
 if the symptoms were due to gastro-intestinal irritation. This distinc- 
 tion is still further emphasized by the fact that in tuberculous meningitis 
 there is great retraction of the abdomen. The scaphoid belly, associated 
 with obstinate constipation, is seen in the majority of cases of tuberculous 
 meningitis. When present it is a symptom that can always be relied upon, 
 although its absence is not necessarily a sign that tuberculous meningitis 
 is not present. Constipation, as a rule, is not a very early symptom of the 
 disease ; at least, it is not conspicuous until the lapse of a number of days. 
 For the first few days it may naturally attract but little attention or may be 
 thought to be due to some trifling or temporary cause. It is exceedingly 
 intractable to drugs, and in some cases there may be great difficulty in 
 securing a movement of the bowels. The cause of this symptom has not 
 been accurately determined. It is possibly due to involvement of the pneumo- 
 gastric nerve. 1 
 
 Convulsions are rarely absent at some stage of tuberculous meningitis. 
 There is no positive law, however, about their occurrence. As already said, 
 a fit is not usually an initial symptom of the disease. It may, however, be 
 the first symptom to arouse the suspicion of the practitioner. I have known 
 of cases in which the correct diagnosis was not made until the occurrence of 
 a convulsion. As a rule — to which, however, there are some exceptions — 
 convulsions do not occur in the first stage of tuberculous meningitis. They 
 usually do not appear until there is some slight evidence of involvement of 
 the psychical faculties, such as is shown by apathy, drowsiness, or even 
 stupor. Hence it may be said that convulsions do not occur much before the 
 middle or end of the second week. The intensity and frequency of these con- 
 vulsions vary greatly in different cases. In some there may be but one, two, 
 or three seizures during the whole course of the disease, and these may occur 
 at intervals of some days. In others the attacks are more frequent. The indi- 
 vidual seizures vary also in their intensity and duration. Sometimes the con- 
 vulsive attack is distinctly focal m character — i. e. it may be confined to a few 
 
 1 According to Landois and Sterling, stimulation of the vagus increases the movements of 
 the small intestine. Hence we might infer that the obstinate constipation seen in tuberculous 
 meningitis is an evidence of paralysis of the pneumogastric nerve. 
 
614 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 muscles or muscle-groups ; thus the muscles of the eye, eyelids, or face may 
 alone be involved, or may be involved more and for a longer time than the mus- 
 cles of the extremities. This is due probably to irritation of the cortical cen- 
 tres that preside over the affected muscles. In most cases, however, the con- 
 vulsion is general and accompanied by profound unconsciousness, and may 
 be succeeded by a long period of coma. In some instances the convulsive 
 attack is more marked on one side than on the other, and in these there may 
 be slight paresis of the affected side remaining after the fit. In a few 
 instances convulsions succeed each other with great frequency, so that the 
 child passes rapidly from one to another, and may even present a condition 
 not unlike epileptic status. In this state the temperature rises and the 
 danger to life is imminent. It is not unusual, in fact, for a prolonged con- 
 vulsive seizure to be the immediate cause of death. 
 
 Alterations in the circulation are very common in tuberculous menin- 
 gitis. In the very early stages there is simply increased rapidity of the 
 pulse. This is in no wise characteristic, and therefore may simply be re- 
 garded by the practitioner as an indication of the general weakness and ill- 
 health into which the patient is passing. Later, however, the pulse assumes 
 an entirely different character, and then furnishes one of the most striking 
 symptoms of the disease. This alteration consists in a slowing and irreg- 
 ularity of the heart's action. The pulse falls frequently as low as 60, and 
 in rare instances even to 50 or lower. With this slowing of the heart 
 there occurs also a disturbance of the rhythm of its pulsation. The heart 
 beats irregularly, the intervals between its pulsations vary, and the indi- 
 vidual pulsations also vary in their force. Thus a few regular rhythmical 
 pulsations of even force may be followed by a feeble pulsation at a longer or 
 even shorter interval than normal, or several of these feeble and irregular 
 beats may occur. This symptom is seldom absent in tuberculous meningitis. 
 It may not, however, be equally apparent at all times, and should therefore 
 be watched for with the utmost care. If the physician does not satisfy him- 
 self of its presence during his visit, he should instruct the nurse or attendant 
 to look for it at frequent intervals during the day. If he finds a suspicious 
 slowing of the pulse, he should especially be on the lookout for this highly 
 characteristic irregularity. Changes of posture affect the pulse under these 
 circumstances. It may for a time become more rapid, and then be followed 
 by a period of slowing, during which the irregularity may be noted. The 
 importance of this symptom is very great, and in cases otherwise doubtful it 
 may furnish the conclusive sign of the presence of the disease. It is probably 
 not seen in all its well-marked characteristics in any other disease of child- 
 hood. When it occurs after an initial period of headache, vomiting, and con- 
 stipation, even though no convulsion has occurred, it may be regarded as 
 pointing unerringly to the diagnosis of tuberculous meningitis. Toward the 
 termination of the disease this slowing and irregularity of the heart gives 
 place to increased frequency and feebleness. The pulse then rises to 140, 
 160, or even higher, and toward the end may be so rapid and feeble as 
 scarcely to be countable at all. 
 
 The temperature in tuberculous meningitis is exceedingly irregular. In 
 the early stages it fluctuates from normal to 101° or 102° F. Later it takes 
 a higher range, and seldom falls to the normal point. It cannot, however, 
 be said to pursue a characteristic range, such as occurs in typhoid fever. 
 Toward the very end it mounts still higher, and at the moment of death may 
 reach 104° or 105°. This range of temperature is well shown in the accom- 
 panying chart from the case of a girl aged eight years who died on the fif- 
 
TUBERCULOUS MENINGITIS. 
 
 615 
 
 teenth day of the disease (Fig. 1). This chart shows also the characteristic 
 variations in the pulse-rate. On some days, it will be noted, the pulse was 
 as low as 80, but later it became as rapid as 200. In some few cases the tem- 
 perature, instead of mounting toward death, falls to an abnormally low point. 
 Thus in a case reported by Gee the temperature on the day of death fell to 
 79.4°. In these cases the breath feels cold to the hand, the pulse is imper- 
 ceptible at the wrists, and yet, according to Gee, the appearance of the 
 patient is very misleading and may even resemble that of a healthy child. 
 In my observation reduction of temperature below the normal point in the 
 last stages of the disease is rather rare. It was well shown in the case of an 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 Temperature Chart from a Case of Tuberculous Meningitis (Methodist Hospital). 
 
 Italian girl aged ten years who died recently in the nervous wards of the 
 Philadelphia Hospital (Fig. 2). While the range of temperature in tuber- 
 culous meningitis is not characteristic, still a careful study of it in doubtful 
 cases is of the first importance. This is so especially in cases in which it is 
 necessary to make a differential diagnosis between this disease and either 
 typhoid fever or tumor of the brain. The very irregularity serves to exclude 
 typhoid fever, and the extreme fluctuations are unlike anything that is seen, 
 as a rule, in cases of tumor of the brain. 
 
 The mental changes occurring in tuberculous meningitis are not without 
 significance, especially in the early stages. Most authors speak of these 
 
616 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 changes as being in some degree characteristic. A very early change in 
 tone, as it were, of the patient's mind may be observed, especially by those 
 to whom the child is well known, as parents and nurses. In addition to the 
 peevishness and fretfulness not uncommonly seen in ailing children, the 
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 and even uncalled-for explosions of ill-temper. In very little children this 
 symptom, associated with evidences of headache, fluctuations of temperature, 
 vomiting, and constipation, may be of some value in helping to a diagnosis. 
 On the other hand, these children sometimes in the early stages become 
 unusually quiet and apathetic. They appear to be in a dream-like state, or, 
 as Meigs and Pepper have well called it, a state resembling mild ecstasy. In 
 
 Fig. 2. 
 
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 Temperature Chart from a Case 
 
 of Tuberculous Meningitis, showing subnormal temperature (Philadel- 
 phia Hospital). 
 
 this condition their thoughts seem wandering and far away, and a distinct 
 impression must be made to recall the child's attention to itself or its sur- 
 roundings. From this condition it is but a step to true delirium, somnolence, 
 and stupor. 
 
 As a rule, the intellectual faculties are not seriously involved in the early 
 stages of tuberculous meningitis. The child does not pass into delirium and 
 stupor until well on in the second week. Exceptions, of course, may occur 
 according to the activity and extent of the infection of the brain-membranes 
 and to the resistive power of the child. In a few cases, for instance, some 
 delirium or mild wandering of the thoughts occurs in the very early stages, 
 particularly when the headache is intense, and more especially on waking. 
 Raving delirium, however, is not common. In fact, the most conspicuous 
 
TUBERCULOUS MENINGITIS. 617 
 
 mental change is somnolence with a tendency to pass into a stupor or a 
 soporose state. In this state the child will often lie quiet and uncomplain- 
 ing for hours, making known few if any of its wants. Occasionally, it will 
 utter the cry of pain indicative of headache, although this tendency dimin- 
 ishes as the disease advances. Still, the child can be roused, although, as a 
 rule, it dislikes exceedingly to be disturbed, and cries out, resists, and gives 
 evidence of pain in the head and of dread of light. It will usually, however, 
 with a little urging, respond to questions and do as it is bidden. Thus it will 
 put out its tongue and take medicine or food. As the case advances, however, 
 the stupor increases and it becomes more and more difficult to excite the child's 
 mental reflexes. Long, loud, and repeated urging is necessary to induce the 
 child to respond. Finally, after some days of such slow and gradual progress 
 that it is difficult to establish the limits of the various steps, the condition 
 passes into one of profound coma, from which the child never rouses. This 
 terminal coma is sometimes of rather unexpected length. When it is once 
 deeply established it is usually associated with such well-marked symptoms 
 of failing vitality, such as rapid pulse, emaciation, and shallow respirations, 
 that the attendants are inclined to anticipate speedy dissolution ; but this 
 expectation is not always realized. Patients, for instance, who seem scarcely 
 able to live over twenty-four hours will sometimes linger for a period of days 
 or even a week or more. 
 
 Various palsies, especially of the muscles supplied by some of the cranial 
 nerves, are encountered in tuberculous meningitis. The muscles of the eye 
 are most frequently affected. Thus a very common symptom is strabis- 
 mus, due to a palsy of some of the orbital muscles. There may be, for 
 instance, an internal strabismus, due to paralysis of the sixth nerve, or an 
 external strabismus with ptosis and dilatation of the pupil, from paralysis 
 of the third nerve. Inequality of the pupils, in fact, is a very constant 
 symptom in this disease, but it is not necessarily associated with the evi- 
 dences of paralysis of the trunk of the third nerve. It is sometimes due, no 
 doubt, to an involvement, by pressure or otherwise, of the nuclei presiding 
 over the iris — i. e. the foremost nuclei of the third nerve beneath the anterior 
 portion of the aqueduct of Sylvius and in the wall of the third ventricle. 
 Of other cranial nerves involved, the commonest are probably the seventh 
 and the tenth. Facial paralysis or paresis is occasionally seen. The slow 
 and irregular action of the heart is possibly due to some involvement of the 
 roots of the tenth or pneumogastric nerve. Unilateral paralysis of the 
 tongue, due to tuberculous meningitis, is probably extremely rare. In some 
 cases paralysis of the limbs occurs ; this is especially noted when there have 
 been severe and long-continued convulsions, the convulsion being followed 
 by a hemiplegia or a monoplegia. These symptoms are probably due to an 
 invasion of the cortical centres by irritating toxins, or even by the meningitis 
 itself, or to pressure upon the motor tracts downward through the peduncle 
 and pons, or to interference with the circulation passing upward to the inter- 
 nal capsule through the anterior perforated space. Paralyses of the leg and 
 arm are not nearly so common as the palsies of the cranial nerves, and when 
 they occur it is usually late in the disease. In some cases, instead of distinct 
 paralysis following a fit, there may be a state of rigidity or of spastic paresis. 
 This is due evidently to a continuously irritating action of toxins upon the 
 nerve-centres. A spastic state, moreover, is not infrequently seen in tuber- 
 culous meningitis independent of a convulsion. It may sometimes appear 
 rather early in the disease, and then usually attends or follows a fit. Opis- 
 thotonos is occasionally seen toward the end of the disease : it is very rare 
 
618 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. 
 
 in the early stages. It is sometimes intermittent or paroxysmal and varies 
 in degree. In exceptional cases the retraction of the head is extreme, pre- 
 senting the condition known as retrocollic spasm. In a patient recently 
 seen in the Philadelphia Hospital this symptom was continuous for days, 
 the child lying on its side with its head retracted to its full extent, so that 
 the occiput rested on the shoulders, and when the child was placed on its 
 back, the face was directed fully toward the head of the bed. In some cases 
 tremor, or, more accurately, a slight ataxia, occurs, especially in the hands, 
 arms, legs, and feet. 
 
 Optic neuritis, or congestion of the optic papilla, is occasionally present 
 in tuberculous meningitis, and would probably be seen oftener if it were more 
 frequently searched for. Tubercles in the choroid are occasionally seen. 
 According to Oliver, tuberculous meningitis is more prone than other forms 
 of meningitis to cause changes in the optic nerves. 
 
 Changes in respiration may be noted. In the somnolent or stuporous 
 condition this is especially so. The respirations become unequal in depth 
 and irregular in rhythm. Occasionally the interval between inspirations is 
 very prolonged, and then breathing will be resumed with a long sighing 
 expiration. Toward the end the respirations may be rapid and shallow. 
 
 True paralysis of the bladder and rectum is not seen, but incontinence 
 of urine and faeces may occur, owing to the mental state. 
 
 Progressive emaciation is usually present in all cases of tuberculous men- 
 ingitis, and when the disease is unduly protracted this emaciation, with pallor 
 of the skin, becomes quite marked. In some cases, however, the nutrition 
 is fairly well preserved, although, as a rule, it is difficult to induce these 
 patients to take sufficient nourishment to repair the waste going on in the 
 system. 
 
 To recapitulate briefly, the symptoms may be grouped with more or less 
 accuracy, so that the disease presents several stages. 
 
 In the first stage, including the prodromal period of ill-health, there may 
 be noted slight mental changes, such as extreme irritability, with headache, 
 vomiting, fluctuating temperature, and obstinate constipation. Occasionally 
 in this stage a convulsion occurs, but this is rare. 
 
 In the second stage these symptoms are aggravated, except that the vom- 
 iting is no longer such a pronounced symptom. Delirium now supervenes, 
 and the child passes into a stuporous or somnolent state. The characteristic 
 slow and irregular pulse appears, a convulsion may occasionally occur, ocular 
 palsies are seen, and the whole appearance of the case suggests more unmis- 
 takably the presence of grave cerebral disorder. 
 
 The third or terminal stage is marked by increasing stupor, passing into 
 coma. The slow and irregular pulse may continue for a time, to be suc- 
 ceeded by a very rapid pulse toward the end. An occasional convulsion may 
 occur, and this may be followed by more or less prolonged monoplegia or 
 hemiplegia. Ocular palsies are more conspicuous and permanent. Spastic 
 states are present. Opisthotonos and retraction of the head may be present. 
 Vomiting no longer occurs, as a rule. Incontinence of urine and faeces may 
 come on. Food is rejected, or difficult to administer because of involvement 
 of the muscles of deglutition. The fateful aspect of the case increases. The 
 temperature ranges higher or falls abnormally low. Profound coma super- 
 venes, and the child dies either from gradual paralysis of all its vital func- 
 tions or from a convulsion. 
 
 Prognosis. — In tuberculous meningitis the prognosis is invariably unfavor- 
 able. A few authors (Jacobi and others) claim to have seen an occasional 
 
TUBEBCULO US MENINGITIS. 619 
 
 recovery, but such cases must always leave a doubt as to the accuracy of the 
 diagnosis. They only serve at least to emphasize the rule that tuberculous 
 meningitis is one of the most unerringly fatal diseases of childhood. 
 
 Duration. — This disease, as a rule, is rather rapid in its course. Few 
 cases linger beyond the fourth week. Some are fatal within the first ten 
 days, especially if severe convulsions supervene. The average duration of 
 the disease is probably about twenty to twenty-five days. 
 
 Diagnosis. — Tuberculous meningitis may be mistaken for simple infantile 
 convulsions, digestive disorders, typhoid fever, brain-tumor, and hysteria. 
 It is occasionally simulated by pneumonia. It may remotely simulate a few 
 other disorders, but the resemblance is so slight as scarcely to demand notice 
 here. 
 
 Infantile convulsions or convulsions occurring in young children should 
 always suggest the possibility, at least, of tuberculous meningitis. If they 
 occur in children who have previously had them, this possibility is of course 
 more remote. A convulsion in a young child may be due to numerous causes, 
 such as indigestion or a beginning exanthem. The only rule is to watch 
 patiently for the cause, which in most of these instances will usually present 
 itself. In a case of commencing tuberculous meningitis the diagnosis would 
 be established especially by the onset of headache, vomiting, constipation, 
 fluctuations in temperature, mental changes, and by the persistence of these 
 symptoms. 
 
 A careless observer might mistake the obstinate vomiting of tuberculous 
 meningitis for an evidence of gastro-intestinal disorder. But the other symp- 
 toms, such as headache, constipation, and fluctuating temperature, as well as 
 the persistence of these symptoms and the mental changes, should indicate 
 that the disease is not due to gastro-intestinal infection. In the very early 
 stage, however, a mistake is readily made. 
 
 Typhoid fever and tuberculous meningitis may closely simulate each other 
 in young children. The differences in the temperature range, however, are 
 well marked, while in typhoid fever, although headache and vomiting may 
 occur, they are usually associated with some looseness of the bowels, and the 
 slow and irregular pulse of tuberculous meningitis is not noted. The charac- 
 teristic eruption of enteric fever, when present, is a determinative sign. 
 Tympany, so common in typhoid fever, is not seen in tuberculous meningitis. 
 Great care, however, is undoubtedly required to distinguish these two dis- 
 eases, and this can only be done in some cases by patient study during a 
 number of days. 
 
 From brain-tumor, especially a tumor of the cerebellum, tuberculous men- 
 ingitis may be distinguished by its more abrupt onset, its shorter duration, 
 its fluctuating temperature, its slow and irregular pulse, and its obstinate 
 constipation. The headache and vomiting, which might cause it to resemble 
 a cerebellar tumor, are usually of greater intensity at the beginning and of 
 briefer duration in tuberculous meningitis. In this latter disease, moreover, 
 there are not the cerebellar ataxia and other disorders of motion so commonly 
 seen in cases of tumors beneath the tentorium. Optic neuritis, while not un- 
 noted in tuberculous meningitis, is not such a prominent symptom and does 
 not lead to such distinct post-neuritic atrophy as is seen in cerebellar tumor. 
 
 Hysteria, which simulates so many diseases, might possibly itself be 
 simulated by tuberculous meningitis in the child. A little care in observa- 
 tion, however, should clear up the diagnosis. The persistent headache, vom- 
 iting, slow and irregular pulse, obstinate constipation, and elevation of tem- 
 perature would be against hysteria in a child, while an absence of some of the 
 
620 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 characteristic mental and physical stigmata of the great neurosis would 
 usually be noted. It must be recalled, however, that hysteria may compli- 
 cate grave organic diseases, and this might be so in the early stages of tuber- 
 culous meningitis ; but the symptoms just enumerated should guard the physi- 
 cian against error. 
 
 Pneumonia in young children, especially if complicated with marked 
 cerebral symptoms, may simulate tuberculous meningitis. The crucial test 
 is of course the detection of the physical signs of the pneumonia. The 
 brain-symptoms, while intense in pneumonia, are not associated with the 
 characteristic slow and irregular pulse. On the other hand, tuberculous 
 meningitis is more apt soon or late to present ocular palsies and convulsions 
 with paresis. In the early stages, however, the main reliance should be 
 placed upon the physical signs, the rapidity of respiration, the evidence of 
 pain in the chest, and a rather higher and more persistent range of tem- 
 perature. 
 
 Quincke's operation of lumbar puncture has given some satisfactory 
 results. Furbringer in 37 cases of tuberculous meningitis found the tubercle 
 bacillus in 30, thus verifying the diagnosis in 80 per cent, of the cases, among 
 which several were so doubtful, from a clinical standpoint, as not to warrant 
 a positive opinion. In 1 case a creamy pus was obtained, aud this per- 
 mitted the establishment of a diagnosis of cerebro-spinal meningitis. In 
 still another case, with the symptoms of combined myelitis and pneumonia, 
 the pneumococcus was found. 
 
 Morbid Anatomy. — The essential process in tuberculous meningitis is 
 the development of small tubercles. These are really the scenes of activity 
 of the bacilli. These tubercles are usually distributed most freely along 
 the course of blood-vessels, and are consequently located, as a rule, in the 
 pia-arachnoid membrane, and are found especially in the main clefts or 
 fissures of the brain, such especially as the fissure of Sylvius. They vary 
 in size, many being as small as a millet-seed, while others are much larger. 
 In some places, in fact, the tubercles grow together or coalesce. Occa- 
 sionally these large masses form veritable tumors, although this is rare in 
 disseminated tuberculous meningitis. The formation of the tubercles is the 
 primary process. As a secondary process there is inflammation, character- 
 ized by exudation of cells and fibrinous tissue, by thickening and consequent 
 opacity of the membranes, and by the exudation of a copious sero-gelatinous 
 fluid. 
 
 The thickening and opacity of the membranes, especially of the pia- 
 arachnoid, are very marked in tuberculous meningitis. The exudation within 
 the meshes of this membrane is usually yellowish or greenish-yellow in color 
 and of a gelatinous consistency. It contains many cells, the result of inflam- 
 matory action, but these are not usually numerous enough to give this fluid 
 the character of pus. The brain-membranes, in addition to being opaque, 
 are usually the seat of more or less intense hyperemia, Some free blood- 
 corpuscles may also be found in the exudate, and occasionally the fluids may 
 even present a slightly bloody tinge to the naked eye. 
 
 The vascular changes have been studied with great care recently by 
 Hektoen in a series of nine cases. Extensive vascular changes were found 
 in all these cases, and these changes indicated that the invasTon of the wall 
 of the blood-vessel frequently occurred from within. Changes in the intima 
 played the essential part. Tubercles were even found in the intima, accom- 
 panied by extensive endarteritis, the presence of which, without changes in 
 the other layers of the wall, seems to prove that this intravascular lesion is 
 
TUBERCULOUS MENINGITIS. 621 
 
 primary and due to irritating agents circulating in the blood. Endarteritis, 
 however, may possibly develop from an agent acting from without. Tuber- 
 cles on the intima, however, are probably always due to a direct infection 
 from the blood-current itself. In these cases the tubercle bacilli are probably 
 engrafted directly upon the intima. Hektoen concludes that tuberculous 
 endarteritis, with the formation of intimal tubercles, may be due to implanta- 
 tion of the bacilli from the blood. Infiltration may then spread into the 
 muscular coat and the adventitia. On the other hand, tuberculous prolifera- 
 tion in the adventitia may invade the media and the intima — i. e. infection 
 may be from without. The veins are constantly the seat of extensive infil- 
 tration resulting from infection from without. 
 
 The lesions of tuberculous meningitis are usually found at the base of the 
 brain ; hence the disease has been called basilar meningitis. The under 
 surface of the frontal and temporal lobes, the optic chiasm, pons, and 
 medulla, and even the cerebellum, may be obscured by the products of the 
 disease. Sometimes, as already said, the affection passes up the fissure of 
 Sylvius, and may appear on the lateral aspects of the brain. The nerve- 
 trunks are imbedded in the exudate or inflamed membranes. It occasionally 
 happens, however, that tuberculous meningitis is not confined to the base of 
 the brain. Strtimpell and others have noted exceptions to the general rule. 
 
 In many cases the substance of the brain itself is more or less involved 
 in the inflammatory process. Thus there may be a diffused cerebritis 
 beneath the inflamed and opaque membranes. Some areas even of softening 
 and disintegration may be observed. This process, however, is usually con- 
 fined to the cortex. The deep structures of the brain are not, as a rule, 
 involved. 
 
 The lateral ventricles in most cases are distended with fluid. From this 
 circumstance the disease was called acute hydrocephalus by the older observers. 
 The ependyma of the lateral ventricles, however, is not involved. The cho- 
 roid plexus is occasionally the seat of tubercles. 
 
 In brief, the disease-process consists in the formation of tubercles as a 
 result of the specific activities of the bacilli, and a consequent inflammation 
 and thickening of the membranes, with exudation of a characteristic fluid. 
 
 Treatment. — The treatment for tuberculous meningitis is, of course, 
 highly unsatisfactory. We know of no drug that will control the specific 
 action of the bacillus of tubercle. Mercurials, especially calomel, have for 
 a long time enjoyed a reputation in all forms of meningitis. Whether this 
 is based upon any specific action of this drug upon the bacillus it is not pos- 
 sible to state. It is doubtful whether the whole mass of the blood can be 
 rendered so aseptic by mercurial salts as to retard appreciably the activities 
 of this microbe. Certainly clinical experience does not warrant any such 
 claim. This disease is never cured by the most active use of mercurials. 
 In one case I saw salivation to an extreme degree obtained without the 
 slightest beneficial effect being noted. Such heroic treatment, it is needless 
 to say, cannot be recommended. If a mercurial is desired, the most appro- 
 priate is probably calomel, which should be given in doses of from one-fourth 
 to one-eighth of a grain three or four times a day, the effects being carefully 
 noted. Iodide of potassium is probably without value in tuberculous men- 
 ingitis. The activity of the bacilli is not in the least retarded by its use. 
 
 The treatment of the individual symptoms in this disease is of importance. 
 Something, at least, can be done to palliate the suffering of the patient and 
 thus to relieve the distress of the parents. Cold applications to the head, 
 especially an ice-bag, are strongly indicated. This bag should be wrapped 
 
622 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 
 with a few thicknesses of flannel and applied to the vertex. It acts bene- 
 ficially by relieving headache, and possibly also by reducing temperature. 
 
 The vomiting, which is a sudden and urgent symptom at first, is not 
 easily controlled by drugs. It is probably due to irritation of the roots of 
 the vagus nerve, and there is no drug that will control this. 
 
 The obstinate constipation is best relieved by large enemata of warm 
 water and soapsuds. The small doses of calomel before referred to may act 
 favorably also by promoting the bowel movement, but, as a rule, the consti- 
 pation is exceedingly rebellious to drugs. 
 
 The convulsions and general nervous irritability, shown by rigidity and 
 spastic states of the muscles, are best relieved by bromides and chloral. In 
 cases in which convulsions succeed each other with rapidity, and the child 
 threatens to sink into an epileptic status, very moderate inhalations of ether 
 may be given. This agent, cautiously administered for this one purpose, is 
 not open to objection. 
 
 Opium or some of its derivatives can be used with advantage in some 
 stages of the disease. When the nervous symptoms predominate, such as 
 extreme irritability, restlessness, headache, jactitation, convulsions, and 
 spastic rigidity, the full effect of an opiate may be sought. This drug 
 probably acts better than either the bromides or chloral to relieve some of 
 these symptoms, but it has several disadvantages, chief of which is its 
 tendency to still further aggravate the obstinate constipation. 
 
 As the vital powers fail, toward the end of the disease, alcohol in small 
 doses is indicated. It can do little more, however, than support the patient 
 temporarily. 
 
 Baths may be of some benefit. A warm bath during a convulsion is 
 sometimes not without advantage. In cases in which the temperature ranges 
 very high a cold bath may control this symptom and relieve some of the 
 patient's sufferings. 
 
 For the various palsies that appear in the terminal stage of the disease 
 no remedies avail. They are usually indications of grave organic changes in 
 the nerve-centres or nerve-trunks, and then only too truly foretell the end. 
 
 Quincke's operation of lumbar puncture has been tried both for diagnosis 
 and as a means of treatment in tuberculous meningitis. The second, third, or 
 fourth intervertebral space in the lumbar spine is chosen. A needle is 
 plunged through one of these spaces and an amount of fluid withdrawn. 
 Fiirbringer reports his observations upon 86 patients, 37 of whom had tuber- 
 culous meningitis. The puncture should be made on the plane of the junc- 
 tion of the superior and middle third of a spinous process, about two fingers' 
 breadth from the median line. Heubner prefers the lumbar puncture to tap- 
 ping of the ventricles in chronic hydrocephalus.. Rotch and Wentworth, 
 however, report alarming symptoms in a child two years old. After lumbar 
 puncture the patient grew restless, respiration became superficial, the pulse 
 rose above 200, and the skin was cool and livid. The child recovered. 
 Lizard claimed that he succeeded in checking convulsions in a case of tuber- 
 culous meningitis by lumbar puncture. The child, however, died in twenty- 
 four hours. On the whole, this method appears to have value for purposes 
 of diagnosis, but is without permanent benefit to the patient, and is not unat- 
 tended with risks. 
 
 Great care should be exercised in all cases of tuberculous meningitis to 
 guard against bed-sores and the evils attendant upon an overloaded bladder 
 and bowel. In children, of course, the tendency to bed-sores is not so great 
 as in adults, because they can be lifted about more readily. Distention of the 
 
TUBERCULOUS 3IENINGITIS. 623 
 
 bladder is not very common in this disease. It should be remembered, how- 
 ever, that constant dribbling of urine may be a sign of distention ; hence this 
 symptom should never be ignored. 
 
 Jansen reports a case presenting typical symptoms of tuberculous menin- 
 gitis in which the patient recovered under the administration of 900 grains 
 of iodide of potassium a day. W. Hale White reports a case in which two 
 old caseous nodules in the fissure of Sylvius were found in a child dead of 
 tuberculous meningitis. The author infers that the old nodules proved that 
 a former attack had been cured. 
 
 Counter-irritation to the scalp and the back of the neck is useless. It is 
 doubtful whether it even relieves the headache It certainly cannot retard 
 the progress of the disease. 
 
HYDROCEPHALUS. 
 
 By JAMES HENDBIE LLOYD, A. M., M. D., 
 
 Philadelphia. 
 
 Hydrocephalus, or dropsy of the brain, is a condition in which the brain 
 is distended by an excessive accumulation of the cerebro-spinal fluid within 
 the ventricles. This distention of the brain may or may not be accompanied 
 with distention of the skull also. 
 
 Hydrocephalus has usually been divided in the past into several varieties ; 
 thus an acute and chronic variety were recognized. By the former was meant 
 the now well-recognized tuberculous meningitis. This was called acute hydro- 
 cephalus, for the simple and wholly inadequate reason that it caused, as a 
 mere secondary symptom, some accumulation of fluid within the skull. This 
 term has now fallen into well-merited neglect. The term chronic hydro- 
 cephalus was, on the other hand, reserved for the affection which we are now 
 considering and which has already been defined. Chronic hydrocephalus, 
 however, has been subdivided into two forms — the internal and external. By 
 the former was meant that variety in which the fluid is exuded and retained 
 in the cavities of the brain ; by the latter, that form in which the fluid is 
 retained in the subarachnoid space on the surface of the brain. This distinc- 
 tion is now recognized as somewhat artificial and entirely unnecessary. As 
 the ventricles of the brain are practically continuous with the subarachnoid 
 space, through the foramen of Magendie, an excess of fluid in the latter must 
 be associated with an excess of fluid in the former, unless this foramen is ob- 
 structed. True hydrocephalus is the hydrocephalus internus, in which the ven- 
 tricles of the brain, and secondarily the brain itself, and even the skull, are 
 distended with fluid. An accumulation of a slight excess of fluid in the sub- 
 arachnoid space is such a common occurrence in such a large number of path- 
 ological states of the brain that there is no occasion for such a distinctive term 
 for it as hydrocephalus externus. This is the more so because this use of the 
 term serves to beget a confusion of this subarachnoid oedema with the true hy- 
 drocephalic distention of the ventricles of the brain which we are here consid- 
 ering. Among the causes which may determine a subarachnoid oedema are — 
 meningitis, cerebral haemorrhage, brain-tumor, senile atrophy, dementia para- 
 lytica, and gross defects of the brain, such as porencephalon. None of these, 
 except the latter, is a developmental defect, and none of them is attended with 
 an expansion of the skull such as is seen in true hydrocephalus. Finally, 
 hydrocephalus is said by some to be either congenital or acquired. In the 
 former variety great distention of the skull may occur while the child is still 
 in utero, and this may prove a cause of serious dystocia ; in the latter the con- 
 dition arises after birth. But as in either of these cases the essential cause is 
 equally obscure, and may even be identical, the distinction is not important in 
 one sense. In another sense, however, the distinction between an early and a 
 lately acquired hydrocephalus is important. Only in the former cases — i. e. those 
 
 624 
 
HYDROCEPHALUS. 625 
 
 in which the affection originates before the complete ossification of the bones 
 of the skull — can there occur the characteristic hydrocephalic enlargement of 
 the head. Hence this term, hydrocephalus, is practically narrowed down to the 
 condition in which distention of the ventricles of the brain, with distention of 
 the skull, is the essential characteristic, and which can only occur before ossi- 
 fication is complete, and from causes that must still be regarded as obscure. 
 The adult form of the disease — upon which some writers still insist — is prob- 
 ably an entirely different affection from the internal hydrocephalus of early 
 life. It is not a disease at all, but simply a ventricular effusion, such as may 
 be caused, just like subarachnoid oedema, by a variety of diseases, as tumor, 
 haemorrhage, meningitis, and atrophy of the brain. The claim that distention 
 of the skull can occur in adult life must be received with caution, and should 
 not be allowed for cases in which an intracranial tumor has eroded the skull, 
 and perhaps caused slight thinning, or even expansion, at some point in the 
 course of a cranial suture. 
 
 Etiology. — The causes of chronic internal hydrocephalus have not been 
 satisfactorily determined. In the intra-uterine cases all sorts of hypothetical 
 causes have been advanced, such as disease of the uterus itself and even mater- 
 nal impression. It is probable that the same general cause or causes acts in 
 both the pre-natal and post-natal cases. Injury may be one of these causes. 
 Syphilis and alcoholism in the parents may, but are not known positively to, 
 act as causes. Two classes of causes, or rather modes of action of causes, are 
 generally recognized as possible : First, a morbid process, especially in the 
 ependyma, that induces a free exudation of fluid. Such a morbid process may 
 be inflammatory in character, and this is thought by some to be proved by 
 the fact that the ependyma of the lateral ventricles is sometimes thickened 
 and beaded. But the exciting cause, in turn, of this ependymitis has not 
 been stated. Second, mechanical obstruction either to the return flow of 
 blood from the skull or to the free circulation of the cerebro-spinal fluid is 
 looked upon by many as a probable cause of hydrocephalus. With reference 
 to the blood-vessel system this explanation is not merely theoretical, but may 
 be considered as having been demonstrated. Thus any lesion that obstructs 
 the veins of Galen may readily cause an excessive exudation of fluid in the ven- 
 tricles. Tumors, tuberculous exudates or nodules, thrombi, and the various 
 forms of meningitis may act thus. The only difficulty in the way of accepting 
 obstructive lesions as causes of hydrocephalus arises from the fact that they 
 explain so few of these cases. In many instances no obstructive lesion is found. 
 As for the circulation of the cerebro-spinal fluid, it is rather difficult to under- 
 stand exactly what this is, and hence how an obstruction to it can cause dis- 
 tention of the ventricles. It is not positively clear that this fluid constantly 
 circulates through the foramen of Monro, the aqueduct of Sylvius, and the 
 so-called foramen of Magendie. These orifices no doubt permit free communi- 
 cation between the ventricles themselves and between them and the subarach- 
 noid space, but this does not prove that the fluid is circulating through them 
 in a steady stream. It may be a practically stationary body of fluid. The 
 claim that obstruction of either or any or all of these orifices is a cause of 
 hydrocephalus, independent of obstruction of the circulation of the venous 
 blood, needs demonstration. It is highly probable that in cases in which 
 obstruction of the foramen of Monro or of the aqueduct of Sylvius has been 
 found some obstruction of the venous system also existed and may have been 
 overlooked. Browning, 1 however, has recently collected a series of cases in 
 which obstructive lesions at or near these openings have apparently caused 
 
 1 Normal and Pathological Circulation in the Central Nervous System, 1897. 
 40 
 
626 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 distention of the ventricles ; but the lesions in some, at least, of these cases 
 were such as to suggest that the blood-vessels also had been obstructed. This 
 whole subject is still somewhat obscure. 
 
 Symptoms. — The most characteristic symptom of hydrocephalus is the 
 enlargement of the head. This usually begins to show itself in early infancy, 
 before the ossification between the bones of the skull has had time to advance. 
 The head enlarges in all directions, but the distention is usually greatest in the 
 frontal and vertical regions. The head becomes globose in shape, and projects 
 especially in the frontal region. The orbital plates are often somewhat de- 
 flected downward, and this causes a downward deviation of the eyes, which 
 may be almost or quite covered by the lids. The fontanelles and sutures 
 are widely distended, and may bulge from the increased pressure of the fluid 
 within. Some authors describe an alteration in the percussion note of the 
 head ; thus, according to them, there may be a " cracked-pot " sound on per- 
 cussion. The scalp, of course, is greatly distended, and may be thin and 
 smooth and covered with a scanty growth of hair. This enlargement of the 
 head is in some cases immense. In such cases the child is usually quite unable 
 to lift the head. Its great weight and the weakness of the muscles cause it to 
 lie helpless on the pillow. In cases that do not prove fatal in early life gradual 
 ossification may occur, and the patient may live to adult life with an immense 
 cranium. Such a patient at present under my care in the Philadelphia Hos- 
 pital has also a spastic hemiplegia. 
 
 The mental symptoms in hydrocephalus vary much. In the worst cases 
 complete idiocy results ; in the milder cases, in which the process apparently 
 stops and the patient lives for years, there is usually mental impairment. The 
 degree of this impairment varies according to the case. Even the milder cases 
 present some degree of hebetude, inability to learn and to fix the attention, 
 weak memory, and possibly defects in speech. 
 
 In the early acute stage pain is apparently a symptom. The child gives 
 an occasional shrill or piercing cry, the muscles of the brow and face are con- 
 torted, and the appearance is that of suffering. 
 
 The motor symptoms are usually prominent, but they also vary. Different 
 degrees of paralysis are observed. In the worst cases the child may have 
 scarcely any use whatever of the limbs. The extreme distention and deformity 
 of the brain evidently impair the cortex and the motor paths, so that in some 
 cases few if any motor impulses can be either generated or transmitted. In 
 long-standing chronic cases spastic diplegia, hemiplegia, or monoplegia may 
 be present. The patient may learn to walk, but with a much impaired gait. 
 The deep reflexes in such cases are usually exaggerated, and contractures may 
 be gradually established. 
 
 Convulsions are not uncommon. They are seen especially in the early 
 infantile cases, and may even be the immediate cause of death. In the cases 
 of patients who survive, epileptic seizures may or may not be occasional 
 symptoms. 
 
 The eyes may be deflected downward by the deformity of the skull, as 
 already said : they may also be deflected outward or inward, thus presenting 
 various types of strabismus. Nystagmus and oscillatory movements are occa- 
 sionally seen. Complete optic atrophy has been observed, and is caused no 
 doubt by the compression upon and the stretching of the optic nerves, chiasm, 
 and tracts. 
 
 In the worst cases the child may have no control over the bladder and 
 rectum, but this is not a common symptom in cases that survive, unless a low 
 grade of idiocy results. Even in such cases there is not a true paralysis of the 
 
HYDROCEPHALUS. 
 
 627 
 
 bowel and bladder, but only the involuntary evacuation that results from men- 
 tal enfeeblement. 
 
 In grave cases the nutrition of the child suffers. Emaciation may be 
 extreme. The skin is sallow and wrinkled. The face has a pinched and, 
 often, a curiously senile appearance. 
 
 In pre-natal cases the enlargement of the head may be great, and may be a 
 cause of serious difficulty in the labor. Instrumental aid may be required, or 
 even the evacuation of the head. Occasionally, however, labor may terminate 
 
 Fig 
 
 Hydrocephalus with Spina Bifida. 
 
 without assistance, but with long delay and much suffering to the mother. 
 In such cases the head after birth presents an appearance of frightful deformity, 
 caused by its long detention in, and gradual moulding by, the parturient canal. 
 I once saw such a case : the head was elongated, and was like a great sac 
 containing fluid. In the walls of this sac, but not nearly filling them, could 
 be felt the cranial bones. The head was scarcely recognizable as such. 
 
 Occasionally hydrocephalus is associated with other defects in the develop- 
 ment of the cerebo-spinal axis. Thus it may coexist with spina bifida. An 
 example of this is illustrated here (Fig. 1) from the writer's service in the 
 
628 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Methodist Hospital. This association tends to prove still more clearly that 
 hydrocephalus is essentially a developmental defect, rather than the result of 
 an active disease-process. 
 
 The duration of cases of hydrocephalus varies. In many cases the disease 
 is rapidly fatal, the child dying in a convulsion or from inanition. The dis- 
 ease, however, is not always incompatible with a long life. Many patients 
 live to adult life and even to old age. In such cases, along with the deformity 
 of the head, there is some degree of mental and motor impairment. The opin- 
 ion that hydrocephalus — at least the chronic internal form that begins in early 
 childhood — is not incompatible with intellectual vigor, and even genius, is not 
 well founded. Hence it is doubtful whether either Cuvier or Swift, as has 
 been asserted, ever had true hydrocephalus. 
 
 Morbid Anatomy. — As can be readily understood from the nature of the 
 disease, the changes within the cranium are striking. The lateral ventricles 
 are greatly distended, one sometimes more than the other. The ependyma 
 may be thickened, and roughened on its surface. The foramen of Monro and 
 the aqueduct of Sylvius, one or both, have been reported occluded by some 
 observers. In severe cases the brain is stretched so as to be little more than 
 a mere shell. The cortex is thus much deformed ; it is thin and its convolu- 
 tions flattened and its sulci almost obliterated. The essential elements, the 
 neurons and their processes, are diminished in number and degenerated. 
 
 Not only the lateral, but also the third and fourth, ventricles may be dis- 
 tended, but this is not so common. The structures at the base of the brain, 
 as the basal ganglia and the mid-brain, cerebellum, and pre- and post-oblongata, 
 may be compressed and undeveloped. Occasionally the aqueduct of Sylvius 
 is distended in the shape of a funnel, its larger opening being toward the third 
 ventricle. The choroid plexus may be thickened and distended ; but more 
 exact observations are needed on the state of the veins, especially the veins of 
 Galen, in these cases. 
 
 The bones of the skull, in cases in which the distention is great and death 
 has occurred early, are thin and translucent. The diploe may be obliterated. 
 The sutures and fontanelles are widely distended, the former as much even as 
 an inch. Small Wormian bones may be found in some of these spaces. 
 
 The membranes over the vault are usually not involved. At the base they 
 may be thickened. 
 
 The optic tracts, chiasm, and nerves may be totally degenerated. 
 
 In most cases, as reported, the pathological findings, although so striking 
 in appearance, have not satisfactorily demonstrated the primary cause of the 
 disease. They are merely the results of, not the essential cause of, the process 
 itself. This probably consists of some accident in development, the exact 
 nature of which is still obscure. 
 
 Treatment.— Hydrocephalus cannot be cured with drugs. All such reme- 
 dies as purgatives, diuretics, and alteratives have only the slightest temporary 
 effect, if they have even that. It has been claimed that an active diarrhoea 
 relieves the distention, but, even if this be so, it furnishes no safe indication 
 for treatment. Any temporary depletion of the cranium by this means would 
 speedily be counterbalanced by renewed exudation of fluid within the skull. 
 Mercury and iodide of potassium are absolutely inefficacious as alteratives in 
 this disease. 
 
 Surgical means are the most direct and rational, but, unfortunately, they 
 have proved of but little value. Puncture, with drainage bv the anterior 
 fontanelle, has been performed, but the results are usually not permanently 
 beneficial. Keen has employed continuous drainage. Lumbar puncture 
 
HYDROCEPHALUS. 629 
 
 according to the method of Quincke may be tried. Such surgical procedures, 
 however, only act by removing the fluid : they do not reach the cause, and are 
 only too apt to be followed by disappointment, and even by death. Trephin- 
 ing is scarcely called for, as the cranium can readily be opened through the 
 fontanelle. It is too soon yet to judge fairly of the somewhat heroic opera- 
 tion, lately performed by several surgeons, of trephining the occipital bone 
 and draining directly from the fourth ventricle (Browning). Strapping with 
 adhesive plaster is an old-time procedure, but it need only be mentioned now 
 to be rejected. 
 
 Altogether, it must be said that the promise of relief, much less of cure, 
 for hydrocephalus is, with our present knowledge, slight indeed. 
 
ABSCESS OF THE BRAIN 
 
 By FREDERICK PETERSON, M. D., 
 
 New York. 
 
 Abscess may form in any part of the brain, but is much more common in 
 the cerebrum than in the cerebellum, and is extremely rare in the basal ganglia, 
 pons, and medulla. The white substance is more apt to suffer than the gray. 
 As a rule, there is a single collection of pus, but occasionally there are multiple 
 abscesses. 
 
 Etiology. — Abscess is the result of a suppurative encephalitis, due gen- 
 erally to an infectious irritant. The septic material may be derived from 
 many sources, mostly local, but some distant. Of the local causes of brain- 
 abscess, in all cases', ear disease is the most frequent. Next follow, in their 
 order, traumata of the skull and scalp, diseases of the nasal cavity, non- 
 traumatic caries of the cranial bones, and, rarely, orbital disease and intra- 
 cranial tumors. Metastatic abscesses of the brain from distant sources have 
 been known to follow pulmonary gangrene, empyema, typhoid fever, ulcera- 
 tive endocarditis, measles, scarlet fever, small-pox, and other general septic dis- 
 eases. • Males are more commonly affected than females. No age is exempt 
 from the disorder, but it is exceedingly rare during the first year of life. In 
 223 cases collected by Growers, 24 occurred under ten years of age and 72 
 under twenty years. In childhood traumatic abscess is rather more frequent 
 than any other form. In some cases no cause of any kind can be discovered. 
 
 Pathology. — The close connection of structures about the head, such as 
 the scalp, bones, ear, and nasal cavity, with the brain, by means of vascular 
 and lymphatic channels, accounts for the conveyance of septic material from 
 these parts to that viscus. The first stage of suppurative encephalitis is known 
 as " red softening." There are inflammatory oedema and swelling, with lessen- 
 ing of the consistence of the affected part, and reddening from distention of 
 the minute blood-vessels, together with extravasations of blood into the tissues. 
 There is infiltration of leucocytes. At first there is no strict delimitation 
 of the diseased area. The ganglion-cells, nerve-fibres, and neuroglia are 
 secondarily affected and undergo necrotic degeneration. As the encephalitis 
 progresses, the pus-corpuscles become more numerous, until a greenish-tinted 
 abscess is produced. At first the cavity containing the collection of pus is 
 irregular and not strictly demarcated from surrounding tissues by a capsule. If 
 the process continues long enough, the capsule begins to form in the shape of a 
 delicate pseudo-membrane, which gradually becomes thick and firm, and gives 
 the abscess a more or less spheroidal form. Usually some two months are 
 required for the formation of encapsulated abscess, but often a much longer 
 time. The capsule may be completely closed, or there may be a fistulous con- 
 nection with the surface of the brain, or communication by rupture with either 
 the outer surface or the ventricles. Inflammatory and degenerative changes 
 may be found immediately about the encapsuled abscess in the neighboring 
 
 630 
 
ABSCESS OF THE BRAIN. 631 
 
 tissues. These abscesses vary in size from a centimetre to several inches in 
 diameter, though from one to two inches is the usual dimension. Multiple 
 abscesses are generally very small, and are sometimes miliary. There is a dis- 
 agreeable fetor in a considerable number of brain-abscesses. An abscess may 
 remain for long periods of time, even for years, in a stationary condition, or, as is 
 more frequently the case, it enlarges until death is produced by interference 
 with brain functions or by its bursting into the lateral ventricles or upon the 
 outer surface of the brain, when purulent ependymitis or meningitis is excited. 
 
 While blows and falls upon the head are common causes in children, some^ 
 times these traumata leave no traces, and the abscess resulting subsequently 
 may not be considered due to so trifling a source. Even when injuries are 
 visible in the scalp, there may be no hurt of bone apparent, and the abscess 
 may lie deep in the brain. Usually, however, there is actual fracture or 
 necrosis of bone, and the abscess is likely to be superficial and connected with 
 the point of injury, though, even then, it may be isolated deep in the brain. 
 The following case, observed by me in 1884 in a boy of twenty, is an illus- 
 tration : In a street-row he was struck with a small heavy snuff-box on the 
 forehead a little to the left of the middle line, causing a scalp wound and a 
 small circumscribed depressed fracture of both tables. These pieces of bone 
 were removed. The dura was normal. The parts were antiseptically treated. 
 On the third day the temperature rose to 100° F. The wound looked well. 
 On the thirteenth day he began to grow stupid, and three days later he died in 
 coma. The autopsy showed the wound quite healed. The skull was exceed- 
 ingly thin. The opening in the bone was f by J of an inch and contained a 
 trifling amount of pus. The dura mater was perfectly normal, as were also the 
 pia and arachnoid. There was evidence of brain-pressure, but no apparent 
 injury to the superficies. In the white matter of the left frontal lobe an 
 abscess the size of a small hen's egg was found which had no connection what- 
 ever with the exterior of the brain. The ventricles and all other parts of the 
 brain were normal. 
 
 Sometimes a month or even a year or two may pass without the manifesta- 
 tion of cerebral symptoms. This may be explained by supposing that at first 
 a very small abscess is formed, and that it remains quiescent for a long period 
 before development. 
 
 The ear disease giving rise to abscess is usually a chronic disorder that may 
 have existed for years, even as long as twenty-five years, before there is an 
 extension of the trouble and the septic material is conveyed to the brain. The 
 abscess generally forms in the temporo-sphenoidal lobe of the cerebrum or in 
 the cerebellum. Here, too, the common seat of the affection is in the interior 
 of the brain, separated from the point of origin by normal brain-tissues. In 
 some cases it is more or less superficial. 
 
 Symptoms. — The symptoms are of two kinds — those which are especially 
 due to the nature of the process, and those which are shared by abscess in com- 
 mon with other new formations, such as tumors, in the brain. 
 
 In the first category we have the symptoms of inflammation, more or less 
 severe according to the acuteness or chronicity of the inflammatory change. 
 There may be every grade of inflammation, from a severe, rapid, and quieklv- 
 fatal process to the slow, long-continued formation of an abscess, with remissions 
 frequently amounting to complete quiescence and latency. Consequently, 
 symptoms may be furibund or vague and indefinite. Changes of temperature, 
 generally a rise of only one or two degrees, are noted ; sometimes the tempera- 
 ture is subnormal. The pulse may at times be rapid, but is apt more com- 
 monly to be much reduced in frequency. There are anorexia, constipation, 
 
632 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 general malaise, and chilly sensations amounting at times to rigors. Headache 
 fs as frequent as in tumor, and similar in its character. Quite frequently it 
 indicates to a certain extent the position of the lesion, especially when the 
 abscess is of traumatic origin. Sometimes there is vomiting. Convulsions 
 are uncommon in the early, but frequent in the later stages. When general, 
 they show the severity and extent of the abscess ; when Jacksonian, they 
 reveal its position in or beneath the motor cortical area. As the disease pro- 
 gresses delirium may appear, followed by stupor, gradually passing into coma. 
 During the "latent" period — which is noted in many cases, and which may 
 last for months or years — some of the above symptoms may be manifested in 
 slight degree and with intermissions ; but the latent period^ usually terminates 
 abruptly°with all of the indications of acute abscess. Vomiting and giddiness 
 are very common in cerebellar abscess, but may also occur in cerebral forms. 
 Paralysis is present in nearly one-half of the cases. The cranial nerves may be 
 affected. Mental symptoms are more difficult to study in the child than in the 
 adult. 
 
 Optic neuritis is often, but not always, present in cerebral abscess. It is 
 inclined to be milder than in the cases of tumor, and more apt to be unilateral. 
 It is very rarely observed in cerebellar abscess. Altogether, choked disk is 
 not so frequently met with in abscess as in tumor. 
 
 Focal symptoms are not so common as in tumor, because abscess is more 
 often situated in parts iike the temporo-sphenoidal and frontal lobes, where lesions 
 are less apt to give definite objective symptoms, and because the pressure of 
 abscess is often less pronounced and more gradually developed than is the case 
 in tumor. 
 
 Rupture of the abscess usually produces sudden evidences of acute puru- 
 lent meningitis or symptoms resembling those of ventricular haemorrhage. 
 
 Prognosis. — The outlook in all these cases is exceedingly grave. Acute 
 abscess may run its course to a fatal termination in from one week to a month. 
 Chronic abscess with a period of latency runs a very uncertain course, sometimes 
 terminating suddenly, sometimes slowly developing acute symptoms. Even 
 where abscess remains latent for years (in one case twenty years), death is apt 
 to follow from some unexpected renewal of its activity. This may occur even 
 after calcification of its capsule and inspissation of its contents. 
 
 Diagnosis. — Usually a diagnosis may be made from the history of an 
 onset after ear or nasal disease or traumatism of the head, and from the symp- 
 toms characteristic of a suppurative encephalitis and of a foreign body in the 
 brain. In acute abscess it is necessary to distinguish between it and menin- 
 gitis, though this is often extremely difficult where the meningitis is of the sup- 
 purative form. The two may coexist, and both are often due to the same 
 causes. The stiffness of the neck, tendency to opisthotonos and convulsions, 
 and the more frequent implication of the cranial nerves in meningitis must be 
 our guide. In the chronic form of abscess the distinction from tumor is often 
 difficult ; but here, too, the matter of cause is of great importance, though 
 injury may indeed give origin to either. Definitely localizing symptoms, 
 gradually extending and tending to involve the cranial nerves, together with 
 more marked optic neuritis, and the greater frequency of tumor than abscess, 
 are strong indications in favor of the former. 
 
 Treatment. — Surgical procedures are advisable in almost all cases, as 
 abscess is almost certainly fatal, even in cases where latency may last for years. 
 Trephining and the removal of pus, either by free opening and drainage or by 
 the aspirating needle where deeply-seated, have been successful in a number 
 of instances, especially in those following injury to the cranial bones and in 
 
ABSCESS OF THE BRAIN. 633 
 
 ear disease. As prophylactic measures, local bone disease from trauma or 
 aural inflammations should be most thoroughly and conscientiously treated. 
 The mastoid operation should be undertaken at the earliest appearance of a 
 tendency to extension of the inflammatory process to the meninges and brain. 
 Kest. the application of cold, the use of derivatives in the way of counter-irri- 
 tants, and the improvement of general health by means of tonics and hygienic 
 measures, have at times their importance in these cases, but too much reliance 
 should not be placed upon these illusory measures. 
 
TUMORS OF THE BRAIN AND MENINGES, 
 
 By FREDERICK PETERSON, M. D., 
 
 New York. 
 
 Neoplasms within the cavity of the skull are quite as frequent in child- 
 hood and youth as in adult life, and are to be met with even in earliest infancy. 
 They occur in any part of the brain, either as metastatic growths from tumors 
 elsewhere, or as primary developments from the neuroglia, vascular channels, 
 membranes, or cranial bones. Sometimes a scalp neoplasm may erode the 
 bones and affect the substance of the brain, as in a case reported by Braun, 
 where a girl of fourteen had a carcinoma of the scalp which partially destroyed 
 some of the cerebral cortex after eroding the bone. 
 
 Etiology. — Males are much more frequently affected by tumors than females, 
 the proportion as given by M. Allen Starr being two to one. Up to the age 
 of twenty years cerebral neoplasms are commoner before the age of eight 
 years than after it. There are a few cases in which the cause may be ascribed 
 to blows or falls upon the skull, yet the traumatic factor is probably not so 
 great as is generally believed. Heredity, fright, mental strain, and the like 
 seem to have little to do with their origin. Primary tumors of the brain are 
 not as frequent as secondary growths, and tubercles, sarcomata, and carcino- 
 mata are- especially, almost alwa}^s, secondary to neoplasms in other parts of 
 the body. 
 
 Pathology. — In Keating's Cyclopaedia, M. Allen Starr has collected 
 300 cases of tumors of the brain in children from current medical journals 
 and including the collections of Bernhardt and Steffan, thus bringing his list 
 up to the beginning of the year 1888. To these I have added some 35 others, 
 obtained from current literature since that date. Upon these cases and those 
 collected by Starr and upon Knapp's monograph {Intracranial Growths, Bos- 
 ton, 1891) this study is mainly based. 
 
 The comparative frequency of the various kinds of tumor in children may 
 be seen from the following table: 
 
 Form of Tumor. No. of Cases. 
 
 Tubercle 166 
 
 Glioma 42 
 
 Sarcoma 37 
 
 Cyst ..'.'. 35 
 
 Carcinoma H 
 
 Glio-sarcoma 5 
 
 Angio-sarcoma 1 
 
 Myxo-sarooma ■ • 1 
 
 Papillary epithelioma 1 
 
 Gumma 1 
 
 Not stated 35 
 
 Total "3^5 
 
 It will thus be seen that tubercular tumors are by far the most common in 
 
 634 
 
TUMORS OF THE BRAIN AND MENINGES. 635 
 
 children, occurring four times as frequently as gliomata and five times as fre- 
 quently as sarcomata. Another feature of great interest is the rather common 
 development of more than one neoplasm in the same brain. This is particu- 
 larly noteworthy in the case of tubercle, 43 of the above-mentioned 166 cases 
 having presented multiple tumors. Thus in a case described by West, a boy 
 aged fourteen had twelve tubercular tumors in the brain, although there were 
 symptoms of but one. Moreover, sarcomata and cysts are occasionally mul- 
 tiple, 4 of the 37 cases of sarcomata and 4 of the 35 cases of cysts having 
 been found to be multiple. 
 
 Tubercular Tumors. — Though occasionally primary in the brain, these 
 tumors are usually due to secondary infection from tubercular processes else- 
 where, in glands, lungs, or bones. Infection may be carried to the membrane 
 from a tubercular tumor in the brain, thus giving rise to a secondary tubercular 
 meningitis. About a fourth of the cases have multiple brain-tumors, the neo- 
 plasms varying from the size of a millet-seed to that of an egg. Usually round 
 or nodular and encapsulated, they are at times very irregular and diffuse with- 
 out marked delimitation. They nearly always arise from the membranes of the 
 brain, chiefly the pia or its prolongations, though occasionally they are to be 
 found in the interior, and not connected with the meninges. They owe their 
 existence to the entrance of tubercle bacilli by way of the blood-vessels or 
 lymphatics. Like gumma, the tubercular tumor is a form of granuloma, and 
 histologically they are very much alike, the periphery being composed of the 
 round-cells of granulation tissue, giant-cells, and often epithelioid cells, while 
 the centre is caseous. A few tubercle bacilli may be found in the outer parts, 
 and in the tubercle the caseous mass is confluent, while in the gumma there are 
 apt to be several separate caseous masses. Characteristic vascular changes, 
 such as endarteritis obliterans and periarteritis, often aid in the differentiation 
 of the syphiloma. The extreme rarity of gumma in children, as seen in the 
 above table, must be borne in mind. In fact, this one case of gumma was in 
 a youth of eighteen. 
 
 Gliomata. — These tumors come next after tubercle in point of frequency. 
 They are due to a hyperplasia of the peculiar connective tissue of the nervous 
 system, the glia or neuroglia. As is well known, this connective substance is 
 allied in some respects to mucous tissue. The glioma resembles neuroglia in 
 its histological characters, but the cells are more numerous and vary much in 
 size. This tumor is a peculiarly nervous one, growing especially in the central 
 nervous system, though sometimes developing in the eye from the retina. Some 
 gliomata are hard, from the greater proliferation of fibrous tissue, but the major- 
 ity are rather soft and cellular, and are prone to undergo secondary changes, 
 such as fatty degeneration and caseation. Often they are rich in delicate 
 blood-vessels which by rupture give rise to haemorrhages. Such haemorrhages 
 may terminate a case, as in ordinary apoplexy, or the clot may become caseous 
 or form a cyst. The glioma being essentially a tumor of nervous connective 
 tissue, it is found generally in the interior of the nervous organs, almost never 
 connected with the membranes. It grows slowly, and is not malignant, though 
 it has a tendency to return after removal. It is always solitary. When hard, 
 it is usually easy to distinguish it from surrounding brain-tissue; when soft, 
 its limits are not always readily defined. The development of mucous tissue 
 in the tumor leads to the designation of myxo-glioma, and of numerous round 
 and spindle-shaped cells to that of glio-sarcoma. Glioma varies much in size, 
 but may attain greater proportions than any other tumor. 
 
 Sarcomata. — In children sarcoma is not quite as frequent as glioma. It 
 is a rapidly-growing tumor, developing anywhere in the brain or from its mem- 
 
636 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 branes. Usually solitary, it may in rare instances be multiple. It is generally 
 primary, but may be metastatic from sarcoma elsewhere. It may be of any 
 size, but as a rule it is rounded or nodular in shape, and well differentiated from 
 the normal tissues. When fibrous tissue is present in unusual proportion, the 
 tumor is hard; when the cellular elements (round, spindle-shaped, giant, and 
 stellate cells) are more abundant, it is soft. The interior may undergo second- 
 ary changes, such as caseation, fatty degeneration, haemorrhage, and the forma- 
 tion of cysts. The proliferation of particular histological elements gives rise 
 to such designations as nryxo-, glio-, fibro-, lympho-, cysto-, angio-, melano-, 
 round-celled, spindle-celled, and endothelial sarcoma. This neoplasm is 
 malignant. 
 
 Cysts. — Cysts may result from secondary changes in old haemorrhages, and 
 such are frequently found in the brains of children suffering from infantile 
 cerebral palsies and organic idiocy. Newly-formed cysts are generally, how- 
 ever, due to echinococcus or cysticercus cellulosae. These are more common in 
 Europe and Australia, apparently, than in America. The cyst of the former 
 (hydatid) is usually single, but may reach a large size. The cysticercus is 
 commonly small, producing few symptoms, and frequently multiple. The cysts 
 may grow anywhere in the brain, but their development is very slow. Both 
 may be recognized by the peculiar cystic character or by the examination of 
 their hooklets, those of the cysticercus being very much larger than those of 
 the hydatid. 
 
 Carcinomata. — About one-thirtieth of the brain-tumors in children are 
 carcinomata, and are always secondary to growths developed elsewhere, or extend 
 directly from the scalp, bones, or orbital tissues. 
 
 Miscellaneous. — Gumma is apparently so rare in early youth that it may 
 be said not to exist. I have not been able to find in literature any case except 
 the one given in the table, occurring at the age of eighteen years. Aneurism, 
 psammoma, lipoma, papilloma, myxoma, fibroma, osteoma, neuroma, adenoma, 
 cholesteatoma, teratoma, and enchondroma are among the greatest rarities. 
 
 Symptoms. — In very young children the head may be enlarged, either 
 generally, as in hydrocephalus, or there may be actual protrusion of certain 
 limited portions of the skull, as in a case I saw some years ago of extreme 
 oxycephalus. The neoplasms at times erode the cranial bones and bulge out 
 beneath the scalp. Displacement of the eyeball has been noted in cases where 
 the tumor has extended into the orbit. 
 
 But in most cases there is no outward indication of the presence of an intra- 
 cranial growth, and we must diagnosticate its presence by certain general mani- 
 festations, such as headache, vertigo, vomiting, sleeplessness, visual disorders, 
 mental changes, spasms, fever, and the like, and by localizing symptoms, as 
 paralysis, limited spasm, anaesthesia, disordered locomotion, and disturbances 
 in the functions of cranial nerves. Some or all of the general symptoms may 
 be present in almost every case of intracranial tumor, no matter what may be 
 its situation, but the exact seat of the neoplasm must be determined by a care- 
 ful study of the motor, sensory, reflex, and psychic symptoms, and based upon 
 an accurate knowledge of the physiological anatomy of the brain. In rare 
 instances tumor of the brain may exist, giving rise to scarcely any symptoms 
 at all. 
 
 Headache. — This is found in the majority of cases of brain-tumor, accord- 
 ing to Mary Putnam Jacobi in about two-thirds of the cases. It is more fre- 
 quent and more severe in cerebellar growths hemmed in beneath the tense 
 tentorium. The pain is doubtless chiefly due to pressure upon, or irritation of, 
 the sensitive dura mater. It may be in any part of the head, but is usually 
 
TUMORS OF THE BRAIX AND MENINGES. 637 
 
 frontal or occipital, without reference to the seat of the tumor. Occasionally 
 the pain is distinctly and constantly localized at one place, and here there may 
 be tenderness of the scalp and head on percussion, this being under such cir- 
 cumstances of value as a localizing symptom. The pain is dull and continuous 
 or intermittent and severe. Infants probably suffer less, owing to the greater 
 distensibility of the skull; and in them pain may be inferred from restless- 
 ness, irritability, sharp cries, sleeplessness, and burrowing movements of the 
 head. 
 
 Nausea and Vomiting. — These symptoms are noted in from one-fifth to 
 one-fourth of the cases. They are commoner in children than in adults. The 
 vomiting may occur without nausea, irrespective of the taking of food, and 
 intermittently or more or less continuously. It may be associated with vertigo, 
 and frequently accompanies severe headache. It is often brought on by move- 
 ment of the body. It is most common in cerebellar tumor. 
 
 Vertigo. — This symptom is not uncommon, and is particularly frequent 
 with cerebellar neoplasms. As it accompanies so .many divers affections out- 
 side of the cranial cavity, it cannot be regarded as of great diagnostic value. 
 
 Optic Neuritis. — The optic nerves are affected, according to Starr, in 80 
 per cent, of cases of brain-tumor, and hence this constitutes one of the most 
 significant objective symptoms. It must be always looked for, since neuritis 
 may exist to a very great extent without visual defect. Usually double, it 
 may at first appear in one eye, and generally one disk is more affected than 
 the other. This symptom, too, is more common in tumors of the cerebellum 
 and at the base of the brain. It must be remembered, however, that it occurs 
 in other disorders beside brain-tumor, such as meningitis, hydrocephalus, and 
 abscess. Optic atrophy may follow the neuritis. 
 
 Convulsions. — Spasms are of frequent occurrence in the brain-tumors of 
 childhood. They may be slight (petit mat) or severe, limited to certain mem- 
 bers, or general, infrequent or frequent — twenty to thirty per day. General 
 convulsions have no significance as to the seat of the lesion, nor can partial 
 epilepsy (Jacksonian) always be relied upon to indicate the situation of the 
 tumor. 
 
 Mental Changes. — In at least half of the cases some psychical disturbance 
 is manifest. This is naturally much varied according to the amount of brain 
 injury and the age of the child. It may show itself in mere fretfulness and 
 irritability, or there may be dulness, lethargy, hebetude. In some cases there 
 may be delirium, maniacal excitement, or an enfeeblement of the mental pro- 
 cesses amounting to dementia. Somnolence is a common symptom in children. 
 As the disease progresses this often deepens into coma. 
 
 Tremor, insomnia, fever, neuralgia, slow or rapid pulse, disturbances of 
 respiration, and constipation, are symptoms occasionally observed in certain 
 cases, but from these no significant deductions can be made. Increase of head- 
 temperature, local or general, as measured by the surface thermometer, has not 
 yet been sufficiently studied to be practically available as a symptom in brain- 
 tumor. 
 
 Localizing" Symptoms. — After due and careful consideration of these 
 general symptoms, we must examine the focal manifestations, which are either 
 irritative or destructive. Localizing symptoms depend altogether upon the 
 seat of the tumor, whether adjacent to the motor area of the cortex (partial 
 epilepsy) or in the motor tract (monoplegia or hemiplegia) ; in the sensory areas 
 or tracts (anaesthesia, hemianesthesia, hemianopsia, etc.) ; in motor or sensory 
 speech-centres or tracts (aphasia in various forms) ; or, finally, impinging upon 
 cranial nerve nuclei or trunks (paralysis of cranial nerves). 
 
638 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 Gradual onset and spread are the rule in brain-tumor. There are occa- 
 sional exceptions, since a secondary meningitis or a haemorrhage in the new 
 growth may produce a sudden exacerbation ; and there are in rare instances 
 intermissions, remissions, or even retrogressions, in the course of its develop- 
 ment. 
 
 Usually the symptoms of cerebral or cerebellar tumor are unilateral, 
 whereas those of neoplasm at the base affecting the cerebral axis are often 
 bilateral. 
 
 The relative frequency with which tumors affect the various parts of the 
 brain may be learned from the following table : 
 
 Site of Tumor. Number of Cases. 
 
 Cerebellum 105 
 
 Pons Varolii 42 
 
 Centrum ovale 41 
 
 Basal ganglia and lateral ventricles 30 
 
 Corpora quadrigemina and crura cerebri 25 
 
 Cortex cerebri 23 
 
 Medulla oblongata 7 
 
 Fourth ventricle 6 
 
 Base of brain 8 
 
 Total 287 
 
 From this it will be seen that tumors of the cerebellum are slightly in excess 
 of those of the cerebrum proper (105 to 94), while the remaining 88 cases were 
 of new growths in the structures about the base of the brain (crura, pons, and 
 medulla). 
 
 Tumors of Cortical and Subcortical Regions. — These are mostly 
 tubercles, sarcomata, gliomata, and cysts. It is difficult to differentiate cortical 
 from subcortical tumors, the symptoms being about the same, and neoplasms in 
 either portion tending by extension to involve the other. The manifestations 
 will vary according to the functions of cortical centres or descending tracts 
 involved. A study of Figs. 1 and 2 will show what functions will be destroyed 
 by tumors affecting the different portions of cortex there represented, while in 
 Fig. 3 the tracts of fibres which convey impulses to and from these various 
 centres are shown. The chief points to be noted in relation to new growths 
 here may be briefly stated as follows : 
 
 Fig. 1. 
 
 SENSORYa/yo 
 
 -Sphenoidal 
 Lobe. 
 
 Scheme of Localization in Cortex of Convex Surface of Hemisphere. 
 
TUMORS OF THE BRAIN AND MENINGES. 
 
 639 
 
 Tumors of the Frontal Lobe often present no marked symptoms. If they 
 impinge downward upon the olfactory bulb, they may give rise to loss of the 
 sense of smell. There are often mental changes, such as difficulty in concen- 
 
 Fig. 2. 
 
 CUNEUS 
 
 Localization on Inner Surface of Hemisphere. 
 
 trating attention, of thinking connectedly, of exercising self-control, of com- 
 prehending with ease, or of acquiring and retaining new knowledge. Some- 
 times there is great mental torpor and enfeeblement amounting to imbecility. 
 
 Fig. 3. 
 .^OTOR AREA 
 
 Temporal 
 Lobe 
 
 Scheme of Position of Fibre-tracts descending from the various areas. 
 
 But irritation from the frontal cortex may extend backward to the motor areas, 
 and thus produce hemi-epilepsy or general convulsions. If the tumor exerts 
 much pressure backward or extends into the motor area or tracts, paresis or 
 
640 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 paralysis of the opposite side of the body, beginning often as a monoplegia, is 
 developed. 
 
 Tumors Affecting the Third Frontal Convolution of the left hemisphere in 
 right-handed persons give rise to motor aphasia, and occasionally agraphia, of 
 imperfect type. In a slowly-growing lesion, like tumor, the opposite hemi- 
 sphere may often gradually compensate for the loss of function in the affected side. 
 This matter of aphasia, however, is not so important a localizing symptom in 
 children as in adults. From studies I have made of hemiplegia in children I 
 have been led to conclude that during the first years of life (perhaps up to 
 eight or ten years or more) the two hemispheres share equally the motor and 
 sensory functions of speech, and that it is only during adolescence that the left 
 hemisphere (in right-handed persons) takes upon itself gradually the greatest 
 part of this burden. 
 
 Tumors about the Fissure of Rolando, or Motor Area, cause convul- 
 sions or paralysis of the side opposite to the lesion, affecting later the face, 
 arm, or leg, or all together, according to the size and exact position of the 
 growth. These local spasms are known as partial or Jacksonian epilepsy. 
 When the spasm precedes paralysis, the probability is that the cortex is first 
 affected. When the paralysis precedes the onset of spasm, we may reasonably 
 conclude that the neoplasm began to develop in the white matter beneath the 
 cortex. There may be some anaesthesia in connection with the paresis, for it 
 is generally believed that the motor area subserves sensation also to a great 
 extent. In all of these cases it is important to study the character and 
 manner of onset of the spasms, whether partial or general. The aura of the 
 epileptic attack is often of great value in determining the exact seat of the 
 lesion. This aura may be a sensation of numbness or tingling, arising, for 
 instance, in the fingers, hands, or toes. Seguin has given to this phenomenon 
 the name "signal symptom." It indicates the starting-point of the cortical 
 excitation. The order of extension of the spasm after the signal symptom 
 must also be noted, for it indicates the path of extension of the discharge 
 along the cortex. In the paralyzed parts the deep reflexes are of course exag- 
 gerated, as in all forms of cerebral palsy, and there is no actual atrophy, 
 though disuse often leads to a diminution in the size of the affected mem- 
 bers. 
 
 Tumors of the Parietal Lobe, like those of the frontal, often give no localizing 
 symptoms, though the studies of M. Allen Starr and Dana are quite conclusive 
 as to the frequency of sensory disturbances (muscular, tactile, pain, and tem- 
 perature sense) in lesions at this point. Thus at times paresthesia and anaes- 
 thesia may be found in the opposite limbs. But irritation may extend from 
 the parietal area forward to the motor, and thus produce, as in the case of fron- 
 tal neoplasms, partial or general convulsions. And by progressive extension 
 the tumor may invade neighboring structures, and thus give rise to focal mani- 
 festations (motor symptoms by forward extension, hemianopsia by downward 
 extension to the visual tract). In adults tumor in the inferior parietal lobule 
 of the left side produces word-blindness, but this indication is of doubtful value 
 in children. We do not yet possess sufficient information on this point to 
 make any definite statements. The same is applicable to the matter of affec- 
 tions of the auditory speech-centre indicated in Fig. 1. 
 
 Tumors of the Occipital Lobe, in addition to general symptoms, give rise 
 to the very important one of blindness of a half of each eye opposite to the 
 the lesion (homonymous hemianopsia). The blindness is opposite to the lesion, 
 but of course the affected half of the retina of each eye is on the same side as 
 the lesion. From the occipital cortex, also, discharges may extend forward to 
 
TUMORS OF THE BRAIN AND MENINGES. 
 
 641 
 
 the motor area and produce convulsions, as in a case now under the care of Starr 
 and myself, where a lesion (haemorrhage at birth) in a girl of fifteen has given 
 rise to hemianopsia and genuine epilepsy. A tumor by continued growth may 
 affect parts forward, such as the sensory tract (hemianesthesia) and even the 
 motor (hemiplegia). 
 
 Tumors of the Temp or o- sphenoidal Lobe will be apt, especially in chil- 
 dren, to cause no definite localizing symptoms. The sense of hearing has its 
 centre in the first and second temporal convolutions, and smell and taste 
 have been assigned to the tip of this lobe. In adults it is probable that the 
 form of sensory aphasia known as word-deafness may be produced by lesion in 
 one part of the left temporo-sphenoidal lobe. We have still much to learn in 
 this connection in the pathology of childhood. 
 
 Tumors or the Basal Ganglia, Lateral Ventricles and Island of 
 Reil, by their encroachment upon the internal capsule, through which so many 
 important tracts pass (see Fig. 3), are prone to give rise to marked and wide- 
 spread symptoms, such as hemiplegia (when anterior part of capsule is affected) 
 and hemianaesthesia and hemianopsia (when the posterior part of the capsule 
 is involved). Other than these no definite localizing symptoms will be noted 
 in children. At times other structures (such as the cranial nerves) may be 
 affected by pressure or distortion by tumors in these regions. 
 
 Tumors about the Crura Cerebri give rise to a variety of symptoms 
 according to the parts affected and the extent of the lesion. The crus contains 
 the motor and sensory tracts, and the two third nerves (motor oculi) rise from 
 the crura very close together (Fig. 4). Thus if one crus is involved, there will 
 
 Fig. 4. 
 
 OPTIC NERVE 
 
 Fourth Nerve 
 Fifth Nerve 
 
 ^Eleventh 
 
 Structures at Base of Brain, to show topography. 
 
 be complete hemiplegia of the opposite side (occasionally hemianesthesia also), 
 and third-nerve paralysis on the same side (ptosis, etc.). This is called alter- 
 nate or crossed hemiplegia. The optic tract is near at hand also, and if 
 
 41 
 
642 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 affected, which is seldom, will give rise to homonymous hemianopsia (probably 
 with hemiopic pupillary inaction). There may be unilateral incoordination. 
 If the tumor be interpeduncular, some of the symptoms here mentioned will be 
 bilateral. Optic neuritis is apt to develop early in these cases. 
 
 Tumors of the Quadrigeminal Region are among the rarities. Some 
 fibres of the optic nerve enter the corpora quadrigemina, and the centre for the 
 reflex to lio-ht lies in them. Contiguous to them lie the nuclei of all of the 
 motor nerves of the two eyes (third and fourth and fibres of sixth). Nothnagei 
 has made a study of tumors of this region based upon 10 cases collected by 
 Bernhardt and 4 cases of his own, so that the symptomatology is pretty well 
 established. There is staggering gait, resembling cerebellar titubation, and a 
 progressive double ophthalmoplegia. The ataxia may be the earliest symptom. 
 When this is followed by the condition of immovable bulbi, we may be quite 
 sure of our diagnosis. The ocular paralyses may be unequal on the two sides. 
 Nystagmus has been observed in but one case. As the tumor develops, hydro- 
 cephalus is produced by pressure upon the aqueduct of Sylvius. A hemiparesis 
 and hemianesthesia, or irregular paralytic and anaesthetic symptoms, may be 
 produced by extension of the growths toward the crus on either or both_ sides. 
 The optic neuritis and blindness observed are due to the same causes at work 
 in conjunction with neoplasms elsewhere. Three years ago I observed a case 
 of quadrigeminal tumor in a little girl at the New York Polyclinic. Her first 
 symptom was staggering gait. Then there was gradual development of oculo- 
 motor paralysis and blindness, and finally slight hemiparesis. At the autopsy 
 I found a tubercle the size of a hazel-nut in the quadrigeminal region. There 
 was also tubercular meningitis, and a few small tubercles in the cerebellum. 
 The case has been reported by Sachs. 
 
 Tumors op the Pons Varolii give generally distinctive localizing symp- 
 toms, because of the cranial nerves which arise from or are adjacent to it. Thus 
 the third nerve rises from the crus close to its upper border, the fifth from its 
 lateral aspect ; the sixth lies upon it ; the seventh and eighth have their super- 
 ficial origin below its lower border. In the interior of the pons are the motor 
 and sensory tracts for both sides of the body, and the nuclei of several nerves 
 (fifth, sixth, and seventh). If unilateral, the tumor is apt to give rise to 
 crossed paralyses or alternating hemiplegia and alternating anaesthesia. In 
 the upper half of the pons a tumor involving part of the crus may cause 
 ptosis and external strabismus, and anaesthesia upon one side, hemiplegia upon 
 the other. In the lower part the growth may produce internal strabismus 
 (sixth nerve), facial paralysis, and deafness, associated, possibly, with paralysis 
 of the arm and leg of the opposite side. If the tumor affects the root or trunk 
 of the sixth nerve, as may be the case in neoplasms growing from the base of 
 the skull, the loss of power is only in the muscle supplied by that nerve. But 
 if the nucleus of the sixth nerve be involved, there is a peculiar disorder of 
 both eyes ; that is, a loss of power in the internal rectus of the opposite eye 
 also, which is only shown in the impossibility of conjugate movement of the 
 two eyes toward the side of the lesion, since the external rectus of one eye and 
 the internal rectus of the other habitually act together. There is in such 
 lesions a conjugate deviation of both eyes to the side opposite to the lesion. 
 
 A lesion may be so placed in the pons that none of the cranial nerves are 
 involved, and only a hemiplegia is produced, indistinguishable from a capsular 
 hemiplegia. If both motor paths are involved, we may have a paraplegia. 
 Such a lesion is generally accompanied by cranial nerve" involvement on one 
 or possibly both sides. 
 
 Both sensory and motor paths may be involved in primitive lesions, but 
 
TUMOBS OF THE BRAIN AND MENINGES. 643 
 
 these paths are rather widely separated by the deep transverse fibres of the 
 pons, and in such cases the lesion must be large. 
 
 Tumors affecting the Medulla Oblongata are prone to give rise to 
 striking symptoms, such as dysphagia, disturbances of the respiration and 
 pulse, severe vomiting, polyuria, glycosuria, etc., from involvement of important 
 nerves (glossopharyngeal, pneumogastric, hypoglossal, and spinal accessory), 
 and widespread paralyses and anaesthesias from their impinging upon the great 
 motor and sensory tracts contained in the medulla. These symptoms are gen- 
 erally bilateral. 
 
 In growths affecting either pons or medulla all sorts of combinations of 
 symptoms may be observed, too numerous to be described here. The general 
 symptoms, such as headache, vertigo, and vomiting, are common, but convul- 
 sions are rare. 
 
 Tumors of the Cerebellum are among the most common of the intra- 
 cranial growths in children. In the middle lobe they produce cerebellar tituba- 
 tion, a staggering gait much resembling that of a drunken man. Vertigo is 
 also an important symptom, and is more severe and continuous than that caused 
 by growths elsewhere. If the middle peduncle of either side be involved, the 
 staggering is more to one side than the other. Tumors of the hemispheres of 
 the cerebellum give rise to no focal symptoms unless they impinge upon the 
 middle lobe or the peduncles. Cerebellar neoplasms by exteosion are apt to 
 injure cranial nerves about the pons or medulla. Hydrocephalus is often 
 observed : it is due to pressure upon the fourth ventricle or veins of Galen. 
 
 Tumors at the Base of the Brain in the anterior, middle, or posterior 
 fossae are diagnosticated by the symptoms characteristic of pressure upon or 
 destruction of the important structures already mentioned. 
 
 Differential Diagnosis. — The presence, site, and nature of a neoplasm must 
 be determined by the facts given in the preceding pages. Brain-abscess is 
 differentiated by its own peculiar symptoms, described in another part of this 
 volume. Tubercular meningitis sometimes presents symptoms similar to those 
 of intracranial neoplasms, particularly when chronic. Ordinary forms are 
 easily distinguished. Chronic hydrocephalus and cerebral haemorrhage, when 
 unusual in character, may simulate tumor, but careful study of the mode and 
 order of development of their manifestations will generally serve to distinguish 
 them. 
 
 Prognosis. — The prognosis is death unless the tumor be removed. M. 
 Allen Starr gives the average duration of life as two years. Death occurs 
 ordinarily by gradually increasing coma, sometimes with convulsions. Occa- 
 sionally haemorrhage in or about the tumor (especially in gliomata) may 
 terminate life. At times a sudden meningitis (in tubercular forms) brings 
 about a fatal end. Sudden death from unknown cause may occur. 
 
 Treatment. — It is evident that medicinal treatment of intracranial tumor 
 must be in most cases merely palliative. Gumma of the brain being a growth 
 almost never met with in children, the question of antisyphilitic treatment need 
 not be discussed here. While it is always wise to make use of antitubercular 
 treatment in case's suspected to be of this nature, it is doubtful if much can be 
 done to diminish the extent or stop the progress of such neoplasms. 
 
 The routine treatment with cod-liver oil, tonics, fresh air, and the like, 
 should certainly be carried out. It is possible that tuberculin or tuberculocidin 
 may after a time be made available for such cases, but as yet the subject is too 
 new to form any pronounced opinion. Klebs's experience with tubercu- 
 locidin in tubercular disease of the lungs, skin, bones, and joints is pro- 
 mising. 
 
644 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 It is usual in most cases of brain-tumor, of whatever nature, to employ 
 iodide of potassium in 10- to 20-grain doses, three times daily after eating, in 
 an abundance of menstruum (water or milk). Arsenic is occasionally as 
 useful. 
 
 In all cases there are symptoms requiring treatment, such as headache, intra- 
 cranial pressure, insomnia, and convulsions. Antipyrin (2 to 10 grains accord- 
 ing to age), cannabis Indica (J to 3 minims of the fluid extract), and morphine 
 (i to JL of a grain) are good agents in headache due to this cause. Intra- 
 cranial pressure may be relieved to some extent by purges, prolonged warm 
 baths, the hot wet pack, and wet leg compresses. These remedies may quiet 
 headache, vertigo, and vomiting, and will relieve insomnia. The bromides are 
 often useful for insomnia, pain, restlessness, and vomiting, and are always indi- 
 cated, combined with chloral, in cases with a tendency to convulsions. 
 
 The question of surgical interference will arise, for in this lies the only 
 hope of effective relief against impending death. The question of the uses and 
 value of cerebral surgery in children is still under consideration. Operations 
 on the brain in children are more dangerous than in adults. The mortality is 
 very great. There is a greater difficulty in diagnosis and localization in chil- 
 dren. There is a larger percentage of cases of multiple tumors in childhood. 
 Some 25 per cent, of the tubercular tumors of childhood are multiple. Con- 
 siderably more than half of the neoplasms of the brain in childhood are situated 
 in structures in the posterior fossa of the skull, and this region deserves the 
 name of the surgical noli-me-tangere much more in children than in adults. 
 Infiltrating tumors, of no well-defined limitation, are not uncommon. Thus 
 we are forced to the conclusion that we must be much more conservative in 
 advising surgical procedures in the brain-tumors of children than we need be in 
 those of adults. When we have pretty certain evidence of the presence of a 
 solitary new-growth in the cortex or centrum ovale of the cerebrum, we may 
 attempt removal with a fair hope of accomplishing a good result. The large 
 percentage of tumors with a recedivial tendency must, however, not be for- 
 gotten. The whole matter of brain surgery as regards children is still in an 
 experimental stage. 
 
THE AFFECTIONS OF THE NERVOUS SYSTEM 
 DUE TO INHERITED SYPHILIS. 
 
 By CHARLES W. BURR, M. D., 
 
 Philadelphia. 
 
 It has long been known that inherited syphilis may lead to disorders of 
 the nervous system, but the matter was little studied until recent years. Many 
 cases have been reported, and a review of the literature shows that as in 
 the acquired disease any part of the nervous system, central or peripheral, may 
 be affected. It is noteworthy, however, that in children born alive the nervous 
 system is much less frequently the seat of disease than are the other organs. 
 The exact percentage cannot for obvious reasons be determined. We have no 
 positive data concerning the proportion of stillborn or aborted syphilitic infants 
 with lesions of the nervous system. Much remains to be learned of the pathol- 
 ogy of the disease, and the present paper will be confined, in large measure, 
 to its clinical aspect. 
 
 Fournier claims that persistent headache with nocturnal exacerbations is one 
 of the most frequent symptoms. Accompanying it, indeed often its only evi- 
 dence, are extreme irritability, sleeplessness, and spells of screaming. Demme 
 records a case in which the following cycle recurred : headache followed by 
 anger, then torpor, and finally diabetes insipidus. Convulsions are very com- 
 mon, and are probably one of the most frequent immediate causes of death. 
 They are usually bilateral, and with tonic and clonic contractions. Laryngis- 
 mus and tetany, though most apt to be due to rachitis, sometimes occur. Bar- 
 low and Bury record the case of a child who had ten to twelve fits daily from 
 the fourteenth day to the seventh month. In another case which came to 
 autopsy at the fourth month extensive meningeal changes were found ; and in a 
 third, there were no cortical changes in the convexity, but symmetrical gum- 
 mata were present on several cranial nerves. In this last case there were con- 
 vulsive seizures in which the mouth was widely opened and the child became 
 very dusky. 
 
 A few cases of apparently idiopathic epilepsy have been recorded in which 
 the only discoverable cause was inherited syphilis. Gowers cites eight, in six 
 of which the fits began after infancy. Abner Post relates an interesting case 
 in which the attacks began with vertigo, the patient feeling as if she were in a 
 boat which was rocking violently. They lasted about half an hour, and were 
 followed by nausea and vomiting. There was never unconsciousness. The 
 attacks occurred as often as three times a week, and disappeared under the use 
 of iodide of potassium. According to Fournier, the condition is apt to be accom- 
 panied by pain in the head, noises in the ears, dimness of vision, vertigo, and 
 intellectual failure. In the greater number of cases there are added to the fits, 
 sooner or later, other symptoms of cerebral or spinal mischief. 
 
 The differential diagnosis between tuberculous meningitis and syphilis is 
 
 645 
 
646 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 often impossible unless a history of hereditary taint or evidence of it can be 
 found. According to Horatio C. Wood, a general indefiniteness of symptoms 
 and slowness of progression should arouse suspicion, especially if the absence 
 of the pulse retardation indicates that the vault rather than the base of the 
 cranium is in fault. Stoeber gives the following points in diagnosis : Tuber- 
 culous meningitis is rare under one year ; there is seldom palsy at the beginning ; 
 pyrexia is present ; and the pulse is slow. Syphilis, on the other hand, may 
 occur soon after birth ; palsy is often present from the first ; frequently fever 
 is absent, and the pulse is irregular. Stoeber further regards retraction of the 
 abdomen, projectile vomiting, constipation, delirium, contractures, and rapid 
 wasting as characteristic of the former disease. Too often, however, diagnosis 
 can only be made when it is no longer needed. Recovery means syphilis, as 
 it is more probable that an error in diagnosis has been made than that a tuber- 
 culous case has recovered. 
 
 Hemiplegia is infrequent. In Osier's series of 120 cases only 1 presented 
 a pretty definite history of syphilis. On the other hand, in Abercrombie's 
 series of 50 cases at least 4 were syphilitic. Barlow and Bury report an inter- 
 esting case in which there was at first loss of speech with right-sided paresis. 
 After about four months of mercurial treatment the patient recovered almost 
 completely, only to be again attacked, this time by left paresis and loss of speech. 
 Finally there was complete recovery. The authors believe that there was 
 endoarteritis of symmetrical branches of the middle cerebral arteries and 
 degeneration of the cortical centres, especially of the third frontal, on both 
 sides. A case of left-sided hemiplegia in a girl ten years old, described by 
 Hughlings-Jackson, is made doubly interesting by the fact that two years 
 before she had had chorea confined to the same side. Marfan relates a case in 
 a child four months old in which recovery followed two weeks' mercurial treat- 
 ment. Ordinarily, one-sided fits precede the palsy, and quite often convulsions 
 continue in the palsied members ; but it may come on without convulsions — 
 without, indeed, warning of any kind. The child simply falls unconscious, 
 and returns to consciousness palsied. In rare cases even consciousness is not 
 disturbed. On the other hand, there may be restlessness, vomiting, and head- 
 ache. The presence or absence of aphasia depends of course upon the situation 
 of the lesion. 
 
 The most common anatomical basis of cerebral syphilis is endoarteritis and 
 thrombosis with sclerosis and meningeal thickening. Angel Money, however, 
 showed a specimen to the Pathological Society of London in which there were 
 atrophy and sclerosis of the left hemisphere without disease of the arteries or 
 membranes. Gummata are very rare. Rumpf cites but two, and M. Allan 
 Starr in a table of 299 brain tumors occurring in persons under nineteen years 
 of age records one only, and that in a youth of eighteen. It is very probable, 
 however, that the small, yellow, and indurated foci found in various parts of 
 the brain by Chiari and others are gummatous. 
 
 Chronic hydrocephalus is sometimes of syphilitic origin. Buffer in a care- 
 ful review of the literature says that it is mentioned as the cause in 20 per 
 cent, of the cases. Mendel regards it as a frequent cause. Lancereaux speaks 
 of a syphilitic woman who gave birth to several hydrocephalic children. The 
 anatomical cause of the condition is, according to Sandoz, inflammation of the 
 ventricular ependyma and plexuses. In some instances, as in a case reported 
 by Negree, instead of the usual thinning of the cranial bones they are much 
 thickened. Heubner reports a case in which the enlargement of the skull was 
 found post-mortem to be due not so much to dilatation of the ventricles as to a 
 pachymeningitis hemorrhagica. 
 
SYPHILITIC NEBVOUS AFFECTIONS. 647 
 
 Paraplegia may result from disease either of the cord and its membranes 
 or of the spinal column. Fournier records a case of hyperostosis affecting 
 several of the dorsal vertebrae and causing symptoms of compression myelitis. 
 Many signs of syphilis were present, and the patient improved under specific 
 treatment. Laschkewitz cured in two months a palsy of all the extremities 
 due to a similar condition in the cervical region. We have no positive know- 
 ledge whether distinctly syphilitic lesions occur in the spinal cord in the inher- 
 ited disease, or whether the inheritance acts only as a strong predisposing cause. 
 So far as we have been able to learn, no autopsy has ever been made in a case 
 of purely cordal inherited syphilis. 
 
 Dixon Mann reports a case in a boy fifteen years old who, after two years 
 of progressing weakness in the legs, became completely paraplegic and anaes- 
 thetic. Muscular rigidity, increased reflexes, girdle pain, paralysis of the 
 bladder, and a slight bed-sore were present. Fever was absent. The patient 
 recovered after four months' treatment. The author considered the symptoms 
 to be due to thrombosis with circumscribed softening. 
 
 In none of the cases of Friedreich's ataxia recorded in Griffith's paper, 
 and in none which we have seen, is there clear evidence of inherited syphilis, 
 while almost all of the few known cases of locomotor ataxia occurring in chil- 
 dren had distinct hereditary taint. Kemak and Fournier detail several such. 
 
 Moncorvo relates three cases of disseminated sclerosis, two of which im- 
 proved under specific treatment. Ozenne relates a case of latent infantile 
 syphilis which was treated for some time for infantile palsy, and which pre- 
 sented the symptoms of that disease, except that fever was continuously pres- 
 ent. A month's specific treatment resulted in recovery. True acute anterior 
 poliomyelitis rarely occurs in children with such hereditary taint. 
 
 Eustace Smith describes a peculiar form of palsy which affects the anterior 
 branches of the brachial plexus. It causes a more or less complete palsy of 
 the arms, sensation and temperature remaining normal. He quotes two cases 
 from Henoch in which the flexor muscles of the fingers alone retained slight 
 traces of contractility. Under specific treatment the palsy disappeared. In 
 some cases a peculiar twisting of the head backward has been noticed when 
 the child has been placed in a sitting position. 
 
 Some years ago Sinkler reported cases of chorea occurring in syphilitic 
 children, and others have been reported since. The total number is, however, 
 so very small — in Rachford's 61 cases, for example, there being only 1 with a 
 syphilitic family history — that the relation cannot be more than coincidental. 
 
 The peripheral nerves are quite apt to be affected, the lesion being either 
 gummatous or inflammatory. Nettleship reported to the Pathological Society 
 of London a case of a girl in whom there was palsy of the third, fifth, and 
 sixth nerves on one side. She was under observation for four years, during 
 which time the condition persisted. Hutchinson relates two cases of ophthal- 
 moplegia externa, in one of which optic atrophy was present. Bury and 
 Barlow speak of two cases in which the seventh nerve was involved. In one 
 there was found post-mortem symmetrical gummata on the third, sixth, seventh, 
 and eighth pairs. Lawford reports two cases of ocular palsy, and quotes one 
 from von Graefe in which there was complete palsy of the third nerve. 
 
 It is probable that the form of deafness described by Hutchinson as occur- 
 ring within a few years of puberty, and being bilateral, painless, and without 
 discharge, is often due to disease of the internal ear or the nerve. 
 
 The most remarkable case of spinal-nerve disease is that reported by 
 Omerod, in the person of a woman twenty-three years old with a tumor of the 
 median nerve, probably gummatous. 
 
648 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Examination of the cases given above will show conclusively that inherited 
 nervous syphilis is not a disease confined to infancy, but that, on the contrary, 
 the symptoms may first appear at puberty or even later. 
 
 Idiocy is rarer than would be expected. The probable explanation is that 
 given by FoUrnier — namely, that the lesions which would cause it are apt to be 
 fatal. Shuttleworth and Beach found syphilitic taint in only 28 of 2380 cases 
 which they investigated. Ireland regards it as rare. Mental disturbance 
 coming on after infancy is more common. Many cases present the same symp- 
 toms as are found in birth-palsy — spastic paralysis, fits, and weak-mindedness. 
 According to Barlow and Bury, juvenile dementia is more often due to syphilis 
 than is usually recognized. Under the title of " general paralysis occurring 
 about the period of puberty " Wiglesworth speaks of eight cases, the two most 
 prominent causative factors being hereditary and congenital syphilis. Mendel 
 reports a case of mania with hallucinations occurring in a child fifteen years 
 old. 
 
 Diagnosis depends entirely upon the history and the presence of signs of 
 syphilis. There are no pathognomonic symptoms. There is a form of syphilitic 
 pseudo-paralysis, the so-called Parrot's disease, which may be supposed to be 
 of nervous origin if careful examination is not made. The apparent palsy, 
 which may be monoplegic or diplegic, comes on spontaneously after birth with- 
 out fever or convulsions and unaccompanied by any trophic changes. Exami- 
 nation will reveal that there is hyperostosis of the long bones or crepitation at 
 the epiphyses from spontaneous fractures. Parrot believed the condition to 
 be almost always incurable, but this has been disproved in quite a number of 
 cases. 
 
 Treatment is the same as in the acquired disease. 
 
INFANTILE CEREBRAL PALSIES. 
 
 By FREDERICK PETERSON, M. D., 
 
 New York. 
 
 The infantile cerebral palsies are symptoms of a variety of pathological 
 lesions in the brain, just as in adult life such paralyses depend upon processes 
 of different kinds taking place in various regions at different levels in that 
 organ. YTe may have a monoplegia of the face, arm, or leg, or a hemiplegia, 
 or a double hemiplegia {diplegia) ; or we may have the two lower extremities 
 affected (paraplegia), for the amount of paralysis depends upon the extent of 
 the lesion. The cerebral palsies of early life, then, are symptoms merely, and 
 our most important duty in connection with them is to discover the nature of 
 the lesion which causes them, and to localize the seat of the pathological pro- 
 cess within the brain. But while the paralysis is the paramount symptom of 
 the destructive process occurring in the brain, there are many concomitant 
 clinical conditions which it behooves us to recognize and study. As a basis 
 for this article I shall make use of a paper by Dr. Sachs and myself, published 
 in the Journal of Mental and Nervous Disease for May, 1890, in which one 
 hundred and forty cases were analyzed ; and, in addition, shall include the 
 results of my personal observations of considerably over one hundred cases 
 studied at the Vanderbilt Clinic, in my nervous wards at Charity Hospital, and 
 in private practice, making a total of about two hundred and fifty cases. There 
 have been added to the literature since 1890 many valuable articles, clinical, 
 pathological, and therapeutic, dealing with these palsies, from which I have 
 drawn liberally such material as has been deemed useful. 
 
 The French are the earliest contributors to the study of these palsies. In 
 1827, Cazauvielh published a paper upon the palsies appearing shortly after 
 birth, and described the pathological conditions which he found in the brain in 
 six autopsies. He speaks of a primary idiopathic agenesis and of a form of 
 agenesis secondary to a variety of cerebral disorders. Duges, Breschet, and 
 Cruveilhier about the same time and later contributed to the study of the 
 atrophied brains of children, though Cotard did more than other Frenchmen 
 to elucidate the pathology of the infantile cerebral paralyses. He found cere- 
 bral atrophies to be accompanied by yellow plaques, cysts, cicatrices, cell-infil- 
 trations, defects, and primary or secondary diffuse lobar sclerosis. The earliest 
 German writer upon this subject was Henoch, who in 1842 wrote De Atrophia 
 Cerebri ; while the earliest English writer to describe these palsies was Little ; 
 and the earliest American, Sarah McNutt. While these are mentioned as the 
 pioneers in the unravelling of the mysteries surrounding these disorders, there 
 have been contributions of enormous importance by many authors of different 
 nationalities. Kundrat in 1882 produced an able dissertation on porencephaly, 
 a name given by Heschl to the defects of brain-substance found in many such 
 cases. Kundrat differentiated between congenital and acquired porencephaly. 
 
 649 
 
650 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and ascribed the origin of these defects to anaemic necrosis from circulatory 
 disturbances. Audry added much to our knowledge of porencephaly by the 
 collection of 103 cases, while Bourneville, Richardiere, Wuillamier, and Jen- 
 drassik and Marie, on the other hand, carefully studied lobar sclerosis. 
 Strumpell endeavored to explain most cases of spastic hemiplegia of children 
 by his theory of an acute porencephalitis, but this theory is now altogether 
 rejected in the light of recent research, especially that of Sachs. Heine, 
 Benedikt, Bernhardt, Wallenberg, Kast, Hoven, Mobius, Feer, P. Marie, 
 Gaudard, Gibotteau, Ross, Hadden, Gowers, Abercrombie, Ashby, and Freud 
 and Rie, in Europe, have all at various times made valuable additions to our 
 clinical and pathological knowledge of these disorders. In America, Weir 
 Mitchell, Hammond, Sinkler, J. Lewis Smith, Knapp, Lovett, Gibney, J. 
 Madison Taylor, and Imogene Bassette have materially increased the literature 
 of the subject, while the monograph of Professor Osier is a rich storehouse of 
 clinical and pathological facts relating thereto. 
 
 Statistics. — The relative frequency of the cerebral palsies of early life, as 
 compared with the infantile spinal palsies, is in the proportion of more than 
 one of the former to two of the latter, so that it is a much commoner malady 
 than has generally been supposed. Boys are somewhat more frequently 
 afflicted than girls. In 452 cases collected to determine the relative frequency 
 of the various forms, there were 332 cases of hemiplegia, 73 of diplegia, and 46 
 of paraplegia. Cerebral monoplegia is extremely rare, there being only 1 in 
 this entire number. In hemiplegia the right and left sides are about equally 
 aifected, the difference in favor of the right being very small. Thus, of the 
 332 cases of infantile hemiplegia, 175 were of the right and 157 of the left 
 side. In bilateral hemiplegia or diplegia usually all four extremities were 
 affected, but occasionally only three (both legs and one arm). As contrasted 
 with the cerebral palsies of adult life, the enormous frequency of diplegias 
 and paraplegias in the cerebral palsies of early life is striking. 
 
 As regards the age at onset, most cases of diplegia and paraplegia are con- 
 genital, while most cases of hemiplegia are acquired after birth. Two-thirds 
 of the acquired palsies have their onset during the first three years of life. 
 But it is worth while to remember that at least 17 per cent, of infantile hemi- 
 plegias are congenital. With Sachs, I found 5 cases where the hemiplegia 
 occurred at the age of eight years, and 4 cases between eight and fifteen years 
 of age ; while Osier gives 14 cases with an onset between the ages of four and 
 ten years. It is a fact, however, that cerebral palsies are often congenital in 
 origin, though the symptoms may not become apparent until some three or 
 four months after birth, so that doubtless many are ascribed to the first year 
 of life which had their origin during intra-uterine existence or at the time of 
 labor. 
 
 rr^ tiol ° gy * — Tte infantile cerebral palsies fall naturally into three groups : 
 I. Those which have their inception during intra-uterine life ; II. Those which 
 result from injury at parturition ; III. Those which are acquired subsequent to 
 
 The palsies of prenatal origin are numerous. Trauma to the mother 
 during gestation is a frequent cause of injury to the cerebrum of the foetus, 
 benous diseases affecting the mother while carrying the child are common 
 causes, particularly such as are septic in character or interfere with the normal 
 circulation. Thus, fevers like typhoid, pneumonia, uraemic conditions, convul- 
 sions, and similar affections have in my experience resulted in maldevelopments 
 ol the foetal bram. Fright also has seemed, in one or two cases, to have 
 Drought about such a catastrophe, and doubtless other psychical strains may 
 
INFANTILE CEREBRAL PALSIES, 651 
 
 produce like results. Premature birth at the seventh or eighth month was a 
 coincidence in four or five congenital cases. Syphilis is extremely rarely a 
 cause in congenital cases. 
 
 The chief cause of the cerebral paralyses occurring dwing parturition is 
 undoubtedly tedious labor. Delivery is especially apt to be slow in primiparse, 
 and the older the primipara the more tedious is the labor usually. In such 
 cases the long-continued pressure upon the head is apt to work mischief to the 
 child's brain. While instruments are often employed in precisely these con- 
 ditions, and sometimes themselves cause injury to the cranium, it is quite cer- 
 tain that the effects of compression in tedious labor are more commonly the 
 cause of congenital paralysis and idiocy than the application of forceps — a point 
 that the obstetrician should keep in mind. 
 
 The third group of cerebral palsies of children, the acquired paralyses, 
 have a great variety of etiological factors, chief among which are the acute 
 infectious diseases of childhood, giving origin to about 20 per cent, of all 
 cases. These palsies may follow measles, scarlatina, small-pox, typhoid fever, 
 whooping-cough, vaccinia, pneumonia, cerebro-spinal meningitis, gastro- 
 enteritis, and tonsillitis. In pneumonia and whooping-cough the strain and 
 engorgement produced by the coughing are probably important factors in the 
 production of the palsy. Other causes of the acquired palsies are simple 
 fright, trauma to the skull, hereditary syphilis, the status epilepticus, and 
 infantile convulsions. There is no evidence of the existence of an acute 
 polio-encephalitis analogous to poliomyelitis. 
 
 Symptoms. — Onset with convulsions is exceedingly common, the convul- 
 sions sometimes being a concomitant symptom of the brain lesion, and some- 
 times the actual cause. Since so large a proportion of the cerebral palsies of 
 early life are due to lesions affecting the cortex, it is not surprising that con- 
 vulsions should be so frequently observed. For the same reason coma is very 
 common at the onset of the paralysis. The repetition of convulsions as the 
 disorder progresses, especially in the form of epilepsy, is the strongest indication 
 of involvement of the cortex in the pathological process. 
 
 The form of the paralysis is either monoplegia, hemiplegia, bilateral hemi- 
 plegia, diplegia, or paraplegia. The first mentioned is extremely rare. In 
 hemiplegia the leg recovers more rapidly than the arm, as in the adult, but in 
 rare instances the leg is, and remains, more affected than the arm. While the 
 face is frequently included in the paralysis, it rarely continues to be paralyzed, 
 but is among the first parts to recover. Traces, however, of facial paralysis 
 may often be discovered in these cases on close investigation. Strabismus is 
 found at times in all the forms of infantile cerebral palsy. 
 
 In children that have learned to talk, aphasia may accompany the palsy, 
 probably quite as frequently a left as a right hemiplegia, for the motor speech- 
 centre does not seem to be specialized in the left hemisphere during the early 
 years of life. But a defective development of articulate speech is common in 
 all forms, and particularly in the congenital cases and the earliest acquired 
 cases. 
 
 I have observed hemianopsia in two or three cases of infantile hemiplegia, 
 and Henschen has noted several such in his great work. Freud has described 
 two. In the great majority of cases the reflexes on the affected side (knee-, 
 elbow-, ankle-, and wrist-jerks) are exaggerated, but in about 5 per cent, they 
 may be normal, diminished, or absent in the paralyzed extremities. Some- 
 times they are difficult to obtain on account of rigidity and contractures. This 
 is especially true of ankle-clonus and the triceps-jerk. Frequently the deep 
 reflexes are exaggerated also, as in the adult, in the normal as well as in the 
 
652 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 1. 
 
 paralyzed extremities ; nevertheless, they are more marked in the parts 
 involved in the palsy. 
 
 Morbid movements are remarkably common in the paralyzed muscles of 
 hemiplegic and diplegic children. The most frequently observed of these 
 motor disturbances is athetosis, occurring in some 20 per cent, of all cases of 
 hemiplegia, and occasionally in diplegia. Next in point of frequency are asso- 
 ciated movements ; that is, the more or less exact imitation by the paralyzed 
 hand and fingers of voluntary movements made by the normal hand and 
 fingers, and vice versa. Such associated movements are to be observed in 
 healthy children, the tendency in childhood being to make use of the two 
 hands simultaneously ; but in cerebral palsy this tendency is often so greatly 
 exaggerated that such nicely co-ordinated movements as are required in 
 writing and buttoning, when executed by the sound hand are closely imi- 
 tated by the affected hand. Choreiform movements are found in some 5 
 or 6 per cent, of the hemiplegics, but are much more rare in diplegia. Ataxia, 
 rhythmical contractions, tremor, and tetanoid contractions are occasionally 
 to be noted. Nystagmus is found apparently only in cases of diplegia. 
 I have remarked nystagmus in three, and Osier, in two such cases. I have 
 recently described as present in two congenital hemiplegias a hitherto unnoted 
 morbid movement to which I have given the name post-hemiplegic polymyo- 
 clonus. The movements are neither choreiform nor 
 athetoid, but are constant clonic contractions of most 
 of the muscles in the limbs affected, not occurring 
 synchronously, and the rhythm being about that of 
 paralysis agitans (five per second). All of these move- 
 ments indicate interference with motor conduction due 
 to lesions in some part of the voluntary and inhibitory 
 tracts. 
 
 Rigidity and contractures are striking symptoms 
 in almost all these palsies, and for this reason they 
 often fall into the hands of the orthopaedic surgeons, 
 who are besought to remedy the rigidly-flexed elbows, 
 wrists, knees, and the various deformities that interfere 
 with locomotion. Adductor spasm in the thighs, 
 causing cross-legged progression, is nearly constant in 
 diplegia and paraplegia. Talipes equino-varus is the 
 most frequent pedal deformity in hemiplegia. Double 
 talipes equino-varus is observed at times in both diplegia 
 and paraplegia. Rarely talipes equinus and talipes 
 equino- valgus are to be found in hemiplegia. While 
 rigidity with contracture is the rule in all of these 
 forms of infantile cerebral palsy, occasionally, but very seldom, cases will be 
 met with in which the muscles are all completely flaccid. 
 
 The chief trophic disturbance encountered in these cases is retardation in 
 growth of the paralyzed members. The paralyzed limbs do grow, but at a 
 much slower rate than the sound extremities. Hence the disproportion is 
 often very striking. The earlier the onset of the palsy, the greater is this dis- 
 proportion. Another peculiarity that I have noted is that the growth of the 
 whole organism is to a certain extent interfered with, the injury to the brain 
 seeming to stunt development and to prevent the patient attaining his normal 
 stature. The patients are more or less undersized and dwarfed. This point 
 was particularly made evident to me in a case of hemiplegia. The mother 
 brought to me her two boys, twins, six years of age, for the examination of the 
 
 Cross-legged Progression. 
 
INFANTILE CEREBRAL PALSIES. 
 
 653 
 
 one affected. One was a tall, well-built lad ; the hemiplegia boy was small- 
 bodied and fully seven inches shorter than his healthy brother. In all of these 
 cases the muscles of the paralyzed and undeveloped extremities react normally 
 to the faradic current. In many cases the affected limbs may be blue and 
 cold, as in paralysis of the spinal type. A very rare phenomenon in these cases 
 is a hypertrophy of the muscles, usually combined with athetosis. 
 
 Epilepsy is undoubtedly the worst feature of these cases, affecting as it does 
 over 45 per cent, of all forms. In the hemiplegic form fully one-half of the 
 
 Fig. 2. 
 
 Fig. 3. 
 
 Right Hemiplegia, with contracture and retarded 
 growth of arm. 
 
 Right Hemiplegia, from age of nine 
 months, in a woman thirty-six years ; 
 contracture and retarded develop- 
 ment of paralyzed side. 
 
 cases suffer from epilepsy, in diplegia 30 per cent., and in paraplegia 36 per 
 cent, of all cases. In most of them the epileptic seizures are general, but 
 about 15 per cent, of the cases of infantile cerebral palsy suffering from epi- 
 lepsy exhibited the Jacksonian type of seizure. I have observed petit mal in 
 two or three cases. A very important fact has been brought out in this con- 
 nection, and that is that many cases that have been diagnosticated as epilepsy 
 alone are, upon close and careful investigation, found to present traces of a palsy 
 often so rudimentary in character that it has escaped attention. In all cases 
 of what appears to be idiopathic epilepsy search should be made for the residua 
 of paralyses. There are undoubtedly cases of genuine epilepsy having its 
 origin in similar pathological processes which beget the palsies of early 
 life, yet in which no vestige of the organic lesion may be discovered at all. 
 It would naturally be expected that as most of the lesions causing cerebral 
 paralyses in early life are cortical, the epilepsy would be Jacksonian rather 
 
654 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 than general, but the contrary is the case. The reason for this is that the 
 original focal lesion disappears, and a general atrophy and sclerosis take its 
 
 place. . • •, t. 
 
 Feeble-mindedness, imbecility, and idiocy m connection with these palsies 
 are more frequently observed even than epilepsy. The proportion of mental 
 enfeeblement is in a direct ratio to the extent of the pathological process, and 
 hence in the diplegias and paraplegias a large degree of imbecility and idiocy is 
 
 Fig. 4. 
 
 Paraplegia : Photographed in Epileptiform Convulsion. 
 
 usually encountered, for here both hemispheres are involved. In hemiplegias, 
 on the other hand, idiocy is relatively rare, though the lower degrees of feeble- 
 mindedness and imbecility are to be noted in nearly one-half of all cases. 
 
 Among the physical defects, or stigmata degenerationis, are often found 
 various cranial deformities, such as asymmetry of face and skull, microcephalus, 
 leptocephalus, macrocephalus, and cranium proganaeum. The Gothic palate, 
 imperfectly developed or supernumerary teeth, hirsuteness, and deformed ears 
 are other physical evidences of imbecility and idiocy at times encountered. I 
 have, in a paper with Fisher, called attention to the flattening of the skull 
 often observed on the side opposite the paralysis in infantile spastic hemi- 
 plegia. 
 
 Pathological Anatomy. — It is seldom that cases of infantile cerebral 
 palsy come to autopsy at the time, or near the time, of their onset, while there 
 are large numbers that have been carefully studied and described after the late 
 secondary pathological changes have become manifest. But it is precisely the 
 initial lesion that it is very important to understand. For a full discussion of 
 the pathology I would refer the reader to the original paper written by Dr. 
 Sachs and myself, and in particular to the chapter on " Cerebral Hemorrhage, 
 Thrombosis, and Embolism," by the former, in Keating's Cyclopaedia of the 
 Diseases of Children. 
 
 At the post-mortem examination the physician usually finds atrophy of a 
 part of the brain, evidences of sclerosis, one or more cysts, or the condition 
 known as porencephalus. All of these are terminal conditions. Cysts are 
 secondary, as a rule, to haemorrhage. Porencephaly may follow upon haemor- 
 rhage, upon anaemic necrosis, or upon other long-antecedent processes. Atrophy 
 and sclerosis, too, are the results of a variety of initial lesions, such as haemor- 
 rhage, thrombosis, and embolism. While it is barely possible that encephalitis 
 may be a forerunner of some of these terminal conditions, there is not sufficient 
 evidence of the existence of the polioencephalitis of Striimpell to establish it 
 as a fact. We may group the pathological processes, after Sachs, as follows : 
 
INFANTILE CEREBRAL PALSIES. 
 
 655 
 
 Groups. 
 
 Pathological Changes. 
 
 I. Paralyses of intra-uterine onset .... 
 
 II. Paralyses occurring during labor . . . 
 
 III. Paralyses acquired after birth .... 
 
 Large cerebral defects (true porenceph- 
 aly). 
 Hemorrhages of intra-uterine origin (soft- 
 ening?) 
 Agenesis Corticalis. 
 
 Meningeal Hemorrhage (very seldom intra- 
 cerebral) . 
 
 Resulting conditions : meningo-en cephal- 
 itis chronica ; sclerosis ; cysts ; atrophies 
 ( porencephalies). 
 Meningeal Hemorrhage (very seldom intra- 
 cerebral ) ; Embolism ; Thrombosis ( in ma- 
 rantic conditions and occasionally from syphi- 
 litic endarteritis). 
 
 Eesults of these vascular lesions: cysts; 
 softening ; atrophy ; sclerosis (diffuse and 
 lobar). 
 Chronic Meningitis. 
 Hydrocephalus (seldom the sole cause). 
 Primary Encephalitis (Strumpell) (?) 
 
 The pathology of the congenital cases is very clear. In a certain number 
 of cases there is defective development, so that often large portions of the brain 
 are wanting. These defects are possibly due to vascular disorders during foetal 
 life. In other cases the defects are circumscribed, and the chief seat of these 
 lesions is the motor areas. That haemorrhages in the foetal brain during gesta- 
 tion may occur is proven by a case of Cotard. Sometimes the defects are not 
 gross and large, but evident only upon close scrutiny, or are even microscopic. 
 Such instances are the confluence of fissures, simplicity of configuration, 
 exposure of the island of Reil, and the like. In these the chief feature is 
 defect in the highest nerve-elements, the cortical cells, a veritable agenesis 
 corticalis. In all such cases of defective development, whether gross or micro- 
 scopic, idiocy is a marked symptom, while epilepsy is rarely if ever present. 
 The absence of epilepsy may therefore be cautiously considered as an evidence 
 of the nature of the lesion ; it seems to prove a simple maldevelopment, an 
 active process being thus excluded. 
 
 Meningeal haemorrhage is the chief cause of all cases of cerebral palsy 
 occurring during labor, although at autopsy the conditions found may be 
 chronic meningo-encephalitis, sclerosis, cysts, atrophy, or porencephaly. These 
 haemorrhages are produced by the compression which the head undergoes in the 
 pelvis during parturition. In this connection I cannot forbear referring to the 
 recent researches of Herbert R. Spencer. Among 130 stillborn children he 
 found 4 cases of thrombosis of the longitudinal sinus, 1 of intracerebral haemor- 
 rhage, and 53 of haemorrhage from the pia and arachnoid : 29 times there 
 was bilateral haemorrhage, 10 times in the right side of the brain only, 10 times 
 in the left, 1 times into the lateral ventricles, and 6 times limited to the base 
 of the brain. He finds the frequency of central haemorrhage greatest with for- 
 ceps delivery, next with breech presentation, and least with natural head pre- 
 sentations. He believes that softness of the skull-bones and their increased 
 mobility may be determining factors in the production of haemorrhage. In 30 
 cases he found haemorrhages into the spinal canal and cord, and I cannot but 
 believe that some, though a very small percentage, of the cases of paraplegia 
 especially, and perhaps diplegia, may be due to cord lesions at birth after all, 
 and not to cerebral lesions. Otherwise it is difficult to explain the great intel> 
 
656 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ligence and freedom from epilepsy, athetosis, and the like, of a select few of the 
 palsies of these forms. 
 
 As regards the third group, or the acute acquired palsies, hcemorrhage, 
 embolism, and thrombosis are the chief causes of cerebral paralysis in children 
 after their birth, just as they are in the adult. We have apoplexies in child- 
 hood as in later life. I have named these causes in the order of their frequency. 
 Sachs and myself collected and analyzed the results of 78 autopsies in infantile 
 hemiplegia as follows : 
 
 Lesions Found. No. of Cases. 
 
 Terminal conditions : 
 
 Cysts, atrophy, sclerosis 40 
 
 Porencephaly 2 
 
 Haemorrhage 23 
 
 Embolism - 7 
 
 Thrombosis 5 
 
 Tubercle _J_ 
 
 Total 78 
 
 It would be impossible to determine the initial lesion in the terminal condi- 
 tions cited in the above table, but doubtless most of these also were vascular in 
 their nature. Haemorrhage in children and adults differs both as to cause and 
 position. In adults, as is well known, the bursting of miliary aneurisms in 
 atheromatous vessels is the common cause of haemorrhage. Miliary aneurisms, 
 as well as large ones, are occasionally found in children, but in them fatty 
 degeneration of the vessel-walls, as described by Von Recklinghausen, is more 
 frequent. In adults haemorrhage generally takes place in the neighborhood 
 of the internal capsule ; in children, in the meninges and about the cortex. 
 Exceptionally, intracerebral haemorrhages do occur in childhood. In the 
 paralyses following acute rheumatism, endocarditis, and scarlet fever, it would 
 be natural to suspect an embolic process, as in the adult ; and in hereditary 
 syphilis and marantic conditions thrombosis would be the lesion most likely to 
 supervene ; but as compared with haemorrhage both embolism and thrombosis 
 must be looked upon as rather infrequent causes. 
 
 The pathological process here described as so common in children may 
 occur, it must be remembered, without producing paralysis ; for where other 
 parts than the motor areas are involved other symptoms may result, such 
 as epilepsy alone or the various degrees of idiocy. A beautiful case in point 
 was one sent to the Vanderbilt Clinic some two years ago, a young girl with 
 epilepsy and a left homonymous hemianopsia, congenital in origin, showing 
 undoubtedly a cortical lesion over the right occipital region (reported by M. 
 Allen Starr). 
 
 Differential Diagnosis. — The hemiplegic, diplegic, or paraplegic form of 
 the paralyses, the rigidity, the exaggerated reflexes, the normal electric reaction 
 of the muscles, the absence of actual atrophy in the limbs, the presence of 
 epilepsy or idiocy or of morbid movements of one kind or another, usually 
 serve to easily distinguish this disorder from infantile spinal paralysis. It 
 would be only in some of the mildest types of either of these affections, or in the 
 case of a monoplegia, that any difficulty might present itself ; and even here 
 some one or two of these indications would suffice for a diagnosis. It is a fact, 
 however, that in many cases of epilepsy, athetosis, chronic chorea (especially hemi- 
 chorea), and in some of imbecility or idiocy, a hemiparesis is often overlooked. 
 
 Prognosis. — Death as a result of infantile apoplexy is very rare. The 
 duration of life in such palsies is generally short. Few cases of diplegia and 
 paraplegia reach the age of twenty years. A certain small number of hemi- 
 plegics may attain the age of forty years. In most cases it may be stated that 
 
INFANTILE CEREBRAL PALSIES, 657 
 
 the face will recover, and that the leg will become sufficiently useful for loco- 
 motion. In the bilateral palsies the prognosis as regards walking cannot be 
 quite so favorable. Except in the severest forms speech will be recovered 
 more or less perfectly. After the lapse of a few months an idea can be obtained 
 as to the mental state, and as to whether imbecility or idiocy is to be appre- 
 hended. The probability of epilepsy is the feature in prognosis requiring the 
 greatest exercise of judgment. Epilepsy may not appear for a year or two after 
 the onset of the paralysis, and the statistics already given as to the enormous 
 percentage of these cases thus affected must be borne in mind. 
 
 Treatment. — In cases seen shortly after birth, showing symptoms of cere- 
 bral lesion, quiet and careful handling are the chief indications. Minimal doses 
 of bromide of potassium or chloral, or chloroform inhalation may be employed 
 if convulsions occur. In the initial stages of the acute acquired palsies we treat 
 the infantile apoplexy in much the same manner as we would apoplexy in the 
 adult. Absolute quiet, cold applications to the head, and emptying of the 
 bowel are the first steps in treatment. In a few days the bromides may be used 
 to ensure greater rest to the brain, and subsequently, combined with an iodide, 
 continued for some time, though not so long as to interfere with nutrition. In 
 the chronic stages relief is generally sought for secondary conditions, such as 
 deformities from contractures, and idiocy and epilepsy. Excellent results are 
 achieved by tenotomy and orthopaedic apparatus properly applied for the cor- 
 rection of the various deformities, particularly of the lower extremities. In 
 one case in this city athetosis in the right arm was so extreme that the limb 
 was amputated at the shoulder, to the great relief of the patient. Electricity 
 (especially the faradic current) may be used to exercise the paralyzed muscles, 
 and, combined with massage, may go far to prevent and remedy contractures. 
 
 The epilepsy is treated with the usual agents, the bromides, chloral, and 
 the like, though, it must be confessed, without much success. To remedy the 
 mental defects very much can be done by careful manual and intellectual 
 training. In fact, surprising results are often achieved in the development of 
 the mind, speech, capabilities, and character of these cases when placed in 
 schools especially adapted for such purpose, as is evidenced by the experience 
 at Bicetre and some of the private schools in this country. 
 
 As regards surgical procedures in any of these cases, either for relief of 
 epilepsy or for the improvement of the mental condition, the most that can be 
 said at the present time is that, upon the whole, little or nothing is to be ex- 
 pected from trephining, craniectomy, and the like. Possibly future experience 
 may justify operative interference in a small percentage ; but the great majority 
 of infantile cerebral palsies are better left to the treatment of the family phy- 
 sician, to the orthopaedic surgeon, and to the developmental influences of special 
 schools. M. Allen Starr states, in a very recent paper, that he has collected 
 some fifty cases of operations in these and allied conditions (like microcephalus). 
 Many of these he publishes in a list, and an examination of his table showing 
 the results obtained is certainly not very encouraging. In addition to these, 
 Sachs gives notes of three of his own cases operated upon, all hemiplegics with 
 epilepsy, in two of which the seizures returned after operation in three and six 
 months respectively, and the other was not seen after three months, up to which 
 time no attacks had supervened. Wildermuth, however, reports two cases of 
 hemiplegia with epilepsy, in which the seizures seemed to have ceased, one 
 having not been observed for three years and the other ten months subsequent 
 to operation. Besides the apparent futility of cerebral surgery in most of such 
 cases, children do not undergo these operations with as little danger as adults, 
 and the proportion of deaths in the cases thus far published is rather large. 
 
 42 
 
SPEECH DEFECTS AND ANOMALIES, 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Physicians are frequently consulted with reference to absence, deficiency, 
 or peculiarity of speech in children at different ages from birth to puberty, but 
 particularly in those under six or seven years old. Healthy infants acquire 
 articulate speech at varying ages, according to inherited qualities, the general 
 health, the influence of some acute disease, or the surroundings of the child. 
 The child of deaf and dumb parents, or one placed where it hears or sees but 
 little, or one not much thrown into the company of talking adults or older 
 children, may be delayed in the initial stages of articulate language. Some- 
 times at the age of nine or ten months unusual precocity is shown. Ordinarily, 
 about the end of the first year or the beginning of the second, parents and 
 physicians look for some decided efforts at speaking, and when eighteen months 
 or two years have been reached without these, anxiety begins to be experienced 
 and inquiries to be made. The problem presented is by no means a simple one. 
 The physician must carefully weigh a number of facts and must investigate 
 from a variety of standpoints. Starting with the peripheral apparatus of 
 speech and proceeding toward the central nervous system, he must examine into 
 the muscles and nerves of articulation, phonation, and respiration ; the external 
 and internal apparatus of hearing, the nuclear centres of several of the cranial 
 nerves ; and the hearing, speech, and visual centres of the cerebrum and their 
 commissures. He must fully consider the mental status of the child, and if 
 this be settled adversely, the rest may need little attention ; but if not so 
 decided, then, step by step, each of the parts and processes concerned directly 
 or indirectly in the mechanism of speech must receive close scrutiny. 
 
 Is the child idiotic or imbecile ? Is it suffering from aphasia, congenital or 
 acquired at or since the time of birth ? Is the speech loss due to brain arrest ? 
 Is the child simply backward in speech ? Is it suffering from some functional 
 or hysterical affection? Is the child a deaf-mute, and, if so, what is the 
 character of this deaf-mutism ? Is it dependent upon periosteal or bone 
 disease ? Is it the result of old or recent inflammatory disease of the ear, 
 either primary or the sequel of some acute infection, as scarlet fever or measles? 
 Is the deficiency of speech due to paralysis of any of the nerves or muscles of 
 articulation ? Is it a spasmodic affection of these nerves and muscles ? What 
 is the shape and size of the oral cavity, and, if deformity of the vault of the 
 palate, of the pharynx, or of any part of the oral cavity be present, is it or is 
 it not associated with true idiocy and imbecility? Is, as mothers so often 
 wrongly imagine, the child tongue-tied, the .frsenum being so attached as to 
 prevent free movements of this organ? Are adenoids or other growths or 
 enlargements present? 
 
 658 
 
SPEECH DEFECTS AND ANOMALIES. 659 
 
 Speech Defects due to Idiocy or Imbecility. 
 
 Dysphrasia, a term applied by Kussmaul (Ziemssens Cyel. Praet. Med.) 
 to defective or absent speech due to intellectual impairment, is more frequent 
 in children than any of the varieties of aphasia, but is of course usually 
 then an accompaniment of idiocy or imbecility. The child cannot speak, or 
 talks imperfectly or foolishly because of an absence or deficiency of ideas ; it 
 does not speak, as Griesinger has said, because it has nothing to say. It 
 does not know anything that would be ordinarily transmuted into language. 
 Even in idiocy the cortical organs of speech, considered as special areas, are 
 doubtless often arrested or diseased, but in addition other parts of the brain 
 concerned in mentation may be lacking or altered. As is well known to those 
 connected with institutions for the feeble-minded, not a few cases with some 
 intelligence cannot by the greatest perseverance be taught to speak; some 
 can be taught a few words and sentences, but cannot get beyond a certain point, 
 which is limited by their ability to assimilate knowledge. Others perhaps can 
 be taught, parrot fashion, to repeat words or even phrases or sentences of 
 the meaning of which they have no idea. Many interesting observations 
 upon the development of speech have been made in all such institutions. 
 Physicians will be called upon to give opinions not only as to arrest of 
 mental growth, but also as to the capabilities of future development in such 
 children ; and such opinions can be only of value when they are based upon 
 a close study of the conditions present at the time of examination, and of 
 the life and family history of the child. Mierzejewsky, cited by Kussmaul, 
 has described in great detail the history of an aphasic idiot who lived to 
 be about fifty years of age, and whose mental powers and speech were about 
 as developed as those' of a one or one and a half year old boy. He could only 
 give utterance to a few of the simplest syllables. His brain was examined, 
 and resembled in the shape and the arrangement of the convolutions that of a 
 human foetus of the ninth month. The methods of diagnosticating idiocy and 
 imbecility will be considered in the next section, and it will therefore not be 
 necessary to call further attention to this subject here. 
 
 Aphasia. 
 
 The term "aphasia" is sometimes carelessly applied to almost any variety 
 of speech disorder, but it is best restricted to the description of complete or 
 incomplete loss of speech from a local cerebral aifection. It is conveniently 
 divided into motor or expressive and sensory or receptive aphasia, and these 
 have special forms, some of which need to be borne in mind even in studying 
 the disorders of speech from which children suffer. Sensory aphasia has several 
 varieties, as word-deafness and word-blindness, which define themselves, and 
 apraxia or mind-blindness, in which the ability to recognize the use or mean- 
 ing of an object is lost. Aphasia may be both sensory and motor, as when 
 the receptive and emissive sides of the brain are both involved in disease. 
 Agraphia is loss of power of writing; amimia, inability to express thought by 
 signs and pantomime. Besides varieties of aphasia resulting from cortical 
 lesions, others may be due to destruction or interference with the commissures 
 or lines of connection between various centres, and these are known in gen- 
 eral terms as paraphasias or conduction aphasias. Alexia is abolition of the 
 power of reading, as agraphia is that of writing; dyslexia refers to difficulty 
 or fatigue in reading; paralexia, to the misuse by transposition or substitu- 
 tion of either words or syllables, while paramimia is the misapplication of signs 
 
660 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 or pantomime. Whether a child can have alexia, dyslexia, agraphia, or amimia 
 will of course depend on its acquirements — on its ability to read, to write, to 
 talk, or to express itself by gestures or pantomime. Children under six or 
 seven years old would need to be studied from different standpoints from those 
 over this age, and children between six and ten would need a consideration 
 which would differ for those from ten to fourteen. 
 
 True aphasia is sometimes congenital : a deficiency of speech not depend- 
 ent upon lack of general intellectual power may be present, or, in other words, 
 a distinction can sometimes, although perhaps rarely, be made between a dys- 
 phasia and an aphasia of prenatal origin. Broadbent (cited by Kussmaul) 
 has reported an interesting case of congenital aphasia in an intelligent boy. 
 When twelve years of age he understood everything that was said to him and 
 did what he was told to do, but could not, as a rule, say anything but " Yes," 
 " No," and "Father" and "Mother," pronouncing the last two words imper- 
 fectly. He used also an indirect expression in answer to all questions ; occa- 
 sionally he uttered a few other words, such as "All right!" "Thank you," and 
 he had other interesting peculiarities. A few cases have been reported which 
 seem to show that the arrest of the organs of articulation was the particular 
 condition present, as one in which the idiot could utter only a few scarcely 
 intelligible words, but could express himself well by an animated and intelli- 
 gible pantomime, and was even able to report on different things that occurred 
 in the asylum. 
 
 Aphasia the result of acute lesions occurring after birth is rare in children 
 as compared with adults, as haemorrhage, embolism, and thrombosis are of infre- 
 quent occurrence in childhood. Of the three, embolism as an accompaniment 
 of rheumatism or endocarditis is probably the most common. When a lesion 
 does invade the speech-areas of the brain on the left side, the other hemisphere 
 more quickly assumes the lost function than in adults. Sachs (Keating s Cycl. 
 Dis. of Children) records seventeen cases of hemiplegia with aphasia. His 
 experience is in accord with that of Bernhardt, who found that aphasia in 
 children accompanied left as well as right hemiplegia. Other acute causes 
 of aphasia in children are meningitis, tumor, and abscess. Occasionally in 
 tubercular meningitis a form of aphasia or paraphasia may be developed, and 
 this particularly when the tubercular deposits or conglomerates are in and 
 around the Sylvian fossa. Sometimes in basal meningitis in children, owing 
 to inflammation and exudation in the pons-oblongata region, a form of 
 dysarthria or articulatory paralysis will show itself. 
 
 The position and size of a neoplasm will determine how far speech or any 
 of its elements or tributaries will be affected. Word-deafness may be present 
 when the first and second left temporal convolutions or the white matter beneath 
 and near these areas are invaded, although such word-deafness may soon in 
 part be recovered from if the right hemisphere be intact. Word-blind- 
 ness in a child that can read or write may result from a tumor situated in 
 the zone where the left parietal borders the anterior occipital region. Of 
 course a tumor of any description involving the hinder part of the left 
 third frontal will cause more or less motor aphasia in a child that has acquired 
 speech, and may arrest the development of the faculty in one of tenderer 
 years. When the island of Reil is invaded, either aphasia or paraphasia may 
 result. 
 
 Intracranial abscess sometimes is the cause of word-deafness or some other 
 variety of aphasia in children. Such cases are usually associated with aural 
 disease, as when purulent disease of the mastoid or of the tympanic cavity 
 leads to meningeal inflammation and abscess of the temporal lobe. 
 
SPEECH DEFECTS AND ANOMALIES. G61 
 
 Aphasia usually with, but sometimes without, monoplegia or hemiplegia 
 may be a consequence of hereditary syphilis. These cases may have several 
 attacks of aphasia with partial paralysis, sometimes affecting different sides of 
 the body. The lesions are usually the outcome of endarteritis or chronic 
 meningitis, particularly leptomeningitis, and in some cases they are forms of 
 cortical sclerosis with atrophy. The child will often show some of the other 
 well-known evidences of inherited taint, as notched or pegged teeth, crack- 
 ing of the corners of the mouth, flattening of the nose and face, or interstitial 
 keratitis. It is important to recognize the syphilitic origin of these cases, and 
 to treat them accordingly with mercurial inunction, calomel, iodide or bichloride 
 of mercury, or the iodides of sodium or potassium. 
 
 In children, as in adults, aphasia has been noticed in the course of typhoid 
 and other fevers : probably in most of these cases the affection is not due to 
 a local lesion, such as a clot or the closure of a vessel, but to a toxic influence 
 exerted by the poison of the disease on the brain. Bassette (Jour. New. and 
 Ment. Dis., July, 1892) has reported two cases of this kind, one in a girl nine 
 years of age, who in the second week of typhoid fever became markedly deaf 
 without middle-ear complications, and also had partial hemiplegia. The para- 
 lysis passed off, and she began to recover her speech about the sixth week. 
 Another, a girl of five years, ceased to speak for eleven days. 
 
 Children, through fright or other cause, sometimes suddenly become speech- 
 less. Hysterical children also have attacks of mutism. Langdon Down (cited 
 by Ashby and Wright in Diseases of Children) records the case of two brothers, 
 who had spoken well and understood two languages, completely losing the 
 power of speech at the second dentition. 
 
 In rare cases children who are not idiotic, and who are not suffering from 
 either central or peripheral disease, are nevertheless exceedingly slow in learn- 
 ing to speak, and in particular for a long time may fail to acquire the proper 
 method of articulating and pronouncing certain letters and sounds. Some- 
 times such children are otherwise intelligent, and eventually develop up to the 
 full standard of mental health and activity. In some remarkable cases chil- 
 dren, even to the age of ten or twelve, have habitually made use of only a few 
 letters. Deferred or retarded speech development must be distinguished from 
 congenital or acquired aphasia of more permanent type. According to Bastian, 
 cases allied to congenital idiocy are observed, in which, owing to some intra- 
 cranial lesion occurring before, during, or soon after birth, the child's mental 
 condition is greatly degraded as well as his motor power. In some of the less 
 severe examples of this type speech is merely deferred, perhaps until the 
 fourth, fifth, or even sixth year, and may become after a time established 
 in a natural manner. Bateman (Aphasia, or Loss of Speech, 2d ed., 1890) 
 mentions a case of this tardy development of the faculty of speech which came 
 under his observation. The child never spoke at all until he was six years old, 
 and it was thought that he would remain dumb. At six years of age he began 
 to talk, and was able to receive an education suitable to his condition in life, 
 but he grew up to manhood a person of feeble intellectual and also of feeble 
 physical power. 
 
 ECHOLALIA AND COPROLALIA. 
 
 In the affections known as echolalia, coprolalia, and by various other names, 
 convulsive or choreic movements are associated with a sudden explosion of 
 speech. The patient with a grimace, contortion, or violent movement of some 
 kind .suddenly bursts into obscene, profane, or absurd expression. This 
 
662 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 expression may be the echo of something overheard — hence the name, echolalia 
 — or it may be a spontaneous outcry. It is not simply a hysterical affection, 
 controllable and curable, but is a true monomania, the affection of speech being 
 beyond the patient's volition; it could properly be discussed under morbid 
 impulses as well as here. One patient of mine, a boy twelve years old, at 
 times, without warning, would in a street-car or other public place, as well as 
 in private, suddenly give utterance to a filthy expression two or three times, 
 accompanying it with a violent movement of the head, shoulders, and one arm. 
 
 Deaf-mutism. 
 
 Deaf-mutism must be carefully distinguished from aphasia and other affec- 
 tions of speech. While some cases are congenital and associated with more 
 or less profound idiocy, the number of these, according to good authority, does 
 not equal those which can be fairly attributed to disease and accident after 
 birth. Even congenital deafness and dumbness are sometimes due to peripheral 
 causes, as to periostitis, ostitis, or imperfect development of the petrous bone. 
 The semicircular canals or other portions of the internal ear may be wanting 
 or altered by intra-uterine disease. Colloid degeneration of the labyrinth is 
 said to be a frequent cause of the absence of hearing, and various diseases of 
 different parts of the auditory apparatus, particularly of the internal and 
 middle ear, may occur before birth. These cases must be separated from those 
 of mutism or deaf-mutism associated with idiocy. A diagnosis may sometimes 
 be made by careful physical examination and a study of the mental condition of 
 the patient. Purulent otitis or, what is more difficult of decision, Voltolini's 
 labyrinthine otitis, or some other form of labyrinthine non-purulent inflamma- 
 tion, may cause absolute deafness, and owing to this deprivation the child may 
 be supposed to be mentally deficient. Indeed, such a child may, under unfa- 
 vorable circumstances, fail to develop to any considerable degree. A process 
 of experimental training of the senses which are left will sometimes enable a 
 decision to be reached in a comparatively short time. The patient who is simply 
 deaf-mute, from whatever peripheral cause, will under proper incitements be 
 able to fix his attention and show intelligent interest in his surroundings. 
 
 The exact age under which a child will lose its speech because of loss of 
 hearing cannot be absolutely fixed ; but when total deafness is caused by 
 purulent disease of the ear or other destructive affections before the age of six 
 or seven years, the child is likely to become mute as well as deaf unless special 
 training has at once been started, and even in spite of this a certain degree of 
 loss or imperfection of speech will result. The original capacity and the 
 acquirements of the child at the age when deafness occurs will of course have 
 a bearing upon the question of deaf-mutism. Occasionally children who have 
 had scarlet fever, measles, or infectious diseases at the age of two or three 
 years, and have become totally deaf in consequence, are supposed to be idiotic. 
 Such children, if naturally intelligent, will exhibit great interest in everything 
 that comes within the range of the senses that are left. Slow or stupid chil- 
 dren deprived of hearing and speech, particularly if treated with neglect or 
 indifference, will sometimes sink into a state of inertia which simulates a true 
 imbecility or fatuity, leaving them with defective mental powers. A physician 
 should be acquainted with the usual time when a child of average mental capa- 
 city acquires the ability to respond to general sounds and noises, and then 
 to special sounds, voices, and eventually to definite words, and also when it 
 first gives vent to feelings of pain or pleasure, when it makes special response 
 to particular sounds, when it imitates sounds connected or not connected with 
 
SPEECH DEEECTS AND ANOMALIES. 663 
 
 ideas, and when, finally, speech becomes a method of expressing centrally 
 initiated thought, no matter how elementary this may be. It is not as difficult, 
 as at first sight might appear, to learn to follow and analyze such processes of 
 development and to determine as to their retardation or advancement. Mothers 
 acquire great facility in this way by comparison of the progress of their dif- 
 ferent children. 
 
 Preyer {The Mind of the Child, part I., transl. by H. W. Brown, 1889) has 
 made a practical study of the development of the different senses and mental 
 faculties, based largely upon the close study of his own child. According to 
 him, the new-born are always deaf, because of temporary local conditions, 
 such as lack of air in the tympanic cavity, collections of liquid or gelatinous 
 substances in the middle ear, and closure by foreign matter of the external 
 auditory canals. Whether this be absolutely true or not, it is certain that all 
 healthy children in a few hours or in a day or two at least react to impressions 
 of sound. Of fifty children who were tested by Mollenhauer, ten, less than 
 twelve hours old, reacted to a brief disagreeable sound. Preyer was not con- 
 vinced until the first half of the fourth day that his child was not deaf. In the 
 eighth week he showed pleasure at piano-playing, and in the ninth the sound 
 of a repeating watch aroused his attention to the highest pitch, while in the 
 eleventh week he moved his head in the direction of the sound heard ; and 
 soon this was always done with great promptitude and certainty. After a half 
 year he enjoyed single notes and military music, and soon he showed evidence 
 of intellectual advance. After the first year the child rapidly advanced in his 
 exhibition of logical activity in connection with hearing. The statement that 
 children from three to four months old possess normally very slight capacity 
 for hearing must be pronounced false, according to Preyer, for long before the 
 third month the human voice is heard by the normal infant, and before the 
 close of the first week normal children react to the stimulus of loud sound. 
 
 Kussmaul distinguishes three periods in the development of articulation. 
 Within the first four months, and about the time of the earliest movements of 
 prehension, children give vent to spontaneous sounds indicating their feelings 
 of joy. These are chiefly lip and vowel sounds, but sometimes they are also 
 lingual and palate sounds. In a second period these savage noises, are grad- 
 ually crowded out by the conventional sounds of the national language, but 
 even these are of a very simple character. Some of them are imitated and 
 some are not. With the commonly used words ma, ma, and pa, pa, the child 
 at first does not connect any idea, but by degrees learns to do this. At a third 
 stage speech becomes an expression of thought, a child learning to associate 
 certain definite objects with the words acquired by practice. All this may be 
 accomplished in the most elementary way by the end of the first year. 
 
 "Sounds such as m-m, ba-ba, da-da," say Ashby and Wright, "may be 
 repeated in a meaningless sort of way, but before long are applied to persons 
 and things. During the second year the vocabulary increases fast, and the 
 child quickly imitates and repeats the words it hears, so that by the end of the 
 second year it not only uses a number of words, but can string together a few 
 nouns and adjectives or has learned the meaning of short sentences. At this 
 period, and for the next year or two, words are indistinctly or improperly 
 pronounced, with a tendency to clip them short or to drop consonants. Some 
 consonants present greater difficulty to the young child than others, and are 
 constantly dropped out of words ; thus s, especially when it precedes another 
 consonant, is omitted, as cool for school, kiveek for squeak, no for snow. Difficul- 
 ties often arise with the aspirate dentals, as th and sh. Ruth becomes roof; 
 the vibratory consonant r is a great stumbling-block, and the distinct pronun- 
 
664 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ciation of it is perhaps never acquired ; grub is apt to become gwub, and roof, 
 
 woof. 
 
 Affections of Speech due to Peripheral Paralysis. 
 
 After acute infectious diseases, and particularly after diphtheria, palatal or 
 pharyngeal paralysis may be present. Occasionally an attack of diphtheria is 
 overlooked or supposed to be some other throat affection, and even so-called 
 latent cases sometimes result in forms of paralysis. Facial paralysis in 
 children would be determined by the appearance of the face, and indeed the 
 affection of speech in such cases is usually very slight. Lingual paralysis of 
 peripheral origin is rare both in adults and in children. 
 
 Stuttering and Stammering. 
 
 The presence and meaning of stuttering and stammering in children may 
 demand careful consideration. Boys are much more likely to be afflicted with 
 this disorder than girls. Stuttering can be distinguished from stammering, 
 although this distinction is often not made. According to Kussmaul, individ- 
 ual sounds are difficult for the stammerer, but not for the stutterer, with the 
 latter the syllabic combinations offering the greatest obstacles. In stuttering 
 a spasm accompanies the impeded utterance, but not in stammering ; and 
 greater nervous embarrassments underlie stuttering. Other differences are 
 given by Kussmaul, but the one which is perhaps of the most practical import- 
 ance in making a differential diagnosis is that stammering is often accompanied 
 by anomalies of the tongue, lips, and articulating organs in general, while 
 malformations, defects, paralysis, etc. are rarely observed in connection with 
 stuttering. It is important for the practitioner to study the duration, possi- 
 bility of improvement, and underlying causes of such defects when presented 
 by young children. Usually stuttering does not show itself so as to attract 
 attention before the age of six or seven, although rare cases have been observed 
 in young children. Sometimes stuttering or stammering is a temporary affec- 
 tion, coming on in children who have been overworked or undernourished or 
 both, who have been subjected to unusual strain or excitement, or who have had 
 an attack of fever ; and in the last case it may or may not be curable. Some 
 forms of stuttering are distinctly hysterical, and may be relieved by attending 
 to the general nervous health of the patient. The condition of the tongue and 
 mouth of a little patient who has been attacked with a spasmodic chronic dis- 
 turbance of speech should not be overlooked, as now and then some affection 
 of the tongue, lips, and palate may be the cause of the difficulty. A spasm of 
 the muscles of articulation and deglutition may cause an affection of speech 
 that will simulate ordinary stuttering. Putting aside all these causes of tem- 
 porary and, it may be, remedial forms of spasmodic utterance, the vast majority 
 of cases will be found to depend upon some original defect in the central 
 nervous apparatus. By prolonged and careful training a few of these cases can 
 be cured, others can be helped, while a large percentage are absolutely beyond 
 remedy. 
 
 Deformities and Defects in the Mouth and Pharynx. 
 
 Sometimes in children who are not mentally defective the palate, and even 
 the jaws, may be of some particular shape, interfering to some extent with easy 
 and perfect speech. The possibility of such cases should always be remem- 
 bered, but, on the other hand, it should be clearly before the physician that 
 
SPEECH DEFECTS AND ANOMALIES. 665 
 
 among the commonest somatic evidences of idiocy and imbecility are the shape 
 and condition of the palate and jaws. In some types of congenital idiocy both 
 upper and lower jaw may be narrow, the roof unusually vaulted or gothic, while 
 in others the vault may be unusually low and flat. All varieties of palatal 
 deformity or aberration are present in various types of idiocy. Teeth also are 
 likely to be imperfect in such cases, and the tongue may be disobedient to the 
 behests of the will. A fair judgment of the mental status of such a child and 
 the meaning of its defective speech can often be reached by a study of these 
 peculiarities and deformities of the head, face, mouth, tongue, teeth, jaw, and 
 palate. 
 
 Mothers are always much inclined to regard a defect of speech in their 
 children as due to what is popularly called tongue-tie. In rare cases a frgenum 
 which reaches too far forward may be present and cause some interference with 
 the pronunciation of a few sounds ; in still rarer cases the tongue itself may 
 be congenitally short or deformed, but such conditions are easily determined or 
 dismissed by careful examination. 
 
 Adenoid Growths. 
 
 Adenoid growths of the vault of the pharynx may be the cause of diffi- 
 culties and peculiarities of speech, as well as of interference with hearing 
 even to the extent of deafness. It will happen now and then that a child of 
 two, three, or four years of age, supposed to be idiotic or imbecile, will in 
 reality be suffering from adenoid deaf-mutism, the lack of mental development 
 being apparently due to privation of two of the most important channels of 
 communication with others. In all doubtful cases careful examination of the 
 mouth should be made. Even if the deafness be not curable, great relief will 
 be afforded to the parents by the knowledge that the child is not idiotic, and 
 special efforts can be made at training and education in accordance with the 
 principles and methods which bear the most fruit in dealing with deaf-mutes 
 who are not primarily deficient in mind. 
 
 Various impediments in enunciation and pronunciation may also result from 
 the peculiar obstruction produced by these papillomata when of large size. 
 The voice is often considerably changed, and in enunciating certain letters 
 muffling may occur; but hasty opinions should not be given as to the future 
 simply because of the discovery of these growths, as they are sometimes present 
 in idiotic children or in stammerers or stutterers. 
 
 Bad Habits of Speech. 
 
 In studying cases of imperfect or nervous utterance attention should be 
 given to the subject of bad habits of speech. Children, through carelessness, 
 through the foolish management of those around them, or of their own motion, 
 may acquire certain habits of speech which will cling to them to such an extent 
 as to become serious impediments in the way of development of good methods 
 of speaking. Among these habits are frequently hesitating, unduly repeating, 
 drawling or hurrying, using babyish or foolish expressions. Children should 
 be coaxed or disciplined out of such habits when once acquired, but it is far 
 better not to let them take possession of the child. 
 
 Treatment of Speech Defects. 
 
 The treatment of different forms of defective speech must depend upon the 
 nature and degree. Aphasia from an acute lesion, such as hemorrhage or' 
 
666 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 embolism, or as one of the effects of inherited syphilis, may often be benefited 
 by time, medicine, and training. The medicinal treatment, after the first 
 period of rest and care during the apoplectic stage, would be chiefly the use of 
 absorbents and tonics, such as iodides, arsenic, iron, and strychnine. Diligent 
 efforts should be made to train an aphasic child. Even some cases of congenital 
 origin can under appropriate and persistent training be much improved. Here 
 the diagnosis as to the presence or absence of true idiocy, and as to the degree 
 of mental deficiency, is of great importance in deciding as to how far to push 
 the treatment by efforts at education and training. In aphasia coming 
 on gradually with more or less dementia in a child previously bright, or at 
 least ordinarily intelligent, the probability of inherited syphilis should ahvays 
 be considered with the view of judiciously using iodide of potassium, iodide 
 of iron, and similar remedies. The diagnosis of acquired deaf-mutism having 
 been made, institutional or very careful individual treatment should at once 
 be given. The oral system of educating deaf-mutes is particularly valuable 
 for such patients, and much advance in the direction has been made in recent 
 years. Great patience and skill are required even in acquired deaf-mutism. 
 Some congenital cases improve, others make no advance, the former being 
 cases in which the causes, whether prenatal or at the time of birth, have acted 
 upon the organs of hearing or their encasements, and not upon the brain as a 
 whole. It is said to be best to commence the instruction of congenital deaf- 
 mutes at the age of about six years, but neglect of some training even before 
 this age may at times be a great disadvantage. Practically, instruction should 
 be begun as soon as it is possible to engage the attention of the child, but the 
 amount of this instruction should be carefully considered. Where there are 
 special impediments of speech, instruction directed to the relief of these may 
 be successful. Of course all local surgical conditions should be carefully 
 attended to, such as the rare cases of attached frsenum, and those conditions 
 which are more common, such as enlarged tonsils and naso-pharyngeal adenoids. 
 Cleft palate and other forms of hard or soft palate must receive the attention 
 of the surgeon and surgical mechanism. Stammering and stuttering can occa- 
 sionally be greatly benefited by treatment, although in some cases all methods 
 prove to be discouraging failures. The greatest attention should be paid to the 
 maintenance of the best physical health, as by good food, careful hygiene, mus- 
 cular and respiratory gymnastics. Systems of respiratory and vocal exercises 
 are given in special works on the subject. Such treatment must necessarily 
 be in the hands of one who has specially trained himself to carry it out. 
 
IDIOCY AND IMBECILITY 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Idiocy. — Three great classes of mental arrest or deficiency are known as 
 idiocy, imbecility, and cretinism. Idiocy is an affection, either congenital or 
 acquired in very early life, characterized by extreme mental deficiency, although 
 it may be of varying grades of severity. Sometimes the idiot scarcely rises in 
 brain power above the level of the lower animals, or he may be able to some 
 extent to take care of himself, or again he may be capable of limited intellectual 
 improvement. The mental deficiencies of idiocy, as a rule, go hand in hand 
 with physical infirmity. 
 
 " The term idiocy," says Langdon Down (Tukes Diet. Psychol. Med.), " has 
 a very vague significance. It is associated in many minds with one type only 
 of mental and physical condition, very often an imaginary type or one wilich 
 rarely exists. It will be well to break down such contracted views and to 
 efface the incorrect and distorted image. Looking around a large assemblage 
 of children whose mental condition brings them under this generic term, it is 
 very evident that they can be broken into well-marked groups, and that 
 instructive life-pictures may be drawn of typical representations of this inter- 
 esting class. Looked at en masse, they would give the impression of being 
 heterogeneous to the last degree, but it will be found on closer investigation 
 that it is possible to arrange them into groups with strong natural affinities 
 among the constituents, and that in many cases a very remarkable family like- 
 ness may be traced." 
 
 The terms "imbecility" and " feeble-mindedness " may perhaps be regarded 
 as nearly synonymous in common medical usage. Although between idiocy 
 and imbecility no absolute line of demarcation can positively be drawn, a dis- 
 tinction is made for some practical purposes in clinical medicine and medical 
 jurisprudence; but it is not correct to attempt to differentiate idiocy and imbe- 
 cility by regarding the former as congenital and the latter as due to some cause 
 acting after birth. Imbecility, like idiocy, may be congenital, developmental, 
 or accidental, but true imbecility is nearly as often congenital as idiocy. Im- 
 becility is therefore best defined as an affection congenital or acquired very 
 early, and characterized by mental deficiency less in degree than idiocy. It 
 must be distinguished from dementia, which in rare cases comes on in children 
 who have been born with average capability and intelligence. Under congen- 
 ital imbecility Clouston (Clinical Lectures on Mental Diseases) places cases 
 which show every degree of mental deficiency, from the smallest amount of 
 mental weakness down to idiocy. Such imbeciles may, according to this 
 authority, have attacks of maniacal excitement or of melancholia ; they may 
 become dangerous and even homicidal ; they may after an attack have secondary 
 stupor, or may become demented as compared with their primitive condition; 
 and they are often terrible masturbators. The clowns and fools of all ages 
 would, as a rule, come under the head of imbeciles. 
 
 667 
 
668 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The medico-legal aspects and bearings of idiocy and imbecility should not 
 be entirely neglected in general medical works, as not infrequently the family 
 physician is the first to be called to give an opinion, which may have present 
 or future importance, with reference to the mental status of the child under his 
 care, although the more difiicult and intricate problems associated with ques- 
 tions as to the mental capacity of the idiotic and feeble-minded are generally 
 submitted for final decision to medical and legal experts. Ingenious efforts to 
 frame legal definitions of idiocy which would stand the test of experience and 
 practice have from time to time been made. The idiot, for example, has been 
 designated by judicial authority as one who from his nativity by a perpetual 
 infirmity is non compos mentis ; or one who cannot count or number twenty 
 pence, or tell who was his father or mother, or how old he is, so that it may 
 appear that he hath no understanding of reason what shall be for his profit or 
 what shall be for his loss ; but if he have sufiicient understanding to know and 
 understand his letters, and to read by teaching or information, he is not an 
 idiot. The defects and shortcomings of this ingenious definition are evident 
 even to careless examination, and have often been indicated both in courts of 
 law and by writers. The whole question of the legal relations and consequences 
 of true idiocy can be dismissed with the assertion that if it has once been 
 clearly established by competent mental and physical examination, it deprives 
 the subject of the legal right and capability of performing acts which will stand 
 in law and equity, and also relieves its subject from civil and criminal respon- 
 sibility. It is simply a matter of careful determination in a given case. It is 
 somewhat different, however, when the issue is that of imbecility or of back- 
 wardness. 
 
 The elder Seguin and others have erected a class of backward children, in 
 whom functional torpidity or backwardness of the nervous apparatus is present, 
 while not sufficiently abnormal to be classed as idiots or even imbeciles. These 
 children are behindhand in mental development, and in some physical develop- 
 ment is also retarded. They do not learn to creep or to walk until a much later 
 period than others. Probably most of them could be classed, were it not for 
 the sensitiveness of those to whom they belong, with the highest grades of 
 imbeciles. Such children show a tendency to be behind their fellow-children 
 in school and work, and even at play and in their sportive relations with other 
 children. They become the butts and slaves of their better-equipped compan- 
 ions, by whom they are teased and hazed, and in various ways have their lives 
 made a burden. 
 
 Moral Imbecility. — Moral imbecility is an affection sometimes classed 
 under juvenile insanities as moral insanity; but a distinction can be made, 
 although not with the same certainty as in the adult, between moral imbecility 
 and moral insanity in the young. In some instances it would appear that per- 
 version of the moral or affective life is brought about through injury, disease, 
 or vicious habits in children who have been previously of a healthy moral and 
 mental tone; but the subject of true moral imbecility is the victim of heredity; 
 his condition is manifested as soon after birth as it is possible to clearly recog- 
 nize by conduct deficiencies in the moral sense. Whatever views may be held 
 as to the substrata of conscience and morals, it is convenient to use such terms 
 as moral faculty and moral sense in their commonly understood significance. 
 The moral sense covers that which causes a human being to weigh, consider, 
 approve, or disapprove his own conduct; it includes that which in common 
 language is called conscience. This faculty or sense, like others, should be 
 regarded as a function or effect of organization, although one school contends 
 for its separation from the physical man and would relegate it to some super- 
 
IDIOCY AND IMBECILITY. 669 
 
 natural sphere. I am not here particularly concerned with discussions of this 
 kind, but as a physician, and in common with others who have seen much of 
 nervous and mental disorder, I have become only too familiar with a class of 
 cases which must be recognized as the subject of disease, and the mental care 
 and treatment of which are forced upon us by every scientific and humane con- 
 sideration. Maudsley speaks of cases of this kind as a group of persons of 
 unsound mental temperament, ' ; who are born with an entire absence of the 
 moral sense, destitute even of the possibility of moral feeling; they are as truly 
 insensible to the moral relations of life, as deficient in this regard, as a person 
 color-blind is to certain colors, or as one who is without ear for music is to the 
 finest harmonies of sound. Although there is usually combined with this 
 absence of moral sensibility more or less weakness of mind, it does happen in 
 some instances that there is a remarkably acute intellect of the cunning type." 
 Such children are incorrigible to reproof and training. Punishment has no 
 eifect upon them, or will only be so heeded as to allow of their escape from 
 immediate difficulty. 
 
 Much difference of opinion has arisen among authorities almost equally 
 competent with reference to the exact nature of such cases. One contention is 
 that such a thing as moral insanity or imbecility does not exist, and that close 
 investigation will show in all alleged cases that intellectual disorder is present. 
 It is held that we should not, even by a convenient label, separate these cases 
 from others of accepted or acknowledged intellectual disorder. The difference 
 is probably largely one of terms. In a well-studied class of cases the brunt of 
 whatever defect or disease is present has fallen upon what every one regards as 
 the moral nature of the individual. Recognizing morality and immorality as 
 facts, no reason exists for not regarding these cases as instances of moral arrest 
 or departure; it is as scientifically correct to do this as it is to subdivide the 
 forms of insanity into intellectual, perceptional, emotional, and other well-known 
 psychological varieties. 
 
 According to Herbert Spencer, higher feeling is merely the centre of co- 
 ordination by which the less complex aggregations are brought under proper 
 relations. In the process of evolution this centre of co-ordination may never 
 be developed and moral imbecility may result, or great waywardness of moral 
 conduct without marked disorder of intellect. The doctrines of moral imbecil- 
 ity and moral insanity are, then, as Tuke says, in full accord with the mental 
 rules of evolution and dissolution laid down by Spencer. 
 
 Ray (Medical Jurisprudence of Insanity) gives numerous examples of moral 
 imbecility, some of the most extraordinary character. One of these of historical 
 interest is that of ''Count Charolais, brother of the duke of Bourbon-Conde', 
 whose sanguinary character has been commemorated by Lacretelle. He man- 
 ifested an instinct of cruelty in the very sports of his childhood. He took 
 pleasure in torturing animals and committing the most ferocious acts of violence 
 against his domestics. He would stand at the window and shoot the artisans at 
 work on neighboring buildings, merely for the pleasure of seeing them tumble 
 from roofs and ladders. It is said he loved to stain even his debaucheries with 
 blood, and committed many murders from no motives of interest or anger." 
 
 Works on medical jurisprudence and on mental diseases, and periodical 
 literature connected with studies of this character, have furnished many illus- 
 trations of what is best classed as moral imbecility. Kerlin (Med. News, March 
 19, 1887) has presented short histories of four children — the first, illustrative of 
 the incipient prostitute whose mental incapacity should be her protection : the 
 second case, that of an incipient burglar ; the third, a hereditary religious hyp- 
 
670 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ocrite and egotist, who, if not permanently sequestered, would fill a dramatic if 
 not an awful role in crime ; the fourth, a confirmed juvenile confidence-man. 
 
 Under the head of idiots savants has been described a class of idiots a few 
 examples of which are to be found in almost every large institution. They 
 exhibit in some special direction extraordinary or apparently extraordinary 
 mental power. They may, for example, be extremely skilful in some simple 
 handicraft ; may have a wonderful ear for music or great skill in playing upon 
 musical instruments ; or they may show a remarkable faculty of making diffi- 
 cult calculations. They are usually instances of over-development in some one 
 direction, the individual faculties in general being stunted and imperfect. 
 
 Varieties. — A thoroughly scientific classification of idiocy is in the present 
 state of our knowledge impossible. Idiocy and imbecility may with reference 
 to classification be briefly considered together. Kerlin {Med. and Surg. Re- 
 porter. May 20 and 27, 1882) has made a practically useful classification of these 
 affections into idiocy, idio-imbecility, and imbecility, considering separately, as 
 I shall also, forms of juvenile insanity which cannot properly be included under 
 either idiocy or imbecility. Under idiots are placed groups of the lowest grades 
 of intelligence and possible development ; under imbeciles, those of low intelli- 
 gence and development, but of higher grade than true idiocy and capable of 
 various degrees of improvement ; and under idio-imbeciles, those which form a 
 connecting link between the others. Following Griesinger, the same authority 
 divides idiots into the apathetic and the excitable, and imbeciles into a low, 
 middle, and high grade. Various other attempts at classification have been 
 made, but it would serve no good purpose to consider each of these in detail. 
 All are more or less deficient, as standards of classification are commingled and 
 confused. Some classes are founded upon teratological and others upon path- 
 ological data ; some upon ethnological and others upon anatomical, etiological, 
 psychological, or other features. The best classification eventually will be one 
 based upon a study of groups of clinical phenomena which can be readily 
 referred to teratological and pathological conditions. 
 
 A useful general classification of idiocy is one suggested by Langdon Down 
 {Tukes Diet. Psyehol. Med.) into congenital, developmental, and accidental. 
 Congenital idiots are born deficient as the result of causes usually unknown, 
 except that bad heredity is commonly present ; and the majority of cases of true 
 idiocy belong to this class, although some authorities improperly exclude from 
 it cases whose pathology seems evident, as porencephalic, hydrocephalic, and 
 microcephalic cases. 
 
 Congenital idiocy is usually recognized at an early period, within a few 
 months or even a few weeks after birth, although in exceptional instances it is 
 overlooked until the child has reached a year or more. 
 
 Developmental idiocy receives its name from the fact that it originates at 
 certain developmental epochs, as at first or second dentition, or perhaps at the 
 beginning of puberty, typical cases being up to a certain age normal and of 
 good, or at least ordinary, physical health. Following a convulsion or a series 
 of spasms, the child may show a marked intellectual change and variation of 
 character, or this deterioration may come on gradually, without any history of 
 spasm or any abrupt attack, in children perfectly normal as to intelligence up 
 to the age of eighteen months or five, six, or even seven years, or perhaps 
 nearly or quite to the age of puberty. In some of the cases which have been 
 reported the mother has been acted upon by malign or depressing influences or 
 has been the subject of disease or deprivation of some kind during pregnancy. 
 Down has advanced the reasonable supposition that, according to the period of 
 embryonic life at which the causative impression is made upon the mother, may 
 
IDIOCY AND IMBECILITY. 671 
 
 be the time of development of the manifestations of idiocy ; occurring at an 
 early period, such disturbances result t in congenital idiocy. 
 
 Accidental idiocy is a form of mental arrest which is caused, as its name 
 indicates, by some accident at or after birth. In not a few such cases the pre- 
 disposition to mental weakness may have existed, but even in these it might 
 not have shown itself in so marked a manner or at all. Haemorrhage or 
 depressed fracture or abscess from aural disease may have been present, and 
 meningitis of either the hard or the soft membranes is sometimes found post- 
 mortem. While recognizing these three etiological varieties as of great impor- 
 tance and value for purposes of study, one cannot get a clear idea of the types 
 of idiocy without a different subdivision, as under the congenital, develop- 
 mental, and accidental classes idiots differing widely in appearance and in their 
 mental and physical possessions are found, although the differences are greater 
 in congenital idiocy than in the other forms. 
 
 Down has also proposed a more elaborate and differentiated classification, 
 giving many different forms, and arranging these into more than twenty sub- 
 classes under the general heads already considered. He has paid particular 
 attention to ethnological features, describing such varieties as the Caucasian, 
 Ethiopian, Calmuck or Mongolian, Malayan, and Negroid. The patients bear 
 a real or fancied resemblance, particularly in face and head, to individuals of 
 the different races indicated by the names. The Calmuck or Mongolian 
 appears to be the most clearly recognizable of these varieties. Among its 
 characteristics are short stature, deficiency of the posterior part of the head, 
 sparse hair, obliquely-placed and widely-separated eyes, and depressed nose. 
 Mongolian idiots are grotesque, seeing the humorous side of things ; they are 
 all characterized by strong self-will and wonderful imitative power, and they 
 have other physical and mental peculiarities to which our space will not permit 
 us to refer. 
 
 Among other varieties of idiocy recognized by Down, Shuttleworth, and 
 others are those the names of which are based upon peculiarities in the size 
 and shape of the head ; but this method of classification, like that based 
 upon ethnological marks, is not capable of being carried out over the entire 
 range of cases. Different shapes of head are found in cases of idiocy with the 
 same or similar mental and physical features, or, on the other hand, either dif- 
 ferent or the same or similar symptoms, syndromes, or conditions are presented 
 by idiots with heads unlike in shape and size. It is true, nevertheless, that 
 some of the varieties present more or less common features, and the terms used 
 are at least convenient for the purpose of investigation and record. Macro- 
 cephalic idiocy in such a classification might describe cases due to hydro- 
 cephalus or to hypertrophy of the bone or intracranial structures, or to both. 
 Microcephalic is a term applied to idiots with very small heads, technically to 
 those whose heads are less than seventeen inches in circumference ; hydro- 
 cephalic idiocy is the result or accompaniment of hydrocephalus ; brachycepha- 
 lic means broad and short-headed, and dolichocephalic long-headed — long in 
 proportion to breadth. The term cephalic index is applied to the breadth of 
 the skull multiplied by 100 and divided by its length, and if above 80 the 
 skull is called brachycephalic. In plagiocephalic idiots the skull is out of 
 shape, so that the features lie in an oblique plane ; scaphocephaly, from a word 
 meaning the hull of a ship, is a term applied to that form of idiocy in which 
 the head is shaped like the keel of a boat turned upside down. 
 
 Ireland, the author of a well-known text book on idiocy and imbecility 
 {Idiocy and Imbecility, London, 1887), has proposed a classification which has 
 been much followed and has much to commend it, but it is by no means suffi- 
 
672 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cient to cover all cases. It is a mixed classification, based on pathological, 
 etiological, and semiological features, and has ten classes, as follows : 1, Gene- 
 tous ; 2, Microcephalic ; 3, Eclamptic ; 4, Epileptic ; 5, Hydrocephalic ; 6, 
 Paralytic ; 7, Cretinism ; 8, Traumatic ; 9, Inflammatory ; 10, Idiocy by 
 deprivation. 
 
 The term " genetous idiocy," as used by Ireland, practically means the same 
 as congenital, but other varieties in his classification are just as truly genetous 
 or congenital. Eclamptic and epileptic idiocy are two varieties, in both of 
 which spasm or convulsion plays a prominent part, but in the eclamptic occurs 
 soon after birth, and is supposed to be due to convulsive seizures, these not 
 infrequently stopping, but leaving the mind permanently affected and arrested; 
 while in epileptic idiocy the convulsion and the idiocy may both come on at 
 different ages, and the epilepsy remain as a permanent accompaniment of the 
 idiocy. According to Brush {Keating' 's Cycl. Dis. Children, vol. iv.), an epi- 
 leptic idiot is one whose mental growth has been arrested by the occurrence of 
 epilepsy in infancy or childhood. From this point of view epileptic idiocy 
 would belong to the etiological variety, while eclampsic might or might not. 
 Microcephalic and hydrocephalic have been already discussed. Paralytic 
 idiots have forms of monoplegia, hemiplegia, paraplegia, and diplegia, as 
 described in this work by Peterson. Very commonly the paralysis is of the 
 spastic variety. Various forms of idiocy might be classed under traumatic. Not 
 a few cases are supposed to result from injuries inflicted during prolonged labor 
 by bruising and squeezing of the child or by instruments in assisting at its 
 delivery. Some, but by no means the majority, of paralytic cases are attribu- 
 table to traumatism ; many are dependent upon sclerosis, arrest of development, 
 neoplasms, meningitis, meningo-cerebritis, or cerebritis, and the pathological 
 process may occur either before or soon after birth. Of course inflammation 
 may be set up by traumatism, when the case might be regarded as either trau- 
 matic or inflammatory. Hydrocephalus is sometimes the result of a tubercular 
 or other inflammation of the membranes or ependyma of the ventricle. Con- 
 firmed idiocy and forms of juvenile insanity occasionally occur during or after 
 the infectious febrile affections of infancy or early childhood, such as cerebro- 
 spinal fever, scarlet fever, measles, whooping-cough, diphtheria, etc., and these 
 are either toxic or inflammatory affections, or both. Sensorial idiocy, or idiocy 
 by deprivation, is the result of the lack or the loss of important senses like 
 sight or hearing. Some, but by no means many, of these cases may by care- 
 ful education and training be lifted out of this idiotic state ; in others the 
 loss of hearing, of sight, or of other senses may, like the mental defects in 
 general, be dependent upon embryonal arrest. Sensorial idiocy and imbecility, 
 therefore, need to be subdivided into at least the two varieties of congenital 
 and acquired or accidental. It may be of great practical importance to be 
 able to decide to which of these two varieties a case belongs. Cretinism will 
 be treated of in a separate article. 
 
 Shuttleworth's classification {British Med. Jour., Jan. 30, 1886), which 
 includes the varieties of Ireland with some additional classes, is as follows : 
 
 "Class A — Congenital. — 1, Microcephalic; 2, Hydrocephalic (also non- 
 congenital) ; 3, Scrofulous (Mongol type) ; 4, Sensorial (also non-congenital) ; 
 5, Primarily neurotic ; 6, Paralytic (also non-congenital) ; 7, Choreic (also 
 non-congenital) ; 8, Cretinoid ; {a) sporadic, (6) endemic. Class B — Non- 
 congenital. — a, Developmental — 9, Eclamptic ; 10. Epileptic ; 11, Syphil- 
 itic ; 12, Post-febrile (also accidental) ; b, Accidental or Acquired. — 13, Toxic; 
 14, Traumatic; 15, Emotional; 16, From mixed causes." 
 
 Strumous or scrofulous forms of idiocy can be clearly placed to the strumous 
 
PLATE XIV. 
 
 
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 % 
 
 
 r* 
 
 c l 
 
 
 x > * 
 
 ," 
 
 
 
 ; 
 
 
 f 
 
 A 
 
 ' A< 
 
 
 m 
 
 V / 
 
 m m 
 
 
 h 
 
 mamk 
 
 Fig. 1. Congenital Idiot of Low Grade. 
 Fig. 2. Epileptic Imbecile. 
 
 Fig. 3. Insane Imbecile. 
 
 Fig. 4. Congenital Idiot Of Low Grade. 
 
IDIOCY AND IMBECILITY. 673 
 
 or scrofulous diathesis ; they belong to the congenital class. The primarily 
 neurotic are those with bodies comparatively well developed and with signs of 
 irregular nervous action. 
 
 The term ''choreic," as applied to idiocy, has been used in several ways 
 — as descriptive of the motor phenomena presented by the patient ; or of idiocy 
 resulting in a child born of a mother choreic during pregnancy ; or of cases 
 in which violent or persistent chorea seems to induce idiocy in the developing 
 child. 
 
 Congenital idiocy due to inherited syphilis is probably but not certainly 
 rarer than a form of juvenile dementia, which usually develops some years 
 after birth, and is described in another section. Some syphilitic children are 
 idiotic from birth, and in these cases treatment is generally as useless as in 
 cases due to other causes, while in syphilitic juvenile dementia specific treat- 
 ment may be very efficient. Shuttleworth applies the term "toxic idiocy" to 
 idiots who without bodily deformity suffer from malnutrition of the brain, which 
 he supposes to be due to some unknown toxic influence. Emotional or excitable 
 idiocy is that which shows shrinking, fear, apprehension, excitement as its chief 
 features. 
 
 Etiology. — A bad heritage is the great predisposing cause of idiocy. The 
 idiot's ancestor may not have been insane, imbecile, or idiotic, but in the majority 
 of cases some constitutional taint or tendency, as syphilis, struma, or tuberculosis ; 
 some toxic affection, as alcoholism; some form of mental disease or defect; 
 some neurosis as epilepsy, hysteria, neuralgia, or neurasthenia, or some organic 
 disease of the brain, as meningitis, sclerosis, softening, or haemorrhage, will 
 with sufficient investigation be found to have been present in near or remote 
 progenitors. Intemperance, alone or combined with other causes, such as 
 epilepsy or insanity, has been shown by reliable statistics to be one of the com- 
 monest predisposing causes. Far too frequently imbeciles of high, or in some 
 cases of comparatively low grade, marry, with degenerate offspring as the result. 
 Numerous studies of heredity in connection with this question of the causation of 
 idiocy have been made. According to Shuttleworth and Beach {Tukes Diet. 
 Psychol. Med.), the most frequent combination of two causes of insanity is that 
 of insanity with epilepsy. Even deaf-mutism, with perhaps in most cases the 
 addition of some other lowering agency, has resulted in idiocy and imbecility in 
 the second and third generation. By the authors above quoted syphilis was 
 found certainly to be the predisposing cause in 17 per cent, of more than two 
 thousand cases. Good authorities place 2 per cent, as covering the cases of 
 syphilitic idiocy, although others would put it much higher. The question of 
 consanguineous marriages has been much discussed in connection with the causa- 
 tion of both insanity and idiocy, and authorities are somewhat at variance ; but 
 it may be regarded as certain that the marriage of relatives in one or both of 
 whom mental or neurotic defects or constitutional or toxic conditions are present 
 will predispose to idiocy and imbecility as to other degenerative diseases. It 
 is better, as a rule, that relatives should not intermarry, as few stocks are 
 absolutely without taint or weakness. 
 
 Bad health in the mother and impressions made on her during pregnancy, 
 the father's health or condition at the time of procreation, age or premature 
 senility of parents, and acute diseases during pregnancy, — all have some etio- 
 logical importance. 
 
 Among causes acting at the time of birth are prolonged and difficult 
 labor in mothers with small or deformed pelves; injuries by instruments or 
 other manipulations or by the umbilical cord, and suspended animation from 
 whatever cause. The use of instruments is, however, a much less frequent 
 
 43 
 
674 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cause of idiocy, infantile paralysis, and convulsions than is commonly supposed. 
 They are often used after the injury has been done by long-continued pressure. 
 The prompt and skilful use of forceps sometimes saves life and health for both 
 mother and child, oftener than the reverse. In these pressure and forceps 
 cases skull depressions and haemorrhages sometimes occur. The causes acting 
 after birth are comparatively few, but among these are injuries from falls or 
 blows, convulsions of unknown origin, fright, febrile diseases, and in rare cases 
 the ingestion of toxic substances. 
 
 Symptoms. — To briefly give the symptomatology of idiocy in general 
 is an almost impossible task. The signs and symptoms will vary widely with 
 classes, and to a certain extent, in considering the varieties of idiocy, I have 
 already described its symptomatology ; but certain physical and mental 
 characteristics belong to almost any form of idiocy, and from studying these 
 the practitioner of medicine, even without special knowledge of the subject, 
 may be able to come to a conclusion as to the nature of such a case at an early 
 period. Much can be learned as to the physical features of idiocy by mere 
 inspection, and much more by careful and detailed investigation. The size 
 and shape of the head and face and defects of feature may prove serviceable 
 in coming to a decision. I have already spoken of varieties dependent on 
 the shape of the head to which special names have been given, as microcephalic, 
 and brachycephalic. Unusual smallness or largeness of the head, or, what is 
 more common, deformity or asymmetry in its shape, is often the first to attract 
 attention. In some types of idiocy, as the Mongolian, a remarkable deficiency 
 of the posterior part of the cranium is often observed ; in others it may be that 
 one side of the head, or even one special region of the cranium, will show 
 marked depression or arrest. In almost every instance of true idiocy some 
 peculiarity of face or feature is present : this may be abnormal position or 
 separation of the eyes ; deformity, unusual size, or peculiar implantation of the 
 external ear ; depression or flattening of the nose, or general asymmetry of the 
 face. The oral cavity of idiots has been the subject of much investigation, and 
 great varieties in the shape of the mouth and pharynx are found ; it is high and 
 gothic ; or low and flat ; or irregular ; or a cleft or partially cleft palate is pres- 
 ent ; and sometimes the entire buccal and pharyngeal cavities are contracted 
 as well as irregular in shape. The greatest possible variations in the shape, 
 size, and implantation of the teeth are to be observed : they are notched or 
 pegged or serrated ; they overlap and are irregularly crowded : frequently they 
 decay at an early period. The jaws may be too narrow or may fail to be 
 properly apposed to each other ; occasionally, instead of being small, the lower 
 jaw is prognathian — of unusual size and projection. The tongue may be too 
 large, or even too small, and frequently refuses to obey the behests of the will. 
 The head cannot be held erect or is carried badly. 
 
 The control which the patient has over ocular movements and facial expres- 
 sion is often of great value to the diagnostician. Strabismus is common, and 
 this may be of one eye or both, or of an alternating or varying type. Of other 
 simple tangible phenomena, drooling or slavering is an important manifestation. 
 Inability to stand or walk at the usual age may lead to suspicion as to the true 
 condition, and even if the child can walk his carriage and gait may be very 
 significant. Some idiots stoop, some have a lopsided method of progression ; 
 many are slouching in station and in walk ; some run when they should walk, 
 or walk when they should run ; the gait is often ataxic or incoordinate, or, 
 rather than this in a technical sense, it may be simply maladroit or awkward. 
 The hands and arms are not used with the same precision, accuracy, and adap- 
 tation of means to ends as by other children. 
 
IDIOCY AND IMBECILITY. 675 
 
 Below the head and neck defects and peculiarities may be as various as 
 above. Curvatures and twistings of the trunk, asymmetry in the development 
 of the legs and arms ; flexures, curvatures, or other deformities of the limbs ; 
 knock-knees or bow-legs or parrot-toes, and numerous other deformities, mal- 
 positions and arrests, may be present. According to the variety of idiocy there 
 may be paralysis, with or without local spasm or contracture, in limbs or face ; 
 sometimes this is one-sided — that is, monoplegic or hemiplegic; sometimes both 
 legs, or both legs and one arm, or all four limbs, may be involved in the pare- 
 tico-spastic condition. 
 
 The skin may be harsh or dry or coarse; it may show evidences of 
 impaired or imperfect circulation in coldness or duskiness of the extremities, in 
 blotches or discolorations, or even in a tendency to trophic affections, such as 
 ulcerations and eruptions. Not seldom the hair is scanty or coarse or badly 
 nourished, and the nails may be of bad shape or abnormal in appearance. The 
 sexual organs may show unusual smallness or deformity or peculiarity of some 
 kind. 
 
 Speech may show many varieties of defect and aberration, and these have 
 to some extent been considered in another section. The incapacity to attend 
 to what is said or what should be done is one of the first things to attract 
 attention to an idiotic child. At an age when infants and small children ordi- 
 narily attend to many matters of passing interest, such a child cannot be made 
 to fix its attention even by the most strenuous efforts; indeed, a close study 
 of this faculty will perhaps throw more light than anything else upon the 
 degree of mental development in children. Self-will, undue emotionality, lack 
 of ordinary obedience, impetuous and unreasonable behavior, inattention to 
 natural wants and demands, are all points of importance in the mental investi- 
 gation of supposed idiocy. 
 
 While some or many of the physical peculiarities enumerated may be present 
 in cases of idiocy, it must not be forgotten that in some types at least they are 
 nearly all wanting. In the so-called accidental idiocy, for example — that which 
 has resulted from injury at the time of or after birth — there may be a striking 
 absence of the usual physical defects and deviations. Such children are some- 
 times scarcely to be distinguished in head, face, form, attitude, or movements 
 from those retaining their mental faculties, although the traumatism may have 
 left its mark in depressed skull or paralytic or spastic limbs. 
 
 Pathology. — Many facts with reference to the pathology of idiocy will be 
 found discussed under such heads as the cerebral paralyses of childhood, 
 hydrocephalus, brain atrophy or hypertrophy, porencephaly, sclerosis, cortical 
 arrest, cysts, softening, haemorrhage, embolism, thrombosis, chronic menin- 
 gitis, meningoencephalitis, and encephalitis ; while many of the symptoms 
 peculiar to idiocy have been or will be considered under such headings as 
 speech defects and anomalies, nystagmus, athetosis and athetoid affections, and 
 epilepsy. 
 
 Idiocy has no fixed pathology, but numerous exceedingly interesting patho- 
 logical appearances and conditions have been reported, as anasmia and hyper- 
 emia of the brain ; hypertrophy and atrophy, general and partial ; softenings 
 usually local ; sclerosis of various forms ; hydrocephalus and porencephalus, 
 meningitis, and tumors ; thickening of the arteries; thrombosis of the sinuses; 
 asymmetry or unusual simplicity of the hemispheres and convolutions ; alter- 
 ations in the relative amount of white and gray matter of the brain. Disease 
 of other organs than the cerebrum is often associated with cerebral disease, as, 
 for example, atrophy, tumors, and cysts of the cerebellum, or spinal affections, 
 
676 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 such as poliomyelitis ; congenital arrest of development of the pyramidal tracts ; 
 descending sclerosis ; chronic myelitis ; or pseudo-hypertrophic paralysis. 
 
 Wilmarth {Alienist and Neurologist, October, 1890), has given the results 
 of the study of one hundred brains, and his condensed statement pre- 
 sents in an unusually interesting and practical form the pathology of most 
 cases of idiocy. I had the opportunity of studying some of the brains and 
 skulls which are included in this list of cases. Sclerosis with atrophy, 12 ; 
 scleroso-tubereuse, 6 ; diffuse sclerotic change, 7 ; degenerative changes in 
 vessels, ganglionic cells, or medullary substance, not constituting the true 
 sclerosis, 15 ; hydrocephalus, 5 ; general cerebral atrophy, 2 ; non-develop- 
 ment in various forms, 16 ; infantile haemorrhages, 1 ; extensive adhesions 
 of membranes from old meningitis, 3; angeiomatous condition of the cere- 
 bral vessels (with degenerative changes), 1 ; glioma (with sclerosis), 1 ; 
 porencephalus, 1 ; and 31 cases where actual disease or imperfect development 
 of the brain proper was not demonstrated ; there was hypertrophy of the skull, 
 6 ; acute softening (recent), 2 ; demi-microcephalic, 2 ; 1 brain was above 
 the usual weight, but the convolutions were large and very simple in their 
 arrangement. 
 
 In 75 cases, or in all in which injections of chloride of zinc or extensive 
 destruction had not made weighing valueless, the brain was carefully weighed. 
 The average weight was 38.3 ounces; in 14 cases the weight was below 30 
 ounces ; thickening of the skull to an extent to constitute hypertrophy was 
 found in 8 instances ; while in 8 the skull was unusually thin, not including 
 cases in which there was distention from hydrocephalus. 
 
 An attempt at a pathological classification of idiocy might be made, 
 although this undoubtedly would contain many imperfections. The classes will 
 be sometimes found to blend and commingle, cases will repeat themselves under 
 different headings, and other objections will appear; but, on the whole, such a 
 classification will indicate in a general way the groups as they would be found 
 in any large institution. 
 
 The most important of these classes are as follows : 
 
 1. Idiocy due to gross organic lesions, the history of which can be deter- 
 mined with more or less accuracy — lesions such as haemorrhage, embolism, 
 thrombosis, tumors, meningitis, meningo-encephalitis, and encephalitis. 
 
 2. Idiocy due to various forms of sclerosis, as the diffuse, multiple, or 
 disseminated ; sclerosis with atrophy, and lobar or tuberous sclerosis. 
 
 3. Idiocy due to arrest of cortical development, a true agenesis corticalis, 
 or absence of normal cells, which has been well studied and described by 
 Sachs of New York (Jour. Nerv. and Ment. Dis., August, 1892). 
 
 4. Idiocy due to large cerebral deficiencies, but sometimes originating in 
 haemorrhage, thrombosis, embolism, sclerosis, meningitis, etc. — such conditions 
 as general atrophy or hypertrophy, porencephalus, and hydrocephalus. 
 
 5. Idiocy due to inherited or congenital syphilis, which perhaps might be 
 included under some other subdivision, but the cases are supposed by some 
 authorities to have a peculiar history and special appearances, and therefore 
 may be placed for practical purposes in a separate group. 
 
 6. Idiocy of toxic origin, under which head would be included cases result- 
 ing from acute poisoning or following infectious diseases, such as measles, 
 scarlet fever, etc. 
 
 Diagnosis. — The diagnosis of idiocy will only be difficult in early infancy 
 and in a few rare cases. The facts to be learned by observing whether or not 
 the child pursues a regular, or at least an average, method of development 
 have already been considered with reference to the sense of hearing, the 
 
IDIOCY AND IMBECILITY. 677 
 
 acquirement of speech, and the development of ideas, when discussing anom- 
 alies and defects of speech. Different children of the same family or healthy 
 children who are known to the physician can be compared with the one 
 alleged to be idiotic. Careful consideration must be given to the question of 
 normal retardation or mere backwardness, or the existence of a true insanity, 
 such as syphilitic dementia. The diagnosis of idiocy and imbecility is always 
 most assisted by a careful study of the physical conditions presented by the 
 child — the shape and size of the head, which have already been discussed ; the 
 condition of the eyes and the ocular muscles ; the appearance of the palate, 
 jaw, and tongue ; the presence or absence of drooling ; ataxic, athetoid, or 
 choreic movements ; peculiarities of expression ; deformities of the ear, nose, 
 or mouth ; ungainly, limping gait ; paralysis or contractures, or both in the 
 same case. The more marked and numerous these arrests and aberrations of 
 bodily development, the more likely it will be that the diagnosis of idiocy is 
 correct. In every part of this article mental disturbances and deficiencies are 
 under consideration, and it is only necessary to say here that such faculties 
 as attention, memory, and inhibition should be particularly studied. 
 
 Prognosis. — The prognosis of idiocy as to cure is of course altogether bad, 
 but it should be remembered that improvement can be made in the condition 
 of idiots even of comparatively low grade. They can be made more comfort- 
 able, happier, less offensive, less destructive, and even, in a limited number of 
 cases, more useful, by care, discipline, education, training, and, to a limited 
 degree, by the use of nutrient and medicinal agencies. 
 
 " During the fifty years over which efforts for the amelioration of the imbecile 
 have extended," says Shuttleworth (Tube's Diet. Psych. Med.), "the sanguine 
 prognostications of early enthusiasts may not have been realized, but neverthe- 
 less a large percentage of benefit has been recorded. An imbecile, however well 
 trained, will always need some kindly aid and consideration from those with whom 
 he is associated. It is not to be expected he will be able to manage his own affairs 
 or compete in the labor-markets of the world. Placed in a niche, however, 
 where he can without molestation exercise his acquired talents, he will in many 
 cases turn out more or less remunerative work ; and, failing this, he will, in 
 consequence of having some resources within himself, cease to be a nuisance to 
 his friends. Even the improvement of habits by systematic training is not to 
 be despised in relation to the comfort of the family ; and it must be borne in 
 mind that the idiot left untrained is sure to deteriorate. A review of twenty 
 years' experience at one of the large English institutions furnishes the follow- 
 ing results : Of patients discharged after full training, 10 per cent, are self- 
 supporting, whilst another 10 per cent, would be so if they had obtained suit- 
 able positions, and about 20 per cent, were reported as useful to their friends 
 at home." 
 
 Treatment. — In considering treatment the subject might be variously sub- 
 divided, as into prophylactic and direct ; into hygienic, educational, gymnastic, 
 and medicinal ; into measures for the affection itself, and for diseases and con- 
 ditions that are intercurrent or resultant. Habitation, diet, and clothing should 
 be carefully selected ; and in doing this particular attention should be paid to 
 the variety of idiocy and to the diathesis from which it may have resulted. The 
 ventilation of rooms at night and proper beds and clothing should receive 
 attention. Cleanliness must be enforced by bathing, which can also be used 
 as an invigorating and strengthening measure. All idiots should have exercise 
 graded to their physical condition and powers; mistakes may be made in 
 attempting to do too much in this direction or by not duly considering their 
 differences from other children. Systematized gymnastic exercises or calis- 
 
678 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 thenics can be used with great advantage, both for physical development and 
 to a limited extent to promote mental power, and to a larger degree to add to 
 the happiness of these defective children. 
 
 Whether or not an idiotic child should be removed from its home to an 
 institution is a question that the physician must frequently meet, and in general 
 terms it may be said that a well-conducted institution, as a rule, is the best 
 place, both for him and for other members of the family. The danger of being 
 made worse by contact with others — an argument which is so often used against 
 sending a patient to an insane hospital, and occasionally with force — does not 
 apply, or to an exceedingly limited extent. In institutions of large size the 
 defective children can be so classified that their training can be carried out sys- 
 tematically and without much jarring and strain, or, if incapable of any im- 
 provement, so that they can be cared for and their happiness promoted in the 
 best possible manner. The presence of an idiot in a family is often painful and 
 deteriorating both to parents and to other children. Home treatment may be 
 pursued where parents have large means and the care and training of an idiotic 
 child can be managed apart from the rest of the family. For the wealthier 
 classes the institutions which take only a small number of children, if these are 
 conducted on thoroughly scientific as well as humane principles, offer some 
 advantages. Amusements, exercises, and social intercourse are all regulated 
 to excellent purpose in institutions like those at Elwyn, Pennsylvania, at Vine- 
 land, New Jersey, and at Barre, Massachusetts. 
 
 The educational treatment or training of the feeble-minded has received 
 much attention in recent years. In 1801 the first great incentive was given 
 by Itard to this method of bettering the condition of the idiotic by his inter- 
 esting account of his own experiences with a child that had been found savage 
 in the woods, but to the elder Seguin {Idiocy and Its Treatment by the Phy- 
 siological Method, 1866), the greatest of credit is due. He was truly the first 
 apostle of the idiot. Volumes have been devoted to this most interesting 
 subject, but to these I can scarcely do more than refer. This training and 
 education should be patiently directed to the development of the deficient 
 senses ; to the training of the hands and feet ; to the improvement of carriage 
 and gait ; to stimulating the slow and to braking the morbidly active ; to the 
 development and improvement of speech ; to arousing attention, imitation, 
 imagination, comparison and judgment ; and to the awakening and cultivation 
 of the moral senses and power of control. 
 
 Not much can be said about the medical and surgical treatment of idiocy. 
 Attention should first be directed to the probability of the idiocy being due 
 to such possibly remedial causes as inherited syphilis or traumatisms. The 
 iodides of potassium and sodium, hydriodic acid, and various mercurial prepara- 
 tions may be tried in cases presumably due to inherited syphilis, but too much 
 must not be expected, as syphilis in the progenitor has established a condition 
 of arrest rather than an active and removable lesion. It is different in infantile 
 and juvenile dementia due to syphilis, which have been treated of in another 
 article ; here the treatment may promise much, and, as the differentiation is 
 sometimes difficult, it may sometimes be employed as a diagnostic measure. 
 Everything should be done to promote the nutrition of the idiot — malt, maltine, 
 cod-liver oil, and nourishing food for the strumous ; the same with preparations 
 of iodine, arsenic, and tonics in general for the rachitic ; digestants like pepsin, 
 pancreatin, the mineral acids, and stomachics for those of weak digestion ; 
 astringents, antifermentatives, and intestinal tonics for those afflicted with 
 diarrhoeas and dysenteries; lime-juice, vegetable acids, bitters, quinine, iron 5 
 and fresh food for the scorbutic ; ointments for the skin, washes for the mouth, 
 
IDIOCY AND IMBECILITY. 679 
 
 lotions for the eyes, — but these will not be to the working of a cure, but to the 
 relief of annoying and depressing symptoms and conditions. For convulsions, 
 bromides, chloral, sulphonal, antipyrine, and similar inhibitors of cortical exci- 
 tability, guarded by arsenic and supported by nutrients, may be administered. 
 For excitement trional and tetronal have been found valuable. 
 
 What to do with backward children is often a serious problem. They 
 certainly should not be sent to the institutions for the idiotic and feeble-minded, 
 nor can they always with advantage be kept at schools of ordinary or high grade. 
 When their parents can afford the expense, it is best, for a time at least, to 
 have them instructed by tutors or to send them to small schools, with the 
 understanding that special attention shall be paid to them, and that their 
 instruction shall be regulated as far as possible in accordance with their needs 
 and capabilities. The physician should be careful not to be too hasty in his 
 prognosis or prophecies in reference to such children. A practical point worth 
 while to be always borne in mind is that sometimes mental backwardness, like 
 physical backwardness or peculiarity, is due to the rachitic diathesis. Just as 
 in well-defined types of rachitic pseudo-paralysis, the bony and other forms of 
 arrest or deformity will yield to an abundance of good air, good food, and 
 treatment with such preparations as cod-liver oil, arsenic, iron, and iodides in 
 various forms, so some cases of intellectual slowness and torpor will be greatly 
 improved or cured by similar measures. 
 
 For evident cranial depression and fracture trephining may be resorted 
 to, though in long-standing cases the outcome is generally doubtful. The 
 surgical treatment of idiocy has recently received an impetus through the ope- 
 rations performed first in France by Lannelongue (X' Union Medicate, July 8, 
 1890), in England by Horsley (Brit Med. Jour., September 12, 1891), and 
 in this country by Keen (Med. News, Nov. 29, 1890, and Amer. Jour. Med. 
 Sci., June, 1891), and others. At the French Surgical Congress in 1891 
 twenty-eight cases of craniectomy were reported, with but one death, and con- 
 siderable improvement was claimed in some of the cases, but a careful reading 
 of the reports of cases shows that the real benefit has not been great. 
 
 The best method of training moral imbecility must be sometimes considered. 
 In most genuine cases, education or philanthropy, kindness or cruelty, the 
 sugar-plum or the whip, the Sunday-school or the reformatory, the asylum or 
 the penitentiary, will equally fail ; or perhaps I should not say equally, as in a 
 few instances some strengthening of the weak and imperfect coordinating 
 centres may be possible. To the typical case, to the vast majority of cases 
 that would come under this designation, belongs the term incorrigible. Some 
 of the most practical and most experienced authorities, as Tuke and Kerlin, 
 believe that education in its ordinary meaning should be largely withheld 
 from this class. The former says of them : " The early detection of these 
 cases is not difiicult : they should be subjects for life-long detention; their 
 existence can be made happy and useful, and they will train into comparative 
 facility and harmlessness if kept under a uniform, temperate, and positive 
 restriction. The school-room fosters the ill we would cure : in teaching them 
 to write we give them an illimitable power of mischief ; in educating them at 
 all, except to physical work, we are adding to their armament of deception and 
 misdemeanor." As Kerlin puts it, we should refuse them the ordinary routine 
 of education, because " we believe that in educating moral imbecility we are 
 training experts for the later r61e of so-called moral insanity." 
 
CRETINISM." 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Cretinism is a form of arrested physical and mental development, chronic 
 and usually endemic, characterized by peculiar appearances and malformations, 
 but especially by smallness of stature, distortion or deformity of the face, head, 
 and body, unhealthiness of the skin, enlargement or absence of the thyroid 
 gland, or fatty growths above the clavicle. The derivation of the word 
 "cretin" is involved in curious uncertainty. Its origin has been assigned, for 
 example, to creta, chalk ; to cretira, stupid, silly ; and to Chretien, Christian, 
 because cretins are supposed to be as happy as Christians ought to be. In 
 different regions and by different writers cretins have been called by various 
 names, as cagots ; but the cagots are not true cretins, but a proscribed people 
 living in Beam and Gascony who may at one time have suffered from a form 
 of leprosy. In Germany cretins are called Kreidlings and Kretins ; in Austria, 
 G-acken and Trotteln ; in Italy, Gfavas, Totolas, Cristiani ; and in South 
 America, Bovos and Tontos (Tuke). 
 
 Cretinism is endemic in various countries, but nearly always in mountain- 
 ous regions, as in the Pyrenees and Alps, in the Highlands of Scotland, and 
 in the Himalayas. In this country a few cases are occasionally found together, 
 as in the mountains of Vermont and California, but the affection is chiefly of 
 interest to American physicians as a sporadic disease. Probably it is found to 
 some degree all over the world. In a few countries in which it is most prev- 
 alent, as in Switzerland, France, Italy, and Spain, it often shows a curious 
 tendency to limit itself to particular spots, even in a region of the same general 
 climatic and geological features — to blight one valley or village, while another 
 close by, and apparently not different in environment, escapes. While pro- 
 nounced cretinism is rare in this country, cretinoid cases are seen with more 
 frequency ; and by cretinoid cases, in this connection, I do not refer to 
 ordinary cases of myxcedema, although Sir William Gull described myxcedema 
 under this term, but rather to cases which I now and then see in which neither 
 myxcedema nor true cretinism is present, but in which the patient in face, head, 
 expression, stature, skin, mental capacity, or other points reminds one of the 
 cretin. 
 
 Symptoms. — The symptomatology of cretinism and cretinoid disease can 
 perhaps be best presented by first describing one or two cases. One studied 
 by me at the Xew Jersey Home for the Feeble-minded, a girl aged nine 
 years, was the seventh child, born after difficult labor, but seemed strong 
 until she was sixteen or eighteen months old, and until this time was bright 
 and active and did not seem defective. At this time she had a severe fall. 
 Her mother was a hard-working woman ; the father had rheumatism and was 
 unable to work, and at times was a hard drinker. She had one brother 
 
 1 This article has been carefully revised for the present edition by Wm. G. Spiller, M. D. 
 6S0 
 
CBETINISM. 681 
 
 and three sisters living and healthy. She was a well-marked cretinoid case, 
 with flat face and open mouth, the tongue filling it, but not protruding. She 
 had a soft, but not large, swelling above each clavicle. Her mental condition 
 was very low. She never gave a direct answer to any question, and had no 
 words at her command ; but she knew her own name, could feed herself, and 
 could walk a short distance with assistance. She was almost as broad as she 
 was long. I have seen a fair number of such cases of cretinoid idiocy, but 
 generally of much higher grade, in private and hospital practice and in the 
 institutions for the feeble-minded both at Elwyn, Pa., and at Vineland, N. J. 
 
 In the nervous wards of the Philadelphia Hospital is a typical example 
 of sporadic cretinism, which I have frequently studied and discussed before 
 my classes. A description of this case has been published by Lloyd {Inter- 
 national Clinics, 1892). The cretin, thirty-five years old, was born in 
 the outskirts of Philadelphia. He has a myxoedematous face with large 
 lips and hypertrophied, protruding tongue; small limbs, even as compared 
 with his body ; protuberant belly ; the sexual apparatus of a small child ; no 
 hair about the pubes or on the face, and a scanty supply on the head ; bad 
 teeth and gums ; eyelids red, tumid, and nearly closed ; the skin yellowish- 
 white and dry, and sweating only on the forehead and forearms. His height 
 is 35J inches. He can walk a little, but is very weak on his limbs. Knee- 
 jerks and the reflexes are normal; sensation seems to be everywhere preserved, 
 and sight and hearing likewise appear to be good. The thyroid gland is 
 wanting, but above the clavicles on each side is a soft mass, probably a fatty 
 growth. While his mental capacity is very low, it is more than his appearance 
 and lack of speech, which is confined to a few words, would indicate. He is 
 observant of much that goes on in the wards, understands much that is said to 
 him, recognizes physicians and old friends, and is appreciative of favors. He 
 has lived along with scarcely any change during the many years that he has 
 been in the hospital, escaping intercurrent disease. His temperature is 
 almost constantly subnormal, and during one week in which it was carefully 
 taken, he being in his usual health, it never reached the normal but once, 
 and most of the time ranged below 97.4° F. (The plate representing this 
 case is from Lloyd's paper.) 
 
 For many years in the neighborhood of the hospital was another example 
 of typical sporadic cretinism, presenting most of the features of the case just 
 described. 
 
 In describing the above case I have practically given the symptomatology 
 of cretinism. The word stunted describes the conditions, physical and mental, 
 better than any other. The cretin is small in stature except in very rare 
 cases ; thus Lombroso has described a family of cretins of unusual stature. 
 The head is frequently contracted from the front backward or in some way 
 is asymmetrical. In typical cases the features are striking — short, flattened 
 nose ; eyes wide apart ; puffy, drooping lids ; small face and protruding 
 tongue. Not only temperature, but pulse and respiration, and all the vital 
 processes, are sluggish ; digestion, secretion, and excretion go on torpidly ; 
 menstruation is established late or not at all. 
 
 Speech varies much in different cases, and efforts have been made to classify 
 cretins with reference to their possession of this faculty, the lowest grade con- 
 sisting of those who are deprived entirely of language or have so little as to 
 amount to nothing. Cretins of this class lead little more than a vegetative 
 life, and are not capable of being improved much by education, training, or 
 change of environment. By a study both of their speech and of their mental 
 deficiencies in general they are sometimes placed in two higher classes than 
 
682 AMERICA X TEXT-BOOK OF DISEASES OF CH1LDBEX. 
 
 the one just described. In one the cretins have some language which is 
 capable of being extended ; they improve somewhat by imitation ; they have 
 limited powers of reproduction, but they have little spontaneity or real intel- 
 ligence, and generally their efforts are confined to matters absolutely necessary 
 to their existence and comfort. A higher class of semi-cretins often possess 
 a fair amount of physical and mental development. They can take care 
 of families, which, unfortunately, they sometimes have, and they are capable 
 of considerable intellectual improvement ; in a few cases, indeed, they have so 
 little the characteristics of true cretinism that they are only to be recognized as 
 belonging to these people by one or two peculiarities. 
 
 A peculiar class of cases of fcetal or congenital rachitis has been observed, 
 the children being born with deformed bones, beaded ribs, etc., the bones in 
 some cases being soft. By some the terms infantile osteomalacia and cretinism 
 have been applied to these cases, chiefly because they have failed to present 
 the macroscopic and microscopic appearances of rachitis. They have been 
 described by Bode, Barlow, and Marshall of Preston, who are referred to 
 by Ashby and Wright. 
 
 Through the kindness of Dr. D. T. Laine of Media, Pa., I had the oppor- 
 tunity of seeing an interesting case of this rachitic pseudo-cretinism. The 
 child was three years and seven months old. The sutures were closed, and 
 the head showed a prominence in the right parietal region, and also a large 
 depression in the frontal bone of the same side. The face was broad, eyes 
 wide apart, nose flattened, eyelids drooping, and she had slight right internal 
 strabismus. The bones of the upper arm were slightly curved ; the lower 
 ends of the radius and ulna enlarged and knobbed, these bones being also 
 slightly bent ; the ribs were beaded or irregularly knobbed and the chest 
 contracted; the bones of the legs showed some bowing and curving. The 
 spine showed a rachitic dorso-lumbar curve, more prominent on the left. 
 Liver and spleen were greatly enlarged. The child could barely sit up and 
 hold up her head, and had never been able to stand alone. In appearance 
 she reminded one at first glance of a cretin, and was probably a case of infan- 
 tile osteomalacia. She weighed eight pounds when born, sixteen when five 
 months old, ten when one year of age, and thirty at the time of observation. 
 When born she was very dark-skinned and hairy all over the body. During 
 most of her life her bowels had been much disturbed, and she had one attack 
 of convulsions when about five months old. She cut her first teeth at fifteen 
 months. During the year previous to the time that I saw her she had slept 
 from twelve to fifteen hours out of the twenty-four. As a rule, she was not 
 cross and cried very little. The family history was not good. The maternal 
 great-grandparents were cousins; the maternal grandmother had paralysis 
 agitans; the paternal grandmother had "bowel consumption." 
 
 Etiology. — Cretinism is especially prevalent in high mountain-ranges 
 remote from the coast ; wet or undrained soil appears to have some influence 
 in its development ; and water charged with lime and magnesia is common 
 in the regions in which it is endemic. Practically, the ultimate cause of 
 cretinism is unknown. Brissaud says that goitrous parents necessarily have 
 cretinoid children. Although goitre may be present and cretinism absent, it 
 is undoubtedly true that where goitre exists to any large extent cretins are 
 likely to be found. When the goitre is not present, and even in some cases 
 where it is, peculiar soft, fatty growths may be found in various parts of the 
 body, but usually above the clavicle. In the Philadelphia Hospital case 
 goitre was absent, and also apparently the thyroid, but soft movable masses 
 were found in the neck. By some these are regarded as distinguishing the 
 
PLATE XV. 
 
 SPORADIC CRETINISM. 
 
CRETINISM. 683 
 
 sporadic from the endemic and epidemic forms of the disease, but this is a 
 mistake. 
 
 Pathology. — The pathology of cretinism is ill-defined. The statements 
 of Virchow regarding the premature ossification of the several parts of the 
 bones at the base of the skull have frequently been misunderstood. Ordi- 
 narily, these parts remain separate until puberty, but, according to Virchow, 
 in cretins synostosis may occur at a very early period : this, however, is not 
 the cause of cretinism. While this osseous peculiarity has been found in 
 many cretin skulls, in some instances of undoubted cretinism it has not been 
 present, and Ewald also says that it is by no means pathognomonic. 
 
 Various changes have been found post-mortem and under the micro- 
 scope which are of minor importance ; the brain-membranes, and partic- 
 ularly the dura, are sometimes thickened and adherent, as it is in not a 
 few other forms of arrest ; great variety in the shape and arrangement of 
 the convolutions is found, the tendency being to undue simplicity and small- 
 ness of size of important regions : the important fissures of the brain are ill 
 defined or in unusual positions, and shallowness of the fissures is common. 
 Asymmetry of both the cerebrum and cerebellum has been noted, and a few 
 observations have been made on the relative thickness of the different layers 
 of the cortex, showing great abnormalities in this respect ; but all these are 
 conditions frequently found in the feeble-minded, and are in no way peculiar 
 to cretinism. 
 
 Much more important are the alterations observed in the thyroid gland. 
 Barker (cited by Osier, Amer. Journ. of the Med. Sci., 1897) found changes 
 in this gland in a case of sporadic cretinism confirmatory of those observed 
 in previous cases of endemic cretinism. The thyroid gland in most cases of 
 sporadic cretinism is small or absent, and no statement regarding its normal 
 appearance is of great value unless microscopic examination has been made. 
 Goitre is usually associated with endemic cretinism, and seems to be in causal 
 relation. It is of little moment whether the gland is pseudo-hypertrophied, 
 atrophied, or absent, for if its functions are seriously affected early in life, 
 the cretinoid appearance is likely to be presented. It is proper to state that, 
 according to Hermann Munk, our views in regard to the importance of the 
 thyroid gland in the animal economy must be greatly modified. The gland 
 is not essential to life, although its removal endangers life ; again, the symp- 
 toms which are supposed to result from its removal do not always follow its 
 extirpation. 
 
 Diagnosis. — While cretinism may be, and usually is, regarded as a form 
 of idiocy or imbecility, or closely related to these affections, it differs from 
 them in several essential particulars, as has been shown by various authori- 
 ties. The cretin is not necessarily born to this state, although after several 
 generations the offspring are likely to be cretins or cretinoid cases. For a 
 long time the individual may show no sign of cretinism, although doubtless 
 having within him the potentiality of the disorder. Removal from a given 
 locality to a higher situation, even during the pregnancy of the mother, will 
 sometimes prevent the development of cretinism. It differs from idiocy in 
 being so often endemic, in the comparative improvability of some of its 
 grades, in the presence of symptoms not seen in cases of ordinary idiocy, 
 and in its apparent dependence upon conditions of air, water, or soil. 
 
 It may be occasionally important, as in the case of Dr. Laine referred to 
 under Symptomatology, to distinguish between true cretinism and osteo- 
 malacia, as treatment in either case may be of very great service if begun 
 sufficiently early. The diagnosis can be made by a close investigation for 
 
684 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 the well-known signs of rickets, such as enlarged liver, beaded ribs, and soft 
 or deformed bones, though it must be remembered that the administration of 
 the thyroid gland to cretins may cause softness of the bones. 
 
 The idiotie myxoedemateuse of Bourneville, as shown in the picture of the 
 "Pacha" of the Bicetre, is so similar to the case of cretinism at the Phila- 
 delphia Hospital that one photograph might almost answer for either case. 
 Many of the distinctions which are made between myxoedematous idiocy, 
 cretinoid idiocy, juvenile myxoedema, endemic cretinism, sporadic cretinism, 
 
 Fig. 1. 
 
 Dr. J. P. West's case of infantile myxcedema, before treatment. 
 
 and even some forms of infantilism, are artificial ones. Ewald says there is 
 no distinct difference between sporadic cretinism and infantile myxcedema. 
 The cachexia strumipriva, which develops after removal of the thyroid gland 
 in youth, has the typical features of sporadic cretinism. All these conditions 
 just mentioned are closely connected with absence or degeneration, total or 
 partial, of the thyroid gland, and the clinical appearance varies according to 
 the degree of development of the gland and the age at which the first symp- 
 
CRETINISM. 
 
 685 
 
 toms present themselves. The cretinoid type is most marked when the func- 
 tion of the gland is insufficiently performed at the period of greatest develop- 
 ment of the body. The endemic cretin comes into the world as the offspring 
 of goitrous parents or is himself goitrous, and his appearance necessarily differs 
 from that of the sporadic cretin who has attained a certain degree of develop- 
 ment before the thyroid gland has become functionally inactive. Although 
 many writers hesitate to say that these various diseases mentioned are one 
 and the same, most recognize the close clinical connection between them. 
 
 Fig 
 
 Dr. J. P. West's case of infar 
 
 months' thyroid treatment. 
 
 Infantilism must frequently be regarded as a forme fruste of infantile 
 myxoedema, and, indeed, it is not uncommon to find evidences of the latter 
 disease in cases in which the adult development has been delayed. Idiots 
 of the Mongol type are also closely related to cretins. 
 
 Prognosis. — The prognosis of cretinism depends largely on the persist- 
 ency of treatment and the age at which this is begun. In such a ease as 
 the one at the Philadelphia Hospital little or nothing could be expected, but 
 
686 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 when the cretin is treated in early childhood persistently and carefully, the 
 results are frequently most brilliant (Figs. 1 and 2). 
 
 Treatment. — Cretinism, once fully developed, always leaves its stamp 
 upon the individual, but even a low-grade cretin is capable of a surprising 
 degree of mental improvement, as has been demonstrated by the enthusiastic 
 philanthropic efforts of Guggenbuhl and others in Europe. In cretinism the 
 physical and mental arrest or deterioration go hand in hand to a greater 
 degree than in idiocy, although, of course, in the latter the truth of this 
 assertion will be measured somewhat by the peculiar form of idiocy which is 
 under consideration. 
 
 Monographs and even treatises have been written to show that cretinism 
 is due to this or that atmospheric, telluric, or other cause. Perhaps in a 
 work of this kind it is better to dismiss any consideration of this matter, 
 except as it may bear upon the prophylaxis of the disease. It has been 
 found by abundant experience that the tendency to cretinism is combated by 
 making careful selection of drinking waters which are contaminated with 
 peculiar salts, as magnesium, iron, etc. ; also, that the removal of the mothers 
 who are pregnant, or of the young children who are born in the neighbor- 
 hoods where cretinism has a tendency to become endemic, to remote and 
 higher districts will sometimes prevent the development of the affection. 
 
 Experimental investigations have shown that a myxoedematous condition 
 develops after removal of the thyroid gland, and transplantation of the 
 thyroid gland from one animal into the abdominal cavity of another in which 
 the gland had been removed has been attended with beneficial results. Act- 
 ing on these suggestions, a number of physicians were led to experiment 
 with the feeding of the raw thyroid gland of the sheep. The dish was most 
 unpalatable to many, and a disgust was often created which was frequently 
 sufficient to interfere with the administration of the remedy. Tablets were 
 then manufactured, and in this way the remedy is now more easily given. 
 Wonderful changes have been observed, and even cures, in cases in which 
 the treatment was commenced early in childhood. Osier begins the admin- 
 istration with a grain of the desiccated gland three times a day in young 
 cretins, and watches for increase in the pulse-rate and the appearance of 
 fever. Older patients may take five grains daily, and this amount may be 
 increased. After a satisfactory degree of restoration has been attained one 
 or two five-grain tablets a week are sufficient to prevent relapse. A physi- 
 cian should not rest content after giving a prescription for the administra- 
 tion of thyroid gland, but the effects of the treatment should be carefully 
 watched. Not infrequently very unpleasant symptoms arise. Tachycardia, 
 pyrexia, insomnia, tremor of the extremities, exophthalmia, polyuria, albu- 
 minuria, and glycosuria — in fact, a complete picture of Graves' disease — 
 have been observed after excessive doses of thyroid gland. Occasionally the 
 rapidity of growth produced by the administration of the gland may lead to 
 curvature of the legs, and this condition has been observed in an extreme 
 degree. General hygienic measures should not be forgotten. 
 
MYOTONIA, OR THOMSEFS DISEASE. 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Myotonia, or Thomsen's disease, like other family forms of disease, such as 
 Friedreich's ataxia and several types of dystrophy, should receive attention in 
 a treatise on diseases of children ; for, although it may develop after puberty, 
 it is most frequently detected before the age of ten years, and it has been 
 observed and studied even in infants. The name by which it is best known is 
 derived from Dr. J. Thomsen of Schleswig-Holstein (Arch. f. Psych., 1876, 
 vol., vi.), who wrote of the affection as occurring in himself and in numerous 
 members of his own family in different generations, although before his time 
 it had been described by Leyden and had been referred to by Sir Charles Bell. 
 In 1886, Erb published a valuable monograph on this subject and a few other 
 articles of more or less value have appeared during the last ten years, one of 
 the most important of these by Gr. W. Jacoby {Jour. Nerv. and Mental Dis., 
 March, 1887). I recorded a case under the title of "Myotonia and Inertia 
 on Voluntary Effort" (Intern. Clinics, April, 1891), and, although this patient 
 was first seen by me when he had reached the age of nearly forty years, he 
 could trace back some of the symptoms of the affection to childhood. When 
 a boy ten years old his father had taken him to a medical college to get advice 
 about his hands, which were even then in some way afflicted with weakness 
 or with clumsiness and difficulty in using them. His feet were also slightly 
 affected in childhood, and he was somewhat stiff in his movements. 
 
 Symptoms. — The special symptom of myotonia, or Thomsen's disease, 
 is a tonicity or stiffness of the muscles, with inertia or inhibition of movements 
 coming on with voluntary effort after a long period of rest, the morbid phe- 
 nomena not being present or not attracting attention during the latter period. 
 The prompt and easy performance of all movements is sooner or later interfered 
 with by the spastic state. After the muscles have been used for a short time the 
 stiffness may pass off, so that the patient who has the greatest difficulty in 
 initiating movements will soon be able to walk with increasing ease, and once 
 fairly afoot may continue to walk without trouble for hours ; but after an inter- 
 val of rest the whole morbid process will be repeated. As a rule, the muscles 
 of the face are not affected, but this is not invariable, and in one of the cases 
 of myotonia reported by me some of the most striking phenomena were exhib- 
 ited by the muscles of mastication, and in a second case of myotonia and athe- 
 toid spasm the facial contortions and snapping of the eyelids were very marked. 
 These cases were adults, although in one of them the affection had originated 
 in childhood, and was probably congenital. Usually the phenomena are most 
 marked in the lower extremities. Sensation is not affected. Trophic changes 
 are not present, but the muscles are bulky, although their strength is not 
 commensurate with their size. Erb and Jacoby have called attention to the 
 peculiar changes in the mechanical and electrical excitability of the muscles. 
 
688 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Erb believes that Thomsen's disease may be diagnosticated by a few clo- 
 sures of the galvanic current and a few blows with a percussion hammer, but this 
 is doubtful, except perhaps in absolutely typical cases. The electrical response 
 has been termed the myotonic reaction. In examining patients for this a large 
 electrode is placed upon the sternum or back of the neck, and another of 
 smaller size in the palm of the hand. Using a galvanic current of sixteen or 
 eighteen cells and allowing the current to flow, a tonic spastic condition of the 
 muscles of the arm occurs. In a little while, particularly after changing the 
 poles with the commutator, curious wave-like contractions take place in a serial, 
 rhythmical order. These undulations move upward or downward according to 
 the position of the anode and cathode — downward when the anode is in the 
 hand, upward when the cathode is in the same position. They move inward 
 from the negative to the positive. Erb has compared the single waves to those 
 produced by a stone falling in water. He considers that the best places for 
 the application are the flexors of the forearm, the palm of the hand, or the 
 volar surfaces of the wrist-joint and nape of the neck. The amount of current 
 requisite for the production of the phenomena varies from six to twenty mil- 
 liamperes (Jacoby). Briefly, the peculiarities of the so-called myotonic reac- 
 tion are increase and change in the faradic muscular response, while the excita- 
 bility of the nerves to this current remains normal. Similarly, to the galvanic 
 current the muscles show increased excitability and qualitative changes, the 
 nerve-reaction not being affected. With Jacoby, I have not been able to verify 
 the difference between nerve and muscle application. The mechanical as well 
 as the electrical excitability of the muscle is changed, so that in a typical case 
 tapping on the muscles will cause unusual response, a slight blow, for instance, 
 producing a marked grooving or furrowing of the muscles. 
 
 Etiology. — Heredity is the most important factor in the production of 
 the common types of myotonia. It is pre-eminently a family disease, although 
 not infrequently, instead of a family history of the affection clearly myotonic 
 in character, the ancestors, direct or collateral, may have suffered from some 
 form of neurotic degeneration or may have been the subjects of some con- 
 stitutional taint or toxic affection, as alcoholism. In one family, that of a patient 
 recorded by Bernhardt, consanguineous marriages were frequent, but these 
 may simply have intensified a pre-existing tendency. It is more often a disease 
 of males than of females. Fright, intense emotion, and injuries, have been 
 assigned as exciting causes. Of the cases occurring after puberty, Gowers 
 records one as having resulted from prolonged and severe exertion continued for 
 two years in a man without hereditary tendency, and the same author cites a 
 lightning stroke as a clearly proved exciting cause. 
 
 Pathology. — No autopsy supported by careful microscopical examination, 
 so far as I know, has as yet been made. As a rule, the disease has been regarded 
 as essentially muscular, rather than of central or peripheral nervous origin, 
 but this must be regarded as an unsettled question. The relations between the 
 muscular and the connecting and controlling nervous apparatus are so intimate 
 that in the absence of pathological proof the real nature of this or any similar 
 affection must remain in doubt. The primary change may be in the nerve-cells 
 of the cord, of the basal centres, or even of the cerebral cortex, or it may 
 be at the other extremity of the system, in the end-plates in the muscles. 
 The evidence so far is in favor of the disease being muscular and functional. 
 In several instances pieces of muscles have been excised during life, and have 
 been submitted to a careful microscopical examination, and Erb and Jacoby, 
 among others, have made interesting reports upon the conditions present. Erb 
 found an enormous hypertrophy of all muscular fibres and great proliferation 
 
MYOTONIA, OB THOMSEN'S DISEASE. 689 
 
 of nuclei, with alterations of the minute structure and a slight increase of the 
 perineurium. Jacoby demonstrated another characteristic change — the distinct 
 division of the muscle-fibres into angular fields, the threads of connecting pro- 
 toplasm being broken almost everywhere. The motor-nerves and the motor 
 end-plates show no deviation from the normal. 
 
 " In Thomsen's disease," says Jacoby, " the motor nerves and motor end- 
 plates do not show any deviation from the normal, so that the nerve impulse is 
 transmitted into the muscle-fibre in the same manner as in the normal condition. 
 The result of the reception of impulse will be a contraction, which, especially 
 after a certain rest, will be a hypercontraction, or, rather, tetanus. This 
 tetanus leads to an agglomeration of a certain number of sarcous elements 
 which break into a continuity of the contracted clusters. In consequence of 
 this tetanus the nerve-influence is inhibited for so long as the tetanus lasts. 
 After the lapse of a few seconds the tetanic contraction will subside, the con- 
 tinuity between the hitherto separated groups of sarcous elements will become 
 re-established, and the propagation of nerve influence will be again rendered 
 possible. We can thus understand the peculiar reaction of the muscles to the 
 various stimuli when applied directly to them, but why the muscles should react 
 differently to indirect stimulation is still inexplicable." 
 
 Diagnosis. — Diseases which have some likeness to myotonia are tetany, 
 pseudo-muscular hypertrophy, and some forms of sclerosis. I have also seen a 
 hysteroidal affection which somewhat closely resembles this disease, but the 
 characteristic spastic phenomena and the conditions of electrical and mechanical 
 irritability will prevent mistake on the part of a careful investigator. A form 
 of myotonia, designated paramyotonia, has been described, which differs some- 
 what from Thomsen's disease, but is also a family affection. One difference 
 which has been noted is that the spasticity is not initiated by voluntary move- 
 ments, but may be by exposure to cold. Myotonia as a symptomatic affection 
 is observed in several forms of spinal and cerebro-spinal disease ; it has been 
 described, for instance, as occurring in connection with ataxia. 
 
 Prognosis. — The prognosis of myotonia is unfavorable, although the 
 disease does not particularly shorten life. 
 
 Treatment. — No treatment is of any practical avail. The patients may 
 live long lives. Thomsen, speaking from personal experience, believes that 
 active muscular exercise is beneficial. Patients learn by experience to take 
 care of themselves. One of the most serious evils of the disease in one of my 
 cases was the tendency of the patient to have sudden falls, owing apparently to 
 the spastic locking of his muscles. He learned by watching his movements to 
 control the occurrence of these falls. Usually in childhood the disease has not 
 advanced sufficiently to call for special protective measures, unless it be the avoid- 
 ance of cold and emotional excitement. 
 
 44 
 
ACROMEGALY. 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Acromegaly, sometimes termed Mane's disease, was first described by 
 Marie about 1886. As the derivation of the word indicates, it means enlarge- 
 ment of the extremities. Acromegaly, as a rule, occurs between the ages of 
 eighteen and thirty years, and therefore the subject is not of first importance 
 in a work on the diseases of children, but a few cases have been recorded as 
 occurring in early childhood, and even as congenital. Recently Moncorvo of 
 Rio Janeiro {Revue Mensuelle des Maladies de VUnfance, Dec, 1892) reported 
 a well-marked case observed in conjunction with microcephalus in a female 
 infant fourteen months old. The mother was a delicate, nervous woman, who 
 during her pregnancy had been subject to violent emotion. At fourteen 
 months the child exhibited congenital microcephalus, idiocy, aphasia, para- 
 plegia, and contractures, and the fundamental symptoms of acromegaly — 
 namely, the retreating forehead ; the vertical elongation of the oval of the face ; 
 the great enlargement of the nose ; the prominence of the superior maxilla ; 
 the thickening and advancement of the lower lip ; the cervico-dorsal kyphosis, 
 with lumbar lordosis and projection of the anterior plane of the chest, compen- 
 sated for by flattening of the abdominal wall ; and, finally, the spade-like hands, 
 with prominent thickening of the palmar surfaces, and short fingers of uniform 
 width and sausage-like appearance. In another case, cited by Moncorvo from 
 Freund, the disease commenced as early as puberty. 
 
 In a series of cases studied by me at the New Jersey Home for the Educa- 
 tion and Care of Feeble-minded Children, at Yineland, one remarkable case 
 was found in a boy who was at the time of examination sixteen years old, but 
 who had suffered for years from the disease then present. This boy was the 
 first-born after difficult labor; his mother was feeble-minded, his father a 
 chronic alcoholic; he could dress and feed himself; his speech was imperfect, 
 but he could read and write a little; he was excitable and inclined to be 
 gluttonous. He attended school with very poor results for seven years. 
 
 He exhibits two different conditions according to the time when he is studied. 
 For weeks he will be in fairly good health, happy, lively, and disposed to make 
 himself generally useful. His hands and feet are dusky and cold. When the 
 hands are pendent, the dusky area reaches to at least two inches above the wrists, 
 but when they are held above the head the entire limbs become to a less degree 
 of the same hue. He has a marked tendency to indolent ulceration, particularly 
 in the distal portions of the extremities. At the end of the index finger of the 
 left hand are the remains of a formation similar to one which appears from time 
 to time at the end of any of the fingers. The finger-tip swells, and in a little 
 time contains serum and sometimes pus. The toe-nails are black or brownish 
 and ridged roughly. Both hands and feet are abnormally large (Fig. 1). No 
 
 690 
 
ACB03IEGALY. 
 
 691 
 
 loss of sensation was determined. Knee-jerk and muscle-jerk are about normal. 
 He remains in about the same condition for weeks, when a change comes on, 
 almost acutely. His face, arms, hands, legs, and feet swell perceptibly, increas- 
 ing sometimes almost one half, and this swollen state will last a month or six 
 
 An Acromegaloid Case. 
 
 weeks, and then gradually disappear, leaving him very weak, his pulse at the 
 end of these periods being scarcely perceptible. During the attacks he is 
 obliged to keep his bed most of the time, and is in a condition of general las- 
 situde and depression. 
 
 While this case may not, strictly speaking, be one of acromegaly, it is a most 
 interesting allied vaso-motor and trophic disorder, with permanent enlargement 
 and transient changes in the extremities, these increasing at periods. 
 
 Symptoms. — Acromegaly is a trophic disease characterized chiefly by a 
 gradual increase in size of the extremities, and usually also of the face. Acro- 
 megaly usually begins with progressive enlargement of the hands, feet, and 
 head. The hands and feet may become of enormous size, the other related 
 parts not increasing proportionately. Marie has suggested the name of battle- 
 dore hands, while the English have sometimes described them as spade-like. 
 Of the parts of the head, the face is usually most strikingly involved, being 
 enlarged particularly from above downward. The hypertrophy attacks both 
 the soft and hard parts. Sometimes the tongue, lips, nose, and lower jaw 
 become enormously increased in size. Rheumatic or neuralgic pains may be 
 present. The skin is often dry. The special senses are sometimes affected; 
 vision, in particular, is likely to suffer. Forms of hemianopsia or sector defects 
 
692 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 in vision have been observed. Anaesthesia is not commonly present. The 
 affection as seen in children, so far as reported cases are concerned, has been 
 chiefly in those who exhibit evidences of idiocy or imbecility. 
 
 Pathology. — The pathology of acromegaly is practically unsettled. In a 
 number of autopsies which have been made, in almost every case some enlarge- 
 ment of the pituitary body has been present ; still, this change is not constant, 
 and some diseases of this organ certainly do not cause acromegaly. A case of 
 pernicious anaemia at the autopsy, in which I took part, revealed a hemorrhagic 
 tumor of the pituitary body, but the patient had none of the phenomena of 
 acromegaly. In this case, however, as in acromegaly, the fundamental perver- 
 sion was of nutrition. Efforts have been made to relate the occurrence of the 
 disease to lesions or absence of other organs, as, for instance, of the thymus or 
 thyroid gland. The truth is that the exact pathology of the disease is as yet 
 unknown, although interesting autopsies have been reported. More is known 
 about the peculiarities of the pathological conditions present in various organs 
 and tissues of the body. The bones, particularly the vertebrae, the clavicles, 
 and the long bones of the limbs, are the seat of hypertrophic processes. The 
 bone enlargement is regarded as a true hypertrophy rather than an inflamma- 
 tion, an increase due to surplus of nutritive energy or pabulum, or both. In 
 one case of Virchow's the pituitary body was carefully examined and found 
 to be absolutely normal. 
 
 Diagnosis. — The diagnosis of acromegaly is not difficult to make, once on 
 the alert for its occurrence. Other affections in children simulate it to some 
 extent, as, for example, myxcedema and cretinoid disease : true cretinism could 
 not be mistaken for acromegaly. In myxcedema the swelling is not particu- 
 larly of the extremities, but of the subcutaneous tissues; and the differences in 
 the color and appearance of the skin, and in the condition of the thyroid, will 
 serve to separate it. 
 
 What is sometimes spoken of as gigantism might be confounded with acro- 
 megaly, but the one differential point is that in gigantism the great dispropor- 
 tion between the extremities and the main portion of the limb is not present. 
 In gigantism the individual may be unusually tall, in accordance with the gen- 
 eral increase in all directions, while patients afflicted with acromegaly are as 
 likely to be under as over the average size. The pulmonary osteo-arthropathy 
 described by Marie would be distinguished from ordinary acromegaly by the 
 presence of the pulmonary lesions and the peculiar deformities of the terminal 
 phalanges. Marie has described these deformities as, if observed sideways, hav- 
 ing some resemblance to the head and curved beak of a parrot, In acromegaly 
 the nails, if anything, are too small for the parts they cover, while the nails in 
 pulmonary osteo-arthropathy are deformed as well as the fingers. In a disease 
 known as partial acromegaly a considerable hypertrophy of one half of the body, 
 or of a limb on one side, or one side of the face, may be present. In this dis- 
 ease, however, true deformity is always present, and it is usually unilateral 
 and congenital. 
 
 Many instances of hypertrophy of the fingers and toes have been reported ; 
 they must be separated from true acromegaly, although it is possible that 
 these diseases have something in common, and such cases might be classed 
 under the head of partial acromegaly. Recently a case of this kind was seen 
 by me in consultation, and was presented at the meeting of the Philadelphia 
 Neurological Society by Dr. W. J. Taylor. The first and second toes of the 
 left foot were enormously enlarged, and the third toe was also hypertrophied 
 to a less degree. The hypertrophy was much the greatest in the second toe. 
 This deformity of the foot, according to the mother's statement, was present at 
 
ACROMEGALY. 693 
 
 birth, but she thought that the left leg and foot had been growing out of pro- 
 portion to the right. The nails were thin and imperfect, showing evidences of 
 bad nutrition. Both feet and hands were of good and perhaps of unusual size. 
 Such affections probably have some pathological relationship to the disease here 
 considered, but one which has not yet been clearly determined. Operations 
 are sometimes resorted to for their relief, but the question of the central nature 
 of the affection and its probable progressiveness deserves consideration by the 
 surgeon. 
 
 Prognosis. — Acromegaly is essentially an incurable disease, but may make 
 no progress for years. 
 
 Treatment. — Some good is reported to have been obtained by the use of 
 remedies like arsenic, the iodides, the alkalies, and special diet. The headache, 
 often present, may be relieved by some of the remedies ordinarily used for 
 congestive or neurotic headaches, as antipyrin, antifebrin, the salicylates, 
 and phenacetin. 
 
ATHETOSIS AND ATHETOID AFFECTIONS. 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Athetosis, a word meaning "without fixed position," is a name first given 
 by Dr. W. A. Hammond to a peculiar mobile spasm observed chiefly in the 
 finger and toes. Strictly speaking, it is not a disease, even in the ordinary 
 clinical sense ; it is usually part of a symptom-group which indicates the pres- 
 ence of some lesion of the cerebrum. The movements of athetosis are diffi- 
 cult to describe. They are most commonly observed in the upper extremity 
 of one side, being particularly marked in the fingers and hand, but occasion- 
 ally they are bilateral. Hughes of St. Louis ( Weekly Med. Review, 1887) has 
 reported a case of bilateral athetosis coming on in a boy about one year after a 
 railroad accident which caused injury both by concussion and direct violence, 
 although the case was not fully developed for several years. This boy had not 
 complete voluntary control over the movements of his muscles ; he could not, 
 by direct effort of the will along the regular channels of nerve conduction, 
 restrain either the rhythmical movements or the spasmodic attitude of the 
 fingers, but he could, by strategy, modify both attitude and movement by 
 bringing one limb to bear upon another and by assuming for the affected limbs 
 flexed positions ; but, no matter how much he succeeded in managing these 
 movements, grotesque attitudes would always recur in one or more of the 
 fingers. His affliction unfitted him for occupation requiring manual dexterity. 
 He tried a number of things, but had to give them up because of physical 
 incompetency. 
 
 Athetosis is most frequently congenital or an affection of early childhood, 
 occurring particularly in connection with some of the forms of cerebral palsy 
 in children which have been described in this work by Peterson. Church 
 (Review^ of Insanity and Nervous Disease, March, 1892), has recorded an 
 interesting case of symmetrical and universally distributed athetosis in a woman 
 thirty years old, who had suffered from the affection since birth. She was 
 lacking in mental development ; face and speech were both affected. Many 
 instances of what might be termed athetoid affections are to be found, particu- 
 larly among idiotic and imbecile children. These differ from typical athe- 
 tosis in the irregularity and wide diffusion of the mobile spasm. Several 
 cases of this kind are nearly always present in the nervous wards of the Phila- 
 delphia Hospital. One, a mentally defective deaf-mute about thirty years old, 
 has been subject, probably from early childhood, as no history can be obtained, 
 to excessive and irregular movements and distortions, particularly of his face 
 and upper extremities. 
 
 Symptoms. — Athetosis, as already indicated, is a word descriptive of a 
 series of grotesque, irregular, and yet monotonous, involuntary movements 
 which are persistent, but subject to exacerbations, and are usually confined 
 to an extremity or the extremities of one side. The movements are more or 
 
 694 
 
ATHETOSIS AND ATHETOID AFFECTIONS. 695 
 
 less rhythmical, and do not seem to cause the patient fatigue, in this respect 
 being like other rhythmical spastic affections of functional or organic origin. 
 By a strong effort of the will the patient can usually control the movement. 
 As a rule, sensation is not impaired. The muscles on the affected side are 
 often hypertrophied. The condition of the reflexes and so-called reflexes 
 vary, but the knee-jerks and other allied phenomena may be increased on the 
 affected side. As the disease is usually cerebral in origin, electrical changes 
 are commonly not present. 
 
 Etiology. — The etiology of athetosis is that of the organic affection of 
 which it is a symptom or with which it is associated. It may be caused by 
 accident, as in Hughes's case of bilateral athetosis to which reference has been 
 made, but whether or not athetosis results will depend upon the particular 
 lesion which is inflicted on the nervous system. The disease has been 
 attributed to fright or undue excitement of the mother during pregnancy, 
 and fright has been given as a special exciting cause in a few instances, 
 but on uncertain grounds. It is much more likely to cause chorea or cho- 
 reoid affections. Many cases of athetosis and of athetoid affections are asso- 
 ciated with well-defined idiocy or imbecility, and are dependent upon the 
 same causes, hereditary, developmental, or accidental, which have led to the 
 latter. According to Striimpell, athetosis may be a sequel of polioen- 
 cephalitis ; and I am inclined to subscribe to this opinion, although the very 
 existence of this disease in children has been denied by authors of ability. 
 Toxic agents by affecting the motor cortex or subcortex may cause this 
 affection. 
 
 Pathology. — The lesions in reported cases of athetosis have been largely 
 in the basal ganglia or their immediate neighborhood. In one case a sclerotic 
 nodule was found in the thalamus very near its central upper surface, and in 
 several other instances lesions have been discerned in the same great ganglion ; 
 but in nearly all of these cases neighboring parts, as the caudate nucleus, 
 internal capsule, or corona radiata, have also been involved. Undoubtedly, 
 mobile spasm may depend upon lesions either of the thalamus, the striate 
 bodies, the motor cortex, or any part of the cerebral motor tract. In one 
 interesting case of athetoid spasm and myotonia, occurring in an adult, re- 
 ported by me, and in which an autopsy was obtained, some light was thrown 
 on the character and situation of the lesions which may in some instances 
 produce athetoid spasm. The most striking features were brought out when 
 the patient attempted any voluntary movement, and among other manifestations 
 his fingers were twisted and thrown into a position which illustrated well one 
 of the forms of athetosis of the upper extremity. Many other phenomena, sen- 
 sory and motor, were present in the case and are detailed in the report (Intern. 
 Clinics, April, 1891). The autopsy showed that in both hemispheres, chiefly 
 over the superior and inferior parietal gyri, the dura was adherent to the pia 
 mater, the pia was deeply injected, thickened, and infiltrated with plastic 
 lymph, and in numerous places was more or less firmly fixed to the brain- 
 substance; but the injection, infiltration, exudation, and adhesions were much 
 more marked in the postero-parietal regions than elsewhere. Beneath the 
 area of meningitis both the cortex and the subcortex were softened, giving the 
 appearance on the right side of a sunken, subcortical, or subpial cyst. On the 
 left side of the brain, in a nearly corresponding but somewhat smaller area, was 
 a similar belt of inflammation and softening. Subsequent incisions on both 
 sides showed that the softening included the whole of the gray matter, and 
 involved to a considerable extent the white, but did not invade the ganglia or 
 capsules ; it was confined to the supraventricular corona radiata. In cases 
 
696 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 unassociated with hemiplegia or diplegia, irritative foci in the motor areas or 
 tracts may give rise to the affection ; and Gowers believes that it is sometimes 
 due to impaired nutrition of the growing motor cells. 
 
 Diagnosis. — Typical cases of athetosis are not difficult of recognition. 
 Occasionally cases of hemichorea and hemiathetosis in children might be tem- 
 porarily confused. The movements of athetosis are said to continue during 
 sleep, and this is certainly true of some cases. Post-hemiplegic chorea and 
 athetosis may be confused ; and, indeed, chorea secondary to a paralytic 
 attack and this affection differ but little in nature and characteristics. In 
 this work Peterson has described, as occurring in two cases of congenital hemi- 
 plegia, an affection to which he has given the name of post-hemiplegic poly- 
 myoclonus, in which the movements are neither choreiform nor athetoid, but 
 are chronic, constant contractions of most of the muscles of the limbs affected. 
 The face is seldom affected alone in a disorder which may properly be called 
 athetosis. In athetosis, as contrasted with chorea, the movements, although 
 irregular and bizarre in themselves, have a certain regularity and monotony in 
 their method of repetition, which is not the case with choreic movements. 
 
 Prognosis. — The prognosis in the vast majority of cases is bad, as the 
 disease is due to an incurable, often congenital, organic condition. A case of 
 primary athetosis which is quoted by Jacoby from Gnauck {Keating 's Cycl. 
 Dis. Children, vol. iv.) resulted in complete recovery, and many cases have 
 been reported as improved, but such reports are always of uncertain value. 
 Usually the affection goes on from bad to worse very slowly. Not infrequently, 
 athetosis or athetoid movements are associated with general convulsions, and 
 the latter may be much improved by the treatment employed for epilepsy. 
 Organic athetosis must, of course, from the very nature of the affection, have 
 an exceedingly unfavorable prognosis. A disease which is due to atrophy, 
 sclerosis, neoplastic formations, meningo-encephalitis, or softening, can scarcely 
 be otherwise than incurable. The only point in diagnosis is to separate a 
 few cases of pseudo-athetosis of hysterical or neurotic origin from those of the 
 common type. Hysterical athetosis is possible, has been observed, and has a 
 favorable prognosis. i 
 
 Treatment. — It follows from what we have already said as to their nature 
 that little can be done in the way of treatment for these interesting but usually 
 hopeless cases. Nerve stretching will temporarily stop the movemerits, just 
 as it will in cases of histrionic or facial spasm due to organic lesion, but 
 as soon as the nerve has recovered from the traumatism the movements will 
 begin to return, and will soon be present again in their original intensity. 
 Galvanism has been frequently employed, 'but is of little permanent value. 
 The iodides, bromides, and mercury may be used in cases in which a tumor or 
 meningitis is supposed to be present. Remedies like conium, hyoscine, opium, 
 gelsemium, may be tried, but from the very nature of the cases can only be of 
 temporary value. 
 
INSANITY IN CHILDREN 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Although juvenile insanity is comparatively rare, it is sufficiently important, 
 both clinically and medico-legally, to demand systematic consideration in a trea- 
 tise on the diseases of children. It is important not only in itself, but also in its 
 bearings on the mental and physical health of the patient after he has reached 
 adult life. The varieties of insanity which occur in early childhood are largely 
 the same as those of youth and manhood, but they have special characteristics 
 due chiefly to age. These affections are distinct from idiocy, imbecility, and 
 cretinism, although idiotic and imbecile children may have attacks of mental 
 excitement or depression, or other evidences of active insanity. The two con- 
 ditions of arrest and of acquired disorder must be separately regarded and dis- 
 cussed. Morison, in his Lectures on Insanity, speaks of having frequently met 
 with violent and unmanageable idiots of a very tender age. 
 
 The mental affections to which particular attention will be directed are those 
 which occur in children presumably born with at least an average degree of 
 intelligent power and possibility. Although it is difficult to separate moral 
 insanity and moral imbecility in children, yet such a distinction can sometimes 
 be made with advantage, and therefore the former will receive brief consider- 
 ation in this section. 
 
 The difference between insanity in the child and in the adult is in harmony 
 with known facts and physiological principles regarding the evolution of the 
 mental faculties. "The insanity met with in children," according to Maudsley 
 [The Physiology and Pathology of Mind), "must of necessity be of the sim- 
 plest kind ; where no mental faculty has been organized no disorder of mind 
 can well be manifest." The forms and degrees of insanity exhibited by chil- 
 dren according to their stages of mental evolution and their acquired habits 
 have been well discussed by this able psychologist and alienist. Violent and 
 convulsive response to sensorial impressions gives rise to mental disorder of an 
 epileptiform character ; or, once the power of definite sensory impression has 
 been acquired, and hallucinations are possible, these may lead to choreic reac- 
 tions. Some forms of nightmare in children are the result of vivid hallucina- 
 tions which have arisen in response to such impressions. Hallucinations may 
 occur before the mind is sufficiently organized to make delusion possible ; but 
 later, after a varying time, ideas or concepts become organized, so that the 
 child is able to think about absent objects. Ideas which are at first simple 
 and isolated become elaborated and grouped, and as soon as ideas are fully 
 organized, delusion, which is an insistent baseless belief, becomes possible. 
 
 True insanity in children has been observed at a very early age ; indeed, 
 Greding has reported one case, cited by Crichton and Maudsley, of a child who 
 is said to have been raving mad when it was born. The mother was about 
 forty years old, was of full plethoric habit, and constantly laughed and did 
 
 697 
 
698 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 strange things, but otherwise was in the best of health ; she was delivered of a 
 male child who possessed so much strength in his arms and legs that four women 
 could at times with difficulty restrain him. His paroxysms of motor excite- 
 ment either ended in uncontrollable fits of laughter or else he tore everything 
 or anything near him. Mania has also been reported by Greding as beginning 
 at nine months in a child who died at eighteen months old ; by Rush and others 
 at the age of two years. Sinkler ( Univ. Medical Magazine, Jan., 1893), has 
 reported two interesting cases in children three years old. Many cases have 
 been reported as occurring between the ages of five and twelve or thirteen 
 years. 
 
 Varieties of Insanity in Children. — It would serve no useful purpose 
 to attempt a formal classification of the insanities of childhood, and it is 
 best, therefore, simply to consider the subject under such heads as experience 
 and published records indicate. All forms of insanity may occur before 
 puberty, although some are very rare. According to Cohn {Arch. f. Kinder- 
 heilk., Bd. iv.), juvenile insanity should be divided into functional and organic, 
 under the former subdivision placing those neuroses which may be in part, or 
 may develop into, psychoses, as the insanities of chorea, epilepsy, and hysteria, 
 and also what might be termed idiopathic psychoses, such as hallucinatory 
 confusional insanity, hypochondriacal insanity, melancholia, mania, and moral 
 insanity; while the latter are comprised under such forms as exhibit clear 
 manifestations of organic cerebral disease, as, for example, the rare cases of 
 paretic dementia and mental affections due to tumor, abscess, meningitis, or 
 other determinable lesions. 
 
 It will be convenient for practical purposes to arrange juvenile insanities 
 under the following heads : 1, Transitory Psychoses ; 2, Mania ; 3, Melancho- 
 lia; 4, Circular or Alternating Insanity; 5, Choreic Insanity; 6, Hysterical 
 Insanity ; 7, Cataleptic or Cataleptoid Insanity ; 8, Epileptic Insanity ; 9, Para- 
 noia or Primary Delusional Insanity ; 10, Moral Insanity ; 11, Instinctive Per- 
 versions and Morbid Impulses; 12, Morbid Fears or Phobias; 13, Paretic 
 Dementia. 
 
 A favorite method of classifying insanity, and one which has much that is 
 practical in its favor, is on the basis of etiology, but it has disadvantages, and 
 may be scientifically misleading. In some instances, however, 4)oth in adults 
 and in children, special causes are so prominent in the production of certain 
 types of insanity that it serves a good purpose to name the affections from the 
 point of view of causation. Understanding that different forms of insanity 
 from the semiological standard may be produced by the same or similar causes, 
 we may have in children such etiological varieties as dementia due to inherited 
 syphilis, febrile and post-febrile insanities, reflex insanity, masturbational 
 insanity, and many others, according to the views of the alienist discussing 
 the subject. 
 
 Transitory Psychoses.— Although any form of non-organic insanity in 
 a child is likely to be transient, because it has not the soil in which to take firm 
 root, still certain phases or varieties of mental disturbance in the very young 
 can because of their fleeting character be conveniently classed as transitory 
 psychoses. Under this head would be placed a form of delirium arising in 
 young children from special causes. It is well known to mothers as well as to 
 physicians that some children have a greater tendency to attacks of delirium 
 than others. In them the slightest rise in temperature, as of one or one and a 
 half degrees, will always be attended with more or less delirium. Sometimes 
 this delirium, mild in type and without any special features, constitutes the 
 entire case ; but an attack of delirium may be prolonged and take the form 
 
INSANITY IN CHILDREN. 699 
 
 of a true although a transient and non-tenacious mania. The child may have 
 frightful hallucinations, especially of sight or hearing. 
 
 Speaking of the insanity of young children, Maudsley well says that " the 
 precocious imagination of a child which sometimes delights foolish parents can- 
 not possibly be anything more than lying fancy ; and this for exactly the same 
 reason that the insanity of children must be a delirium, and cannot be a mania 
 — the incomplete formation of ideas and absence of definitely organized asso- 
 ciations between them." 
 
 Pavor nocturnus, or night-terrors, might be classed with the transitory 
 psychoses of children, but this affection is discussed in another article. 
 
 These transient psychoses may take the form of an excited or agitated 
 melancholia, as mentioned by Clouston ( Clinical Lectures on Mental Diseases, 
 1884), the patients in such cases screaming, sobbing, weeping, and giving evi- 
 dence of great mental suffering and depression, usually without being able to 
 give any reasons therefor, although they will sometimes speak of seeing or hear- 
 ing something, or more or less vaguely of being worried or frightened by appre- 
 hensions of evil or injury. 
 
 The affection variously known as transitory frenzy, mania transitoria, or 
 ephemeral mania, which in the adult has often been the subject of medico- 
 legal dispute, occasionally has been observed in children — an abrupt, rapid dis- 
 order, lasting only a few minutes or hours. Morel {Maladies Mentales, 1853), 
 speaks of a little girl eleven year old who after the sudden disappearance of a 
 skin eruption exhibited choreic symptoms, and soon after those of a true mania- 
 cal fury in which she became homicidal ; and other cases of transitory fury, 
 some traceable to special causes and some not, have been reported by various 
 observers. 
 
 Mania* — Mania is the form of insanity of most frequent occurrence in 
 childhood. It usually shows itself by active delirium, great motor excitability, 
 screaming and crying, incoherence, and sometimes by hallucinations, and even 
 delusions of slight tenacity in children old enough to have ideas. Exacerba- 
 tions of extreme fury or violence come on in the course of the general excite- 
 ment ; convulsions sometimes occur, and speech may be lost, as in a case 
 reported by Morel of a girl ten and a half years old. It was necessary to send 
 her to an asylum, and she never seemed to be happy unless she was destroying 
 something or tormenting somebody. A boy five years old was suddenly fright- 
 ened, lost the power of speech, was turbulent, and had frequent maniacal 
 paroxysms. These little patients sometimes exhibit great anger and destruc- 
 tive and even homicidal impulses and propensities ; but these acute morbid 
 impulses and propensities must be distinguished from those which are due to 
 character, and will be referred to later when speaking of instinctive insanity 
 and morbid impulses. 
 
 Melancholia. — Melancholia is not an uncommon form of insanity in chil- 
 dren, but it is not likely to occur before the age of five or six years. It is 
 always necessary to distinguish between monomanias or paranoias and melan- 
 cholias, but genuine uncomplicated melancholia is sometimes seen in children, 
 and has been reported by numerous observers. Hallucinations may or may 
 not be present with the mental depression. Melancholy in a child seldom 
 assumes the extreme form which is observed so frequently in the adult, but now 
 and then a true agitated melancholic frenzy is observed. Ordinarily a child 
 suffering from melancholia will be sad, anxious, weeping, restless by day and 
 by night, wanting in the liveliness and changeability of children — blue, 
 depressed, worried and worrisome, knowing not why. Delusions so common 
 in adults, as of self-condemnation, of the unpardonable sin, of coming to want, 
 
700 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 or of fatal organic disease, are often absent in the melancholia of children. 
 Children brought up in morbidly religious or in distressing surroundings 
 sometimes exhibit a delusional state of a religious or painful character, but 
 this does not obtain the same depth and fixity as in adults. The varieties of 
 melancholia most frequently observed in children are the simple, the hypochon- 
 driacal, the excited or agitated. Suicide in children is not commonly due to 
 melancholia, although it is occasionally, when an inherited taint will often be 
 found to be present. Children, like adults, are now and then driven to melan- 
 cholia and suicide by want of care and ill-treatment. The suicides of children 
 are sometimes dependent upon the most trivial causes or notions, as a trifling 
 chastisement. 
 
 Circular or Alternating Insanity. — A well-known and most interest- 
 ing type of insanity in the adult is that which is characterized by alternating 
 mental states, in which, for example, the patient suffers first from exaltation or 
 mania, then from depression or melancholia, then has a sane or lucid period, 
 and again starts on the vicious circle with an attack of exaltation. Sometimes 
 other forms of alternation appear, or simply depression and exaltation in rota- 
 tion. This mental disorder, which has been designated folie circulaire, or cir- 
 cular insanity, and also alternating insanity, is sometimes observed in children. 
 
 Choreic Insanity. — Several varieties of choreic insanity have been 
 described. One form of choreic mania usually does not commence until the 
 motor disorder has lasted two, three, or four weeks. Before the onset of the 
 mental disorder the -motor disturbances become more severe and irregular; the 
 movements never cease, even in some cases during the little sleep which is 
 obtained, and insomnia becomes almost as complete as in delirious mania. As 
 a rule, the sufferers preserve more knowledge of themselves and their surround- 
 ings than would seem likely from the apparent mental disturbance. They do 
 many things which appear to be purposive or hysterical in character, as strug- 
 gling, striking, hurling things, breaking furniture or dishes, jumping, rolling 
 or thumping themselves against the floor and walls. These cases have been 
 well described by Meyer (Tube's Diet, of Psychological Medicine), who also 
 briefly details the symptoms of acute choreic delirium, in which great excitement 
 with anguish, vivid hallucinations of vision, hearing, smell, taste, and also with 
 stupor, are reported. Fever and evidences of endocarditis are usually present. 
 Idiots not infrequently exhibit choreic disturbances of limbs and language. 
 The insanity of choreic cases is not to be regarded so much as caused by the 
 disorder as an essential part of it, the peculiar delirium, irregular and inco- 
 herent, being comparable to the choreic movements themselves. 
 
 Hysterical Insanity. — Occasionally hysterical mania and chronic forms 
 of hysterical insanity are observed in early life. Even in adults it may be diffi- 
 cult to distinguish between common acute mania and hysterical mania, and it is 
 sometimes even more difficult in children ; indeed, these two affections run more 
 together in childhood. The association of other hysterical phenomena, such as 
 ecstasy, catalepsy, trance, mutism, aphonia, fantastical notions, sensational 
 deceptions, or pseudo-palsies, will be aids to diagnosis. Hysterical mania in 
 childhood usually comes and goes, the attacks being short and showing great 
 emotional excitement. Some, at least, of the acts may be purposive, although 
 apparently beyond control. Sometimes, alternating with these maniacal attacks 
 or independently of them, children are caught in sensational deceptions of such 
 outrageous character, and repeated so often, that they can only be regarded as 
 due to mental perversion. "You may be sure that a young girl is on the 
 premises," says Wilks, "when you read of loud rappings in a house at night, 
 
INSANITY IN CHILDREN, 701 
 
 of a room being constantly set on fire, of sheets torn by rats, and of similar 
 extraordinary occurrences." 
 
 Hammond {Treatise on Insanity in Its Medical Relations, 1883) records 
 the case of a girl whose disposition was always sullen, capricious, and eccentric, 
 and who never exhibited the least feeling of tenderness toward her parents — 
 who laughed and cried without cause, and committed from an early period of 
 her life all kinds of singular and ridiculous acts. She could not be prevented 
 from using obscene and ridiculous language ; and soon she exhibited a series of 
 spontaneous and delirious acts, such as are met with in hysterical mania. One 
 day she crowned herself with flowers, took a guitar, and announced that she 
 was going to travel through the world. She got up in the night and washed 
 her clothes in the chamber-pot. She had convulsive seizures, mewed like a 
 cat, tried to climb up a wall, was violent in her acts toward others, and finally 
 fell into a state of stupor. These accessions were periodical, and it became 
 necessary to send her to an asylum. 
 
 The dancing manias, child-pilgrimages, and other epidemic and endemic 
 nervous disorders may be regarded as forms of hysterical insanity ; at least they 
 are fundamentally psychoses. Occasionally these endemics from imitation are 
 observed in homes and schools. Usually convulsions, speech affections, pseudo- 
 paralyses, contractures, visual hallucinations, or spells of great emotional excite- 
 ment are among the phenomena exhibited. 
 
 Cataleptic or Cataleptoid Insanity. — Katatonia, a clinical type of 
 insanity first described by Kahlbaum in 1874, has in rare instances been 
 observed in children. It is a cyclical or alternating insanity, sometimes hav- 
 ing as many as five stages — beginning, for instance, with mania, and then 
 melancholia, stupor, cataleptoid, and dramatic periods following. The different 
 stages may vary in duration and continuation ; thus, depression and exaltation 
 may be present with cataleptoid and histrionic phenomena. Some cases recover, 
 and others pass into a state of chronic dementia. It has been claimed that 
 katatonia cannot be regarded as a distinct clinical entity, as various cataleptoid 
 and convulsive phenomena and histrionism are present in other types of 
 insanity, as mania, melancholia, paranoia, imbecility, while others, again, 
 hold that it is an hysterical disorder. It is certain, at any rate, that in child- 
 hood mental disturbance of peculiar character, associated with catalepsy, ecstasy, 
 and trance-like states, is observed ; and transient maniacal attacks may be 
 present in these cases. Occasionally seizures of this kind have been observed 
 in undoubted epileptics, although the attacks are not to be regarded as epileptic 
 in their nature. A true epilepsy is occasionally developed in children who begin 
 with cataleptic, hystero-epileptic, and hystero-maniacal spells. 
 
 Epileptic Insanity. — Congenital epileptics are not infrequently idiots or 
 imbeciles or sufferers from some form of paralytic or atrophic disease ; in other 
 cases epilepsy appears early in life in children of fair mental health, some of 
 whom develop epileptic insanity ; sometimes a true epileptic dementia comes 
 on even before the period of childhood has passed, showing itself by loss of 
 memory, judgment, and general mental enfeeblement. Mania may occur 
 before or after an epileptic paroxysm, or may take the place of such a par- 
 oxysm, just as in the adult. When without sufficient apparent cause a child 
 has transitory fury or frenzy, even though no known history of epilepsy 
 be present, the possibility of the attack being epileptic should be borne 
 in mind. Sometimes very young children have maniacal outbreaks, and 
 subsequently develop regular epilepsy; or the epileptic seizures may be 
 nocturnal, and thus be overlooked ; or, again, attacks of petit mat may be 
 undemonstrative in character, so that their true nature may not be recognized. 
 
702 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Attacks of fury followed by epileptic convulsions, and of epileptic convulsions 
 followed by furious excitement, in children under ten years of age are recorded 
 by many, and have been observed by every one who has had much experience 
 with epileptic children. Epileptic children also show peculiar perversions of 
 character and manners. Post-epileptic conditions of stupor, delirium, or con- 
 fusion are sometimes present, and a chronic maniacal state may accompany the 
 epilepsy. 
 
 Paranoia or Primary Delusional Insanity. — Paranoia, a Greek word 
 meaning insanity, has been reintroduced into the literature of mental disease. 
 Primary delusional insanity, suggested by Stearns {Lectures on Mental 
 Diseases, 1893), is a better term, although even this is open to objection. It 
 is a chronic insanity, in its completest type characterized by recognizable sys- 
 tematized delusions, but showing itself also by general mental instability, insist- 
 ent ideas, morbid impulses, and perversions of character, the foundation of 
 these being in reality a delusional state. The delusions of paranoiacs may or 
 may not be accompanied by hallucinations. While paranoia is rare under the 
 age of puberty, the children who subsequently develop primary delusional insan- 
 ity have often such marked peculiarities and eccentricities as to lead physicians 
 experienced in mental diseases to forecast the probable occurrence of this affec- 
 tion later in life. They show oddities of dress and conversation, excess of self- 
 consciousness, a tendency to scheming and dreaming, ambitious and egotistical 
 notions, conceits and misconceptions, and periods of moodiness, depression, 
 anger, or excitement. Recently, Moyer and Lyman {Med. and Surg. Reporter ', 
 March 25, 1893) have reported paranoia in a boy between twelve and thirteen 
 years old. He imagined that his mother was going to poison him and that he 
 had yellow fever and tape-worms. In a strict sense, he was neither exalted nor 
 depressed. Two maternal grandaunts died insane. This case might be regarded 
 as one beginning at puberty, but now and then a case with definite delusions 
 of a systematized character is seen at an earlier age. According to Spitzka, 
 imperative conceptions, morbid fears, and folie du doute are frequent in infantile 
 masturbators, and hypochondriacal and persecutional paranoia in a crude form 
 is similarly detected at this period. 
 
 Moral Insanity. — It is difficult, as already stated, to, make a distinction 
 between moral imbecility and moral insanity in children, and sometimes the dis- 
 tinction is of little importance. In moral insanity the perversion of the moral 
 or affective life may be brought about by injury, disease, or vicious habits in chil- 
 dren who to all appearances have been of healthy moral and mental tone. The 
 moral imbecile is the victim of heredity, his condition being manifested as soon 
 after birth as it is possible to recognize deficiencies in the moral sense. Extra- 
 ordinary perversions of character have been recorded in considerable number 
 due to acute fevers in children. Psychical phenomena approaching attacks of 
 true insanity sometimes occur during malarial fevers, and sometimes seem to 
 take the place of malarial attacks. 
 
 Instinctive Perversions and Morbid Impulses. — Instinctive perver- 
 sions and morbid impulses flow out of the same inherited or constitutional con- 
 ditions which are at the root of fully-developed monomania or paranoia. Chil- 
 dren who show these perversions and impulses sometimes later in life become 
 examples of paranoia. Maudsley prefers to consider these symptoms or con- 
 ditions under the general head of affective insanity, under which he would 
 also include moral insanity proper. With regard to both adults and children 
 it is important to determine whether such manifestations are symptoms of mania, 
 melancholia, or epilepsy, or whether they are constitutional or paranoiac in 
 type. One must have a clear idea of certain terms now frequently used in 
 
INSANITY IN CHILDREN. 703 
 
 considering these questions, such as concepts, imperative concepts, morbid 
 concepts, imperative acts or movements, insistent ideas, and morbid propen- 
 sities. Concepts are distinct or isolated thoughts, the elements of thought- 
 processes ; they become imperative when they dominate or tyrannize the mind. 
 Imperative acts or movements or morbid impulses are the results of these im- 
 perative conceptions. The term insistent idea, suggested by Cowles, describes 
 a habit of thought resulting from the repetition and multiplication of morbid 
 concepts ; after a time these insistent ideas hamper and manacle the individual's 
 will and intellect. Morbid propensities, like insistent ideas, sometimes steadily 
 hold possession of the mind ; they are often simply exaggeration of the normal 
 propensities, but to such a degree as to become a true insanity. They are per- 
 versions chiefly of the desire for food and of the sexual appetite. 
 
 Under morbid impulses, monomanias, partial ideational insanity, and 
 partial moral mania have been described such affections as moral mania ; 
 homicidal mania or the impulse or propensity to kill ; suicidal monomania ; 
 kleptomania or the propensity to theft ; erotomania or the tendency to fall 
 in love with everybody ; nymphomania which may be distinct from eroto- 
 mania and exhibit itself in sexual precocity and salacity ; pyromania or the 
 impulse or propensity to incendiarism ; and dipsomania Or the irresistible 
 periodical craving for drink. It is perhaps better to regard these as desig- 
 nations of the most prominent symptom or symptoms in a case of insanity, 
 rather than to erect them into a special variety of mental disease, although the 
 latter procedure sometimes serves a good practical purpose. 
 
 Almost every variety of monomania or morbid impulse has been observed 
 in young children, and many cases might be given. Esquirol speaks of a girl 
 aged five years who repeatedly attempted to kill both her stepmother and her 
 brother. Not a few cases have been reported like that of the boy Pomeroy — 
 children who have shown an insane inclination to cruelty as well as to homicide, 
 this often exhibiting itself in a tendency to give pain, to mutilate, to harm in 
 various ways the lower animals or other children. Such cases usually belong 
 to the inherited paranoiac type, but in others the inclination to injure or kill 
 may be simply one of the violent manifestations of a curable acute mania. 
 
 Both thieving and lying can sometimes only be regarded as true mental 
 perversions, although it is certainly difficult in the child as in the adult 
 to separate such forms of monomania from conscious and controllable vicious- 
 ness. Girls at or approaching puberty are known to exhibit such tendencies 
 to a morbid degree, in many cases recovering from them in a shorter or longer 
 time, but occasionally even younger children show the same monomaniacal 
 inclinations. Such a child will lie without rhyme or reason, and will steal 
 without a desire to gratify appetite or passion. 
 
 What is known as erotomania is more frequently exhibited in adults than 
 in children, but rare juvenile cases have been observed. Erotomania and 
 nymphomania are not the same, although often confounded. In erotomania, 
 as a rule, the tendency to indecency and excess is not present. The eroto- 
 maniac boy becomes the adorer of most of the girls he meets, or the girl the 
 admiring slave of the boys. Nymphomania or satyriasis exhibited in an insane 
 degree is by no means uncommon in children, and even occasionally in very 
 small children, both boys and girls. Cases have been reported of children 
 two and three years old who have exhibited the most remarkable sexual pre- 
 cocity, as shown by indecency of attitude and act. 
 
 Some of the most extraordinary instances of morbid impulses and propen- 
 sities in children are those which have been reported as cases of pyromania, the 
 child persistently and perversely striving to set fire to anything and everything 
 
704 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 that it thinks will burn, and using sometimes great cunning and skill both to 
 succeed and to conceal the act. 
 
 Hammond relates the case of a girl less than fifteen years of age, affected 
 with nostalgia, who twice set fire to the house in which she lived. She declared 
 that from the first minute of entering her master's house she had been seized with 
 the desire to destroy it by fire. It seemed to her that a ghost standing before 
 her constantly urged her on to the act. This girl had suffered from pain in the 
 head and disordered menstruation. 
 
 Morbid Fears or Phobias. — In a philosophical sense, sanity and insanity 
 are relative terms whether applied to conditions in children or in adults ; 
 certainly, not a few cases are observed which may be properly regarded as 
 on the borderland between mental health and disease. They are perhaps best 
 regarded as examples of partial or quasi-insanity ; that is, forms of mental 
 disease which in a certain manner and degree have the attributes of insanity. 
 They are abortive or imperfectly-developed mental disorders. Sometimes they 
 are as transient in duration as they are limited in phenomena ; but in other 
 instances the few elementary deficiencies or disturbances may persist without 
 much change or increase through life. Many of these cases, like the morbid 
 impulses just treated of, belong under the head of paranoia. They have been 
 described as morbid fears or phobias, as morbid doubts, as emotional mono- 
 manias, and even as forms of neurasthenia. They are fundamentally depend- 
 ent upon the domination of the mind by morbid concepts and insistent ideas. 
 They are sometimes observed among young children, although more common 
 after than before the period of puberty. Morbid fear may be the result of 
 functional disturbance or disease in a normally constituted individual, but the 
 cases which afford the most striking instances of morbid fear or phobia occur 
 in those who have not been subjected to any physical or mental strain sufficient 
 to break down a healthy organization. Persistent fear of the monomaniacal 
 type occuring in children is rarely due to overwork or fatigue, as at school, as 
 is frequently supposed. The real cause is generally in a child's progenitor or 
 progenitors. They are cases of the class referred to by Oliver Wendell Holmes, 
 the cure of which should have been begun two hundred years ago. 
 
 These quasi-insanities or phobias have been much divided and subdivided ; 
 not infrequently several of the so-called varieties are present at the same time 
 in the same case. Among the forms of morbid fear which have been described 
 by particular names are pathophobia, or fear of disease ; misophobia, the fear 
 of contamination, defilement, or pollution; agoraphobia, the fear of open 
 squares or places ; claustrophobia, the fear of closed or narrow places ; topo- 
 phobia, the fear of places in general; monophobia, the fear of being alone; 
 pyrophobia, the fear of fire ; astrophobia, the fear of lightning ; and hydropho- 
 bophobia, or fear of hydrophobia. Some cases belong to a class which may be 
 described as pantophobia, or fear of everything. 
 
 A few cases have been observed in comparatively young children. Hurd 
 (cited by Stearns), reports an interesting case from an account written by the 
 patient herself. When about twelve years old she began to have strange 
 fancies, as fearing the blood flowing from a cut finger would harm those who 
 came near her. Subsequently, dressing, walking out of doors, eating, were all 
 greatly interfered with through the same morbid ideas. She feared contagious 
 diseases because she might communicate them to others. The insistent idea 
 changed from time to time, but seemed to spring always from the emotion of 
 fear. She eventually recovered. Hammond cites from King, of Sedalia, Mis- 
 souri, an interesting case of pyrophobia in a boy of ten years. Day and night 
 he was infested with fear of this kind. On one occasion, when the morning 
 
INSANITY IN CHILDREN. 705 
 
 was cool, he succeeded, after a contest with his mother, in opening the stove- 
 door and pouring a bucket of water on the fire. He is said to have been 
 cured by quinine, the bromides, and the use of evaporating applications to 
 the head. 
 
 A few cases in comparatively young children have been reported and some 
 have come under my notice. A boy eleven years old, developed what was practi- 
 cally a pantophobia, although his disorder exhibited itself chiefly as a patho- 
 phobia, or fear of disease. He was kept almost constantly under the care of 
 phvsicians. Sometimes his morbid ideas revolved round real affections of slight 
 importance; sometimes his fears and suffering were due purely to morbid con- 
 ceptions and insistent ideas. Now his eyes were the source of morbid dread; 
 soon his limbs were the seat of rheumatic pain ; he narrowly escaped laparotomy 
 for typhlitis, probably of psychical origin ; to a moderate degree he suffered 
 from mysophobia, spending unusual time at his ablutions, teeth cleaning, in 
 dressing, and in the care and arrangement of his clothes. Anything in the 
 nature of a symptom or a disease mentioned in his presence was likely to take 
 possession of him. His morbid notions and apprehensions were fed and encour- 
 aged by the unceasing attentions of members of his family. He was practically 
 cured by taking him from his home-surroundings, disregarding his complaints, 
 forcing him to do things on time and after the manner of others, at the same 
 time carefully but not obtrusively looking after his general health. 
 
 Another boy at the age of ten began to develop the scrupulous and myso- 
 phobic type of monomania ; in fact, he was, as so many of these cases are, an 
 illustration of the admixture of several of the so-called classes of morbid fears. 
 He was constantly worrying about many things he said and did in his inter- 
 course with others. If left alone, he would spend hours in bathing and wash- 
 ing himself, and often imagined he had been polluted or would contaminate 
 others. The symptoms were in many respects like those of the lady described 
 by Hammond, and to whose case he first applied the term mysophobia, who 
 could touch nothing without being irresistibly impelled to wash her hands, and 
 who in many other ways was tormented by the fear of contamination. This 
 boy improved greatly under mental discipline, out-door exercise, and careful 
 tonic medication. 
 
 These cases of morbid fear, particularly when they assume the form of patho- 
 phobia or dread of disease, are sometimes incorrectly regarded as examples of 
 hypochondria or hypochondriacal melancholia, but they differ from the latter 
 as monomania or paranoia differs from mania or melancholia. 
 
 Paretic Dementia. — From its nature and pathology paretic dementia is 
 essentially a disease of adult life. It usually arises in patients more than thirty 
 years of age, and is most common between the thirtieth and fortieth years ; but 
 occasionally it is observed in the aged, and in very rare instances in the young. 
 The youngest paretic dement observed by Spitzka in 346 cases was eighteen 
 years old. Other cases, however, still younger, have been reported, as one by 
 Turnbull {Jour. Mental Science, October, 1881) in a boy of twelve years, 
 who was first observed by the reporter at the age of eighteen years. Up to the 
 age of ten he had been healthy and apparently like other boys, but at this age 
 he had an attack of hemiplegia, which passed off in a week and left him with a 
 certain amount of stupidity. He continued to perform his duties as a messenger- 
 boy, but from the age of twelve a mental weakness increased gradually but dis- 
 tinctly. His symptoms, as described, were certainly those of general paralysis, 
 except that he had not delusions of grandeur. The boy died in less than a 
 year after his admission to an asylum, and the post-mortem findings were those 
 usually seen in cases of paretic dementia. 
 
 45 
 
706 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Etiological Varieties, and General Etiology. — A form of juvenile 
 dementia, the result of inherited syphilis, sometimes occurs, and it is necessary 
 to separate this from idiocy and imbecility, whether of syphilitic or other origin, 
 which may be done by remembering that the dementia usually comes on after 
 the child is four or five years old, and therefore when the mental condition has 
 been determined not to be that of idiocy. In rare cases, however, it happens 
 that a juvenile or infantile dementia occurs when the child is two or three 
 years old, so young that its true mental status has not been fully determined. 
 With this word of caution as to the possibility of inherited syphilis showing 
 itself in a child otherwise healthy in the first year or two of life, most of 
 the cases of this form of dementia will be comparatively easy of recognition. 
 A family history of syphilis will often, but not always, be obtained ; often the 
 upper incisors will be pegged and notched, while cicatrices at the angle of the 
 mouth and the characteristic physiognomy will be present ; and sometimes the 
 child will have attacks of keratitis, choroiditis, or iritis, or a history of snuffles 
 or of a rash, and sometimes epilepsy will have developed. 
 
 Febrile and post-febrile insanity is, on the whole, not rare in children. 
 Many cases have been put on record. They have been arranged by Nasse into 
 three classes — those coinciding with the fever, those which are apparent con- 
 tinuations of the fever, and those developing during convalescence. Accord- 
 ing to Spitzka (Keating s Cycl. Diseases of Children), the latter group is more 
 benign in character and prospect than the other two, and is most often found 
 in adults, the first two groups being more frequent in children. Of course 
 delirium is an accompaniment of most fevers, and this is more pronounced and 
 sometimes of a peculiar character in childhood ; but, setting aside ordinary 
 febrile delirium, mental disorder sufficiently intense and persistent to be classed 
 as insanity is of comparatively common occurrence. The fevers during which 
 or after which insanity is most likely to develop are typhoid, scarlatina, measles, 
 rheumatism, and diphtheria. Owing to the intensity of the psychical pheno- 
 mena, the true nature of typhoid fever in the child or adult is sometimes over- 
 looked. Most cases of febrile and post-febrile insanity recover in periods 
 varying from a few days to a few weeks or months. Rarely, however, a true 
 dementia is originated, and when this does result the child is sometimes left 
 weaker in mind and less capable of development than before the attack. 
 
 Under the head of reflex insanities might be included a large variety of 
 cases, chiefly illustrations of mania, which has been attributed, and apparently 
 with correctness, to splinters in the great toe, to a carious tooth, to ascarides 
 and other varieties of intestinal parasites, to rectal and preputial irritation. In 
 one case seen by me in consultation a tape-worm was the apparent cause, as 
 the symptoms disappeared when the parasite was discharged. Affections of 
 the nose and throat and digestive disturbances are other assigned causes of 
 juvenile insanity; probably such causes simply act as excitants in children who 
 are predisposed by heredity to mental disease. Some of the conditions which are 
 regarded as causes are really due to the mental condition. Spitzka refers in this 
 connection to the functional disturbances of the digestive * apparatus in girls 
 about the age of puberty, who go on from slight dyspeptic symptoms until they 
 get an aversion to food, and sometimes even delusions about eating, so that 
 they may actually starve to death, forced feeding being resorted to too late. 
 
 Masturbational insanity, as occurring both in children and adults, has been 
 both overrated and underrated, but, on the whole, the tendency has been to the 
 former rather than the latter. Some alienists deny that this vice is ever the 
 true cause of insanity, holding that it like the insanity is due to the neuro- 
 pathic state of the individual, or that at the most, it is merely a concomitant or 
 
INSANITY IN CHILDREN. 707 
 
 aggravating cause. My experience leads me to believe that while, as is known 
 to almost every one, the vice is extremely common, especially among boys, it 
 only in rare instances is the true cause of mental disease, but that these in- 
 stances must be recognized. Of recent writers, Spitzka has laid the most stress 
 upon the existence of masturbational insanity, and has ably described it from 
 his point of view. According to this writer, the typical masturbational psy- 
 chosis occurs between the thirteenth and twentieth years, and therefore at a 
 time which just removes the subject from consideration in an article on diseases 
 of childhood proper ; but occasionally the same symptoms and conditions are 
 observed before puberty, although before this period Spitzka believes that the 
 dementia is more like a true imbecility, and that infantile insane masturbators 
 are more liable to epileptiform attacks than to outbursts of mania. 
 
 Juvenile insanity may be directly inherited, but far more frequently, it is 
 the tendency rather than the psychosis which is inherited. Besides syphilis, 
 which has already been considered, alcoholism exerts its sinister influence in 
 this as in so many other directions. Neurasthenia, hysteria, chorea, epilepsy 
 may be present in the immediate ancestors. Other causes are great heat or 
 cold, exposure to the sun, variations in temperature, and fright which acts 
 unexpectedly, especially to excite the maniacal or hysterical forms. Injuries to 
 the head are of so much importance as to almost warrant the creation for pur- 
 poses of convenience of a class of traumatic juvenile insanities. In many of 
 these traumatic cases the mental affection is of the maniacal type, and is often 
 associated with epileptic or vertiginous attacks. Sometimes insanity originates 
 in connection with disease of the heart or some form of kidney affection, although 
 these causes, and particularly the latter, act much more frequently in adult life. 
 Poor food, bad ventilation, and bad hygiene generally, may be auxiliary causes. 
 
 Diagnosis. — Much that has already been said in the general consideration 
 of the subject, and also in connection with the discussion of special varieties of 
 insanity, will assist in the diagnosis. In the first place, insanity in childhood 
 must be distinguished from idiocy and imbecility, or the existence of both in 
 the same case must be determined. The delirium which ushers in or accom- 
 panies a continued or ephemeral fever must not be set down as insanity, the 
 febrile disease being overlooked, although, as has been considered, the occur- 
 rence of true febrile insanities must be borne in mind. The distinction between 
 vice and insanity is not always easy to make either in the child or in the adult. 
 I agree with Tuke {Diet. Psychol. Med.), that it is difficult to lay down rules 
 to differentiate moral insanity from moral depravity ; each case must be decided 
 in relation to the individual himself, his antecedents, education, surroundings, 
 and social status, the nature of certain acts and the mode in which they are 
 performed. Hysterical excitement or mania may be difficult to distinguish from 
 mania of either toxic or unknown origin, but the past history of the child, and 
 the presence of certain hysterical stigmata, such as aphonia, convulsions, or 
 paresis, will be of great assistance in making the diagnosis. The existence of 
 epileptic insanity can often be determined by a close investigation of the history 
 of the case, which will sometimes unexpectedly reveal the fact that the child 
 has had at least serious petit mal during the day and probably spasms during the 
 night. Every child who has sudden and unaccountable outbursts of extreme 
 violence should be watched for a time both day and night with the view of deter- 
 mining as to the existence of larvated epilepsy. It is sometimes highly 
 important to decide as to the type of insanity from which a child is suffering. 
 If the symptoms point to paranoia or primary delusional insanity, even if of an 
 imperfectly developed form, the prognosis will not be as favorable as if the child 
 is suffering from true mania or melancholia. The mode of onset, the condition 
 
708 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of the logical faculties, the amount of emotional manifestation, will aid in the 
 diagnosis, and the trained observer will recognize in the paranoic child that the 
 changes are fundamentally those of temperament and character. Transient 
 morbid fears and doubts must not be always regarded with great apprehen- 
 sion. Children, like adults, are subject when neurasthenic to such fears and 
 doubts, but these only arise to the importance of mental disease when persistent, 
 progressive, and of peculiar character. Their importance should be neither 
 overrated nor misunderstood. Paretic dementia is so rare in children that its 
 diagnosis has not much practical importance ; the only point of interest would 
 be, in a case which simulated general paralysis, to decide whether it might not 
 be one of juvenile dementia due to inherited syphilis, rather than a true paretic 
 dementia of unknown origin. Much help will be given in the diagnosis of the 
 latter by a study of the physical evidences, such as interstitial keratitis, cho- 
 roiditis, acute iritis, and optic neuritis. The eye should always be carefully 
 examined in suspected cases. The occurrence of deafness independently of 
 acute aural disease is important. Notching and pegging of the incisor teeth, 
 fissuration of the corners of the mouth, flattening of the bridge of the nose, 
 and changes of the knee-jerks may be other physical evidences. 
 
 Prognosis. — On the whole, the prognosis of insanity in childhood is good, 
 but differs somewhat with the varieties. The transitory psychoses, mania, 
 melancholia, circular, choreic, hysterical, and cataleptoid insanities generally 
 recover under appropriate treatment. The rare cases of primary delusional 
 insanity, and the more numerous instances of morbid perversions, impulses, 
 and propensities, w T hile they may be recovered from in whole or in part, are 
 likely to lay the foundation or to be the precursors of serious mental affections 
 later in life. This, however, is not the invariable rule. Young patients suffering 
 from morbid fears or phobias, worried and driven by insistent ideas, may be 
 much benefited, and sometimes permanently relieved, by a treatment which con- 
 sists more in moral management, discipline, and general hygiene than in the use 
 of medicines. These cases also sometimes become instances of life-long mono- 
 mania of mild or severe type. Dementia due to inherited syphilis may be 
 arrested if recognized sufficiently early. True paretic dementia is practically 
 hopeless in the child as in the adult. Some cases of masturbational insanity 
 are rescued ; others pass into incurable dementia, or at least to a lower plane 
 of mental life. 
 
 Treatment. — "Great care," says Tuke (Op. cit.), " has to be given to the 
 surroundings of the patients, especially in acute mania. If the patients have to 
 keep in bed, the quiet of being in a room without noise or without exciting im- 
 pressions is to be preferred to isolation in a cell, but one scarcely ever can do 
 without the padded room. Lukewarm baths, with cold showers on the head 
 and back if wanted, are very useful, because of the good they do to the skin, 
 which is in many places injured." In the treatment of mania at home every 
 effort should be made, in the first place, to remove sources of irritation and 
 excitement. The child should be kept in a room away from the rest of the 
 family, and noises and to some extent even light should be excluded. The 
 bowels should be thoroughly opened if they show any tendency to constipa- 
 tion, but sometimes the reverse is the case. Attention should be given to the 
 action of the skin and the kidneys, using diaphoretics and diuretics, either 
 alone or in combination with some of the remedies to be presently mentioned, 
 for the more striking manifestations which are present. Food should be sys- 
 tematically urged upon the patient, although in some cases the tendency may 
 be to eat too much rather than too little. It will rarely be necessary in 
 mania, or even in melancholia, in children, to resort to feeding either with the 
 
INSANITY IN CHILDREN. 709 
 
 nasal or the stomach tube, but this should be done rather than to let the child 
 go for several days with little or no food. The food should be of a digest- 
 ible character, and should be such as can be easily taken or given to the 
 patient, as milk, broths, milk toast, egg custard, soft boiled eggs, or tender 
 meat- 
 Sleeplessness and excitement are among the most important indications to 
 be met with in the mania of children by such remedies as chloral, bromides, 
 conium, hyoscine, or other preparations of hyoscyamus, sulphonal, opium, can- 
 nabis Indica, acetanilid, antipyrine, chloralamid, amylene hydrate, paraldehyde, 
 somnal, urethan. Of these the most valuable in the treatment of acute mania 
 in children are the bromides, chloral, hyoscine hydrobromate, conium, sulpho- 
 nal, and opium. The doses should be proportioned to the age of the child, 
 bearing in mind, however, that larger doses can be borne than in children not 
 suffering from extreme mental excitement. It is a good plan to combine bro- 
 mides and fluid extract of conium, with or without chloral, in one preparation, 
 to be given four or five times daily, and in addition to use one or two doses of 
 about yot to To~o °f a g ram °f hyoscine hydrobromate twice daily. The com- 
 bination of bromides with tincture of cannabis Indica will be sometimes found 
 very serviceable. 
 
 The melancholia of children is generally of brief duration. It should be 
 treated, in the first place, by rest and change : a trip to the seashore or to the 
 country or mountains will sometimes be quickly efficacious. All the secretory 
 and excretory glands and organs should be kept in good condition. Fruits, 
 laxatives, mineral waters, salines, syrup of figs, and preparations of aloin, 
 strychnine, and belladonna, combined with cascara or podophyllin, will serve 
 a good purpose in regulating the bowels. Opium is of more service in melan- 
 cholia than in mania, and may be used in small doses combined with bromides. 
 Squibb's deodorized tincture of opium is excellent. Food should be regularly 
 administered, and even in children the very careful use of stimulants may prove 
 advantageous. The preparations of malt will be found preferable. Various 
 combinations of tonics and digestives will prove of service, among the best 
 being nux vomica with liquor pepsin, the compounds of calisaya, iron, and 
 strychnine, and arsenic in the form of Fowler's solution administered with the 
 compound syrup of hypophosphites. 
 
 The treatment of choreic insanity is practically the treatment of a bad case 
 of chorea, plus that of mania. In a severe case seen in consultation, a girl 
 eight years old developed chorea shortly after an attack of scarlet fever, and 
 the movements were incessant, violent, and uncontrollable ; the patient 
 sleepless and at times semi-delirious. Arsenic, cimicifuga, bromides, and mor- 
 phine had been used without effect, but the following treatment was successfully 
 adopted: At first she was ordered Squibb's fluid extract of conium and Fow- 
 ler's arsenical solution, each 5 minims, well diluted, every two hours ; and also 
 hydrobromate of hyoscine, grain -^g, every two hours until some effect was 
 produced. Clysmic water was ordered to be taken freely, and poultices were 
 used over the kidneys. The choreic movements abated somewhat, but after 
 two doses of hyoscine had been administered she had a hysterical convulsion, 
 the tongue became very dry, and her delirium increased. The hyoscine and arsen- 
 ical solution were discontinued in about twelve hours, and she was then ordered 
 Squibb's fluid extract of conium and tincture of digitalis, each 5 minims, every 
 two hours, with neutral mixture. This treatment was kept up steadily for 
 forty-eight hours. One dose of chloral, 30 grains, and bromide of potassium, 
 60 grains, was given by rectal injection. The poultices and clysmic water were 
 continued, and a purgative was also administered. The chorea showed marked 
 
710 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 improvement in forty-eight hours. The conium and digitalis were continued, 
 but with gradually decreasing frequency, for a week. Two or three doses of 
 chloral, of 10 or 15 grains, were given in the latter part of the day. Great 
 attention was paid to the administration of nourishment, chiefly in the form of 
 milk. 
 
 In epileptic insanity, or when epilepsy is suspected, bromides should be 
 administered, guarded by arsenic, and at the same time nutrients, such as cod- 
 liver oil and the preparations of malt, and also tonics in small doses, should be 
 given. 
 
 The remarks made in another chapter about the treatment of moral imbecility 
 will apply with almost equal force, at least in most cases, to the treatment of 
 moral insanity ; but the cases which have been referred to as arising from trau- 
 matisms, toxic diseases, and blood-poisoning should be borne in mind when 
 considering the question of treatment. Doubtless some of these may be amen- 
 able to surgical or medicinal treatment. When children are found to suffer 
 from instinctive perversions and morbid impulses, they should be watched with 
 the greatest care; they should be kept as far as possible from temptations; 
 their moral training should receive particular attention, and as far as possible 
 they should lead healthful out-door lives, great care being observed as to the 
 choice of their companions. In some cases these perversions and impulses 
 pass away at puberty or adolescence. The treatment of children who are the 
 victims of morbid fears and doubts, of pathophobias, mysophobias, pyropho- 
 bias, and the host of other phobias, is worthy of careful thought. While 
 the tendency which has led to these disturbances is usually inherited, much 
 may be done to prevent their full development, and in some instances the 
 affections may pass away under appropriate treatment. Such children often 
 require to be removed from their home-surroundings, as almost invariably mis- 
 takes are made by their parents and guardians either in the direction of too 
 much sympathy and coddling or of too much harshness or want of appreciation 
 of the disorder. They should be prevented from constantly thinking about 
 themselves, their aches and ailments, and if any real disease be present, it 
 should receive appropriate but not too anxious consideration. They should be 
 disciplined to act promptly in all cases — to act twice before thinking once. 
 
 By no one better than by Clouston has the treatment of masturbational 
 insanity as occurring in youths been discussed, and some of his advice and rules 
 are applicable to the disease in childhood. The paramount indication is to 
 brace up the youth mentally and morally. As soon as the child can be reached 
 by judicious instruction, efforts should be made to strengthen both bodily and 
 mental inhibition. The mistake should not be made of unnecessarily calling 
 the attention of young children to their genital organs and sexual feelings; 
 occasionally parents and physicians err in this direction. A healthy child 
 should be let alone, and too much anxiety and interference should not be shown 
 because of some physiological sexual manifestation. Ordinary attention to 
 health will often suffice to keep a child straight. My own view, as already 
 stated, is that mental disorder in children from masturbation may occur, but is 
 not common, and that the habit sometimes weakens children who are mentally 
 and physically deficient from other causes. The physician or parent should 
 not take for granted, as is done so often, that a large majority of the nervous 
 and mental symptoms and affections of children are attributable to this vice. 
 Some mothers and fathers seem to live in constant worriment about this matter, 
 and are always suspecting their children of self-abuse. Clouston 's particular 
 suggestions with reference to the treatment of this form of insanity must of 
 course be qualified by considerations of age. "Avoid flesh," he says, " as the 
 
INSANITY IN CHILDREN 711 
 
 incarnation of rampant, uncontrollable force, sexual and otherwise. Be much 
 in the open air, work hard. Finally, so fill up and systematize the time that 
 none is left for day-dreaming." 
 
 Spitzka holds that painful corporal punishment should follow every attempt 
 by infants at touching the privates or executing friction, as to no other argu- 
 ment is so young a child accessible. It is doubtful whether this advice is of 
 universal application, but it is perhaps best followed in some cases. As soon 
 as children are old enough appeal can be made to the sense of shame and of 
 self-respect. Any local source of irritation, such as adherent prepuce, irri- 
 tative affections of the genito-urinary apparatus, and worms in the alimentary 
 canal, should of course be removed, although this last source of trouble is likely 
 to be overrated. 
 
IMPERATIVE MOVEMENTS IN DEFECTIVE CHIL- 
 DREN: ALSO HEAD-NODDING, HEAD-SHAK- 
 ING, HEAD-ROTATING, HEAD-BANGING, AND 
 
 NYSTAGMUS IN INFANTS. 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 Under various but similar names, such as head-nodding, head-jerking, 
 head-rotating, and head-banging, certain acute affections in infants and young 
 children have been described. The reports of these cases show that they differ 
 in character, and to such an extent that for the practical purposes of prognosis 
 and treatment distinctions must sometimes be made between different varieties. 
 Among the authors who have contributed to our knowledge of this subject are 
 Henoch, A. Baginsky, S. Gee, Stephen Mackenzie, and, more than all, W. B. 
 Hadden (Lancet, June 14, 1890, and St. Thomas' Hospital Reports, 1890) 
 and for most of the facts contained in this brief sketch I am indebted to the 
 valuable papers of the last named. 
 
 Imperative Movements in Defective Children. — Before considering 
 the affections described by Hadden, it should be borne in mind that in well- 
 known organic affections of the nervous system, so-called imperative move- 
 ments, due to dominating conceptions and insistent ideas, may be present either 
 in children or adults. These may take the form of the salaam or bowing 
 spasm, of snapping the eyes, of contortions of the face, of shrugging of a 
 shoulder or shoulders, or of some repeated movements of the arm, trunk, or 
 leg ; or, again, they may be some peculiar combination of movements executed 
 together or in succession. They may in other rare instances be shown as 
 an irresistible tendency to touch some special point or to handle an object 
 in some particular way. Occasionally such imperative movements are asso- 
 ciated with explosive expressions which may be of profane or obscene 
 character, and to these I have referred in discussing speech-defects and ano- 
 malies. Among the idiotic, interesting instances of imperative and automatic 
 movements are observed. At the New Jersey Home for Feeble-minded 
 Children at Vineland one little epileptic patient has at frequent intervals 
 attacks of head-shaking, nodding, and jerking. Another girl has curious 
 recurring rhythmical movements which can be started by music or by beat- 
 ing monotonously some object, as a fan or desk. Holding one hand open 
 with the little finger of the other, she rapidly vibrates the fingers of the open 
 hand or, standing squarely on her feet, she continues for a long time a semi- 
 rotary movement of the trunk, at the same time tossing the head from right to 
 left and bending the body from side to side. 
 
 At the Pennsylvania Training School for Feeble-minded Children at Elwyn 
 is, or was, a little patient familiarly spoken of as "The Dervish." The 
 
 712 
 
IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. 713 
 
 boy was of small stature and weight, a demi-microcephalic epileptic and 
 mute idiot. At all times he was subject to certain automatic tricks with his 
 hands, putting them and twisting them into various positions. Periodically, 
 almost every day, he gave exhibitions of the habit which had led him to be 
 called The Dervish. He commenced by tattooing his chin with his left hand ; 
 next he deliberately and delicately touched the fingers of his left hand to the 
 wrist of his right, made two or three salaams, and then impulsively gyrated 
 the body from left to right. 
 
 Sometimes peculiar movements are associated with ordinary epilepsy in 
 children not imbecile or idiotic. At least some of the cases particularly 
 described in this article may have some alliance with eclampsia nutans of the 
 salaam convulsion form, to which affection the terms nodding spasm, spasmus 
 nutans, and eclampsia rotans have also been applied. 
 
 Head-nodding, and Head-jerking. — The cases particularly described 
 by Hadden in his series of papers on "Head-nodding and Head-jerking in 
 Children, commonly associated with Nystagmus," are, in his own words, 
 " characterized by nodding or lateral movements of the head, either singly 
 or associated with one another or with movements of rotation. Further, these 
 movements of the head may be almost constant, or may occur more especially 
 during efforts at fixation or during excitement, always ceasing during sleep 
 or when lying down. In most cases there is nystagmus of one or both eyes, 
 vertical, horizontal, or rotary, often occurring simultaneously with' the onset 
 of the head movements, but sometimes preceding or following them. The 
 nystagmus is much more rapid than the head movements, and has an inde- 
 pendent rhythm ; it is aggravated by attempts at fixation or by forcibly restrain- 
 ing the head, and may even be induced, when previously absent, by these 
 means." 
 
 Hadden's first observations were based on an analysis of twelve cases. His 
 second series included nine cases of which he had kept notes, although in all he 
 had seen fourteen since the publication of his first series. His deductions from 
 an analysis of twenty-one cases can be summarized as follows : Pure nodding, 
 like the movements of a mandarin doll, is rare ; in others the movements were 
 lateral, although combined or alternated nodding or rotation was common. He 
 sees no reason for subdividing the cases into nodding and shaking as separate 
 classes, as one of these movements may replace the other. The movements are 
 chiefly seen when the child's attention is attracted to an object, and are 
 increased each time it makes a new effort at fixation. They cease during sleep 
 and when the child is lying down and when the eyes are covered. The asso- 
 ciated nystagmus is rapid and of short range, and is not constantly present, the 
 movements of the eyeball being usually horizontal or combined with some 
 rotation. In one case the head-nodding and nystagmus were vertical, and in 
 another the nystagmus was confined to one eye and associated with side-to-side 
 movements of the head. 
 
 The pupils were almost always normal. Hippus or oscillation of the pupil 
 was present in some cases. No unhealthy ophthalmoscopic appearances were 
 found. In nearly half of the cases the children had a tendency to cock the 
 head on one side or to hold it in some other unusual position when looking at 
 an object. In a large percentage of cases they had attacks as if conscious- 
 ness was in abeyance — seizures much resembling in character the descriptions 
 given of petit mat or epileptic vertigo. Convulsions were present in a few 
 cases, and attacks of convulsive laughter were observed in one child. Rickets 
 was present in nine out of the twenty-one patients. 
 
 Head-banging. — An affection has been described by Gee (St. Bartho- 
 
714 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 lomews Hospital Reports, 1886), as head-banging, in which children have a 
 habit of turning on their faces at night and banging their heads into the 
 pillow. According to Gee, the affection is perhaps a habit. As few of these 
 cases have been recorded, I give Gee's brief account of three cases : 
 
 " I. — Gilbert G , two and a half years old when seen with Dr. Donald Hood, 
 
 had been affected thus for two or three months past. At night in bed, both when awake 
 (half awake ? ) and when sound asleep, he would turn over on his face and bang his fore- 
 head into the pillow. In this way he sometimes behaved nearly all night long; in 
 which case, it need hardly be said, he awoke very weary. He never had convulsions 
 of any kind ; indeed, no disorder, past or present, other than head-banging. A year 
 and a half afterward this disorder continued when he was not tied down in bed. He 
 had never suffered from nightmare or sleep-walking. (Four months after the last notes 
 the patient's mother told me that he continued to bang his head at night when not tied 
 down. Even when tied down he rolls his head from side to side, being asleep. Put 
 asleep with a younger brother, the latter began to bang his head also ; separated, he, the 
 younger child, lost the habit. The first boy continued healthy and cheerful.) 
 
 " II. — George H , five years old, a patient of Mr. Patten's, was backward in un- 
 derstanding and speaking, but there were no signs of cretinism. He was a first child, 
 born at full time after a long labor in which no instruments were used. He had knock- 
 knees and splay-feet, but his dentition was very regular. He was restless, but clean in 
 his habits, and never wet the bed. There were no other signs of disease. He never had 
 convulsions of any kind. Head-banging began when he was two and a half years old 
 (that is to say, as soon as he could hold his body up), and it had continued until the time 
 when he was seen. He used to turn over on to his face and bang his forehead into the 
 pillow about six times in succession. The act was seldom repeated in the same night, 
 and seldom occurred more than one night in four. He was fast asleep at the time, but 
 was easily roused. 
 
 " III. — Francis C , two and a half years old, had been subject for six months to 
 
 banging his head on the pillow at night for two or three hours at a time. He had an 
 inguinal hernia ; he had erections of the penis at night ; he masturbated, and the fore- 
 skin was adherent ; otherwise the child seemed well. A year afterward Mr. J. Lucas 
 Worship wrote this about him : ' While he was staying in Sevenoaks, about a month ago, 
 he was better of knocking his head about, but the nurse said that whilst at home it 
 was as bad as ever. He was a great deal in the meadows, and slept well from being 
 in the open air so much, which he was unable to get while living at home in the town. 
 He was operated upon for his phimosis, which is all right now, and he does not mastur- 
 bate since then.' " 
 
 At the meeting of the Pennsylvania State Medical Society in May, 1893, 
 two interesting cases of head movements were reported, the first by Dr. J. C. 
 Gable of York, Pa., to whom I am indebted for notes. The patient was a girl 
 ten months old, well developed and apparently healthy at birth. The family of 
 the child was of more than ordinary intelligence, but had a pronounced neurotic 
 and tubercular taint. The mother suffered from chorea when a young girl. 
 The paternal grandparents died of pulmonary tuberculosis, and an aunt suf- 
 fered from an attack of tubercular arthritis of the right knee, which eventually 
 necessitated a thigh amputation. When the doctor was first called to see the 
 little patient he found her suffering from singular and seemingly very distressing 
 semi-rotatory, oscillatory bowing or bobbing movements of the head. These 
 were somewhat varied in character and degree, but continued with a monotonous, 
 rhythmical regularity, as long as the child remained awake, during a month, 
 and then gradually began to diminish, and ceased entirely in about eight weeks. 
 There was no nystagmus, nor any other special symptom except a somewhat 
 demented expression of face, which caused the anxious parents to fear that the 
 child was suffering from unsoundness of mind, until assured that its complaint 
 was a special and a rare form of chorea, which yielded to zinc treatment and 
 proper hygienic measures. 
 
 The second case was reported by Dr. J. C. McAllister of Driftwood, Pa., who 
 also has kindly furnished me with brief notes. The child was born in April, 
 
IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. 715 
 
 1892, with forceps delivery, the labor being the first and quite difficult ; but the 
 baby was, however, a strong and well-nourished boy, and no history of nervous 
 trouble in the family could be obtained. In February, 1893, when the child 
 was about ten months old, the doctor was consulted for the relief of choreic 
 movements of the hands and arms, and also for certain nodding and rotatory 
 movements of the head. Aside from this, constipation was the only symptom. 
 Bromide of potassium and Fowler's solution were prescribed for the movements, 
 and the constipation was also treated. After a few weeks the bromide was 
 stopped, but the arsenical solution was increased to two drops four times a day. 
 The infant had a long prepuce, and the doctor performed circumcision, April 
 26, 1893. The movements of the hands ceased under the use of the arsenic 
 before the operation, but the other movements continued until after the cir- 
 cumcision, when they gradually disappeared. 
 
 Nystagmus. — Nystagmus may be described as a constant involuntary 
 movement of the eyeballs, which is usually horizontal, but sometimes ver- 
 tical, and even in rare cases may be in a slightly oblique direction ; and 
 rarely also the vertical and horizontal oscillations may alternate regularly or 
 irregularly, or a vertical movement may be present in one eye and a hori- 
 zontal in another. The commonest form of nystagmus is that in which the 
 movement is bilateral, horizontal, and consentaneous. Nystagmus is present 
 in several organic affections of the nervous system, as in disseminated scle- 
 rosis, and to a less degree in other forms of sclerosis, diseases of the cere- 
 bellum, and hereditary ataxia. It is sometimes due to local affections of the 
 eyes which interfere with sight, as opacities of the cornea or of the lens or 
 humors of the eye. It is very common in albinism, and is, as is well known, 
 of frequent occurrence among miners. As an affection of children it is chiefly 
 of interest as it occurs either in rare cases of cerebellar or other form of brain 
 tumor, or as it occurs associated with head-jerking and head-nodding, described 
 in this article. Nystagmus seems to be an essential element in a majority 
 of these cases, and Hadden describes and discusses these movements as fol- 
 lows: 
 
 " This is very rapid, about four to six movements per second, and of very short 
 range. One mother said it was ' like Perry's pens at the underground stations,' 
 and this homely description is not inapt. Nystagmus is not usually constant ; not 
 infrequently it has to be induced by making the child fix objects here and 
 there, by forcibly restraining the movements of the head, or by placing the 
 child on its back. On two occasions it was especially well marked when the 
 child was put to the breast. I verified this by personal observation. 
 
 " The movements of the eyeballs are usually horizontal, combined with 
 some rotation. As a rule, the movements of the head and eyes are in the 
 same direction, but this is by no means invariable. In my solitary case of 
 head-nodding the nystagmus was vertical, whereas in another patient there 
 was vertical nystagmus limited to one eye, associated with side-to-side move- 
 ments of the head. 
 
 " There is occasionally a relation between nystagmus and the position of 
 the eyes or evident ocular state. In one case the nystagmus was exaggerated 
 on extreme conjugate deviation to the right. In two instances the nystagmus 
 was chiefly evident when the eyes were directed upward, and in one of these it 
 was generally horizontal, and tended to become vertical when the eyes were 
 turned upward. The nystagmus may vary in direction apart from this : in two 
 instances the nystagmus was sometimes vertical, sometimes horizontal, and 
 sometimes rotatory." 
 
716 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Nystagmus may be the only form of movement present in cases exactly 
 similar in nature to those in which the head movements are also present ; as Had- 
 den put it, the disorder may be indicated by nystagmus alone just as there may 
 be tabes dorsalis without ataxia or paralysis agitans without shaking. He gives 
 one instance in which nystagmus alone was present for a year, but after this the 
 patient showed occasional slight movements of the head. 
 
 Etiology. — In some of the reported cases a decided predisposition to neu- 
 rotic disorder was present. In six out of the twenty-one cases a history of con- 
 vulsions in other children of the same family was obtained. Rickets was pres- 
 ent in the family in three instances, and decided evidences of rickets were shown 
 in nine out of the twenty-one of Hadden's patients. The affection often 
 appears to be due to reflex irritation from the alimentary canal or from denti- 
 tion. Henoch attached great importance to dentition as a cause, but on it 
 Hadden does not lay so much stress. Head-jerking occurs sometimes at an age 
 before the process of teething has begun, and a history of injury to the head, 
 usually by falls, has been present in a large number of cases. The affection 
 is more common in females than in males. In the majority of cases it begins 
 between the ages of six and twelve months. Usually the head movements and 
 nystagmus occur simultaneously at the onset. 
 
 Pathology. — The pathology of the cases of imperative movements described 
 is that of the idiocy or imbecility with which they are associated. With refer- 
 ence to the nature of head-nodding cases, Hughlings Jackson has suggested 
 that they are a variety of spinal chorea, a symptomatic condition allied to canine 
 chorea; but Hadden believes that the seizures point to instability of motor- 
 centres above the nuclei in the spinal cord and fourth ventricle, and he would 
 therefore attribute the disorder to a functional or other disturbance of the cere- 
 bral cortex. The child has acquired certain voluntary or purposive movements 
 of the head and eyeballs, but these have not as yet become thoroughly organ- 
 ized and fixed in the psycho-motor areas of the brain ; hence a dissolution 
 takes place because of the inability of the strained cortical centres to stand the 
 work to which they have been too early subjected. He compares these head 
 movements to the tremors in the head which often occur in aged people and 
 those seen sometimes in adults. 
 
 Diagnosis. — The chief point in the diagnosis of these cases is to distin- 
 guish between the different varieties of head movements, particularly as to 
 their occurrence in children otherwise healthy or diseased. Imperative or auto- 
 matic movements suggest the presence of idiocy or imbecility, and should lead 
 to a study for these affections. Knowing that epilepsy is an accompaniment of 
 some forms of repeated head movements, the existence of this disease should 
 be determined or dismissed. Bearing in mind a few important facts of this 
 character, the explicit and careful descriptions afforded by Hadden and Gee 
 will serve to identify these curious cases. 
 
 Prognosis. — As a rule, these little patients recover, the disorder lasting for 
 varying periods. Sometimes the movements will pass away in a few weeks, 
 and at others several months or even one to two years may elapse before 
 recovery takes place. Nystagmus is said to persist longer than the head move- 
 ments, and shows a greater tendency to recurrence. One case was observed by 
 Hadden for two years and a half, nystagmus not being present. In making a 
 prognosis a distinction must be made between the acute and curable cases, such 
 as have been reported by Hadden, Gee, and others mentioned in this chapter, 
 and the patients suffering from idiocy, imbecility, epilepsy, or other serious 
 
IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. Ill 
 
 forms of mental or nervous disorder, who are the victims of imperative and 
 automatic movements described in the beginning of the chapter. 
 
 Treatment. — Any sources of reflex irritation should be carefully attended 
 to, but in this, as in many other cases, reflex irritation has been made a 
 scapegoat for ignorance or imperfect knowledge. The general health of the 
 child should be carefully looked after, although in some of the reported cases 
 this seems to have been very good. The somewhat frequent occurrence of 
 rachitis should give this constitutional condition an importance in connection 
 with therapeutics. Fatty and albuminous foods in easily-digested form should 
 be given ; cod-liver oil in some of its various combinations, as with lime or 
 malt ; maltine with pepsin and pancreatin ; iron, particularly in the form of the 
 powder or the carbonate ; glycerin, cream, peptonized milk, and such nutrients 
 as are commonly chosen in rachitic cases, may prove of service in some instances, 
 as are also such medicinal remedies as Lugol's solution of iodine; Donovan's 
 solution of arsenic, mercury, and iodine; Fowler's solution of arsenic, the syrup 
 of the hypophosphites, and similar strengtheners and builders. Iodide of iron, 
 tartrate or malate of iron, and phosphate of sodium may prove useful. Among 
 the remedies which are supposed to have some influence upon the disorder bro- 
 mides hold the first place, but they should be given with care, and not in the 
 same doses as in undoubted epilepsy. Five to seven grains of bromide of 
 potassium or sodium, with two or three minims of tincture of belladonna, or one 
 minim of the fluid extract of conium, may be used with advantage, and at times 
 this dose may be increased until a decided impression is made. Sulphonal or 
 chloralamid in small doses is worthy of trial. The children are usually not old 
 enough to have their eyes refracted. In view of the theory that the condition 
 is allied to canine chorea, and in the light of the suggestion of H. C. Wood 
 [Jour. American Med. Assoc, February 25, 1893), that in chorea, and par- 
 ticularly canine chorea, the inhibitory apparatus which controls motor power in 
 the spinal cells is weakened to a greater extent than is the discharge power, 
 and also that quinine has a great controlling power over choreic movements in 
 the dog, the importance of at least trying quinine in increasing doses in the 
 treatment of these movements is suggested. 
 
HEADACHE. 
 
 By CHARLES K. MILLS, M. D., 
 
 Philadelphia. 
 
 The term "headache," which defines itself, is used to describe pain due 
 to causes either outside or inside of the cranial cavity. Its general synonyms 
 are cephalalgia and cephalsea, and for one of its most common varieties the 
 synonyms are migraine, megrim, hemicrania, or sick headache. Headaches in 
 children are less frequent in occurrence, fewer in varieties, and less severe in 
 type than in adults. Headache is most frequently a symptom of some recog- 
 nizable functional or organic disease, and its occurrence in many affections, 
 such as infectious fevers, will not, of course, here receive consideration. The 
 wisdom of discussing headache separately has been questioned, and with good 
 reason ; but it may be the ruling feature of a case which is presented to the 
 doctor for diagnosis and treatment, and if it is banished from the picture little 
 is left except to the most critical research, although even in such a case care- 
 ful study will generally show that it is simply a symptom of some rheumatic, 
 dyspeptic, hysterical, inflammatory, or other morbid state. 
 
 The mechanism of pain in the head is worthy of brief attention. It is 
 a well-known fact, although one often overlooked, that the brain substance is 
 practically insensitive, and pain in the head, even when the result or the 
 accompaniment of disease of the brain, is not due directly to lesion of its 
 tissue. The brain of man and of the lower animals can be excised without 
 giving rise to any sensory response, although the gentlest electrical application 
 to a motor centre may excite the liveliest movement. Nerve end-organs, which 
 are an essential portion of the apparatus of sensibility, are wanting in the 
 brain itself. Disorders of sensibility due to disease of the brain tissue are 
 referred to more or less distant parts of the body. The membranes of the 
 brain play an important role in intracranial pain, as has been shown by Duret 
 {Brain, April, 1878), Ferrier (Brain, January, 1879), and others. The dura 
 is highly endowed with nerves of sensation derived from the trigeminus, and 
 in rheumatic or neuritic headaches and in those due to organic disease the pain 
 is frequently dependent upon direct involvement of these nerves. The pia or 
 pia-arachnoid membrane is not so largely supplied with sensory nerves as the 
 dura. The pia is largely an immense network of. vessels, whose supply is from 
 the gangliated nervous system, and is concerned in head pain through varia- 
 tions in pressure and tension within the cranial cavity, as well as to a less 
 degree by direct nerve irritation. Inflamed arteries and veins cause pain, prob- 
 ably through their direct or indirect influence upon nerves of sensation. Blood 
 charged with toxic matter also causes pain both by direct and indirect irritation 
 of nerves. In explaining headaches it is necessary, then, to consider neural 
 or membranous inflammation, alterations in pressure or tension, and toxic states 
 of the blood. 
 
 718 
 
HEADACHE. 719 
 
 The varieties of headache which best deserve to be ranked as special types 
 are (1) migraine, and (2) the headaches of organic intracranial disease. Other 
 so-called varieties are usually based upon etiological considerations, and will be 
 considered under that heading. It is indeed of questionable propriety to class 
 migraine as a headache, and this is only done because it seems to be the most 
 practical method for physicians likely to use a general treatise on diseases of 
 children. The disease is migraine, and headache is only one of a series of 
 important phenomena — visual, gastric, motor, and mental ; but it is the symp- 
 tom which causes the patient the greatest suffering and for which he appeals 
 for help. 
 
 Migraine. 
 
 Migraine, megrim, hemicrania, or sick headache is by no means uncommon 
 in children. Sometimes very young children have mild attacks of sick head- 
 ache ; these at first come very seldom, and apparently only under special excit- 
 ing causes, as over-eating, excitement, or exhaustion ; and at first the intervals 
 between the paroxysms may be many weeks or months, but gradually they 
 become shorter. At first, also, the attacks can be scarcely recognized as genuine 
 sick headaches, pain not being prominent, but as years progress they become 
 more prolonged and severe ; still, under the age of puberty, however clear may 
 be the type, migraine does not usually assume the severity and intensity which 
 it shows after this period. I have seen a few instances of migraine in children 
 under six years of age. A boy, now ten years of age, began to have mild 
 attacks of migraine at the age of three, at first having only two or three attacks 
 a year, but these gradually became more and more frequent, until now he aver- 
 ages a spell about once a month. A history of migraine is present in four 
 generations — in the mother, and in the maternal grandfather and great-grand- 
 father. Three other children in the same family are not affected in the same 
 way. The child in other respects is unusually robust and free from disease. 
 
 Symptoms. — Except that the symptoms are less pronounced and severe 
 and have fewer concomitants, the phenomena of migraine in children are prac- 
 tically the same as in adults. It perhaps shows less tendency to recur at 
 regular periods. The child may suddenly or unexpectedly exhibit an indis- 
 position to play, may look pale and troubled, may complain of nausea or of 
 being chilly, or may speak of disturbances of sight ; then the pain comes on, 
 and at first is often confined to one temple or at least to one side of the head. 
 Soon it becomes more and more severe, and the little patient, without urging, 
 is glad to go to bed in a quiet room. The pain may last for hours or the better 
 part of a day, or in some instances in young children it is relieved in an hour 
 or two, usually by vomiting, followed by sleep. The migraine of childhood is 
 not so likely to occur early in the morning as in adult life. The visual pro- 
 dromes are comparatively common in children, although they may be absent. 
 They may take the form of photopsia, as balls or rims of fire or zig-zag colored 
 lines, or hemianopsia, or general obscurity of sight. The more complicated and 
 profound cerebral phenomena sometimes seen in adults, such as amnesic aphasia, 
 hemiparesis, monoanesthesia, and hallucinations of sight or great mental per- 
 turbation, may be present, but are not as common in children as in adults. 
 Putnam (cited by Sinkler, St. Louis Med. Review, October 29, 1887). has 
 recorded a case of a patient in whom, in boyhood, migraine was represented 
 by repeated attacks of numbness and tingling in the right side of the face and 
 right half of the body, with aphasia and hemianopsia, followed by a trifling 
 headache or none at all ; but later in life he had attacks of pain. The pain of 
 migraine is usually one-sided, and may be confined to the supra -orbital or 
 
720 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 temporal region. The attacks are usually much the same, except that they 
 grow in severity as the years advance. Nausea and vomiting are of frequent 
 occurrence, but not invariable. 
 
 Etiology. — Heredity is the most important predisposing cause of migraine, 
 as of some other forms of headache. Of exciting causes, excessive fatigue, 
 mental or nervous exhaustion, and indigestion are the most important. Dis- 
 orders of digestion are often placed in the front rank of exciting causes, but it 
 may be forgotten that the nausea and vomiting are frequently of central origin. 
 Rheumatic weather seems to have an influence in precipitating attacks of 
 migraine. 
 
 Pathology. — The pathology of migraine is practically unknown, as no 
 theory which has been advanced has well withstood the attacks made upon it. 
 It does not explain its true pathology to show that attacks may be induced or 
 excited by eye-strain, or disordered digestion, or intestinal putrefaction. These 
 attacks are certainly sensory explosions, analogous in their methods of exhibi- 
 tion to the spasms which result from discharges of the cortical motor centres. 
 Migraine, as has been claimed, has many of the appearances of sensory epi- 
 lepsy. Cortical discharges of the visual cerebral centres would best explain the 
 curious and frequent visual prodromes. Whatever may be its pathology, it is, as 
 a rule, a cerebral affection. Anstie regarded migraine as a variety of neural- 
 gia of the first or ophthalmic division of the trigeminus ; and in favor of this 
 theory is the occurrence of certain local trophic affections, such as herpes zos- 
 ter, ulceration of the cornea, and changes in the color of the hair ; but cases of 
 neuralgia or neuritis of branches of the fifth nerve, not instances of true 
 migraine, are sometimes confounded with the latter. In the so-called tic- 
 douloureux and in other less severe forms of painful disease of the branches of 
 the trigeminus, trophic disorders are frequent. True migraine and trigeminal 
 neuralgia or neuritis may be present in the same case ; indeed, the affections 
 sometimes blend in the same person. Migrainous subjects are vulnerable to the 
 same influences as are neuralgics and neuritics ; but these and similar facts do 
 not prove that the disorders are identical. Much stress has been laid upon 
 the exact state of the vessels of the brain during attacks of migraine. Accord- 
 ing to one view, in one form of hemicrania the blood-vessels of one side of the 
 brain or of a limited area of the brain are in a spastic state, while in another 
 variety a paretic state of the vessels exists. To explain the pain Du Bois- 
 Reymond held that the spasm of the vessels caused pinching of the nerves in 
 their sheaths. 
 
 Diagnosis. — A clear understanding of the usual prodromata and of the 
 method of progression of the symptoms is the best key to the diagnosis of 
 migraine. It is perhaps most likely to be confounded with headache of organic 
 origin, particularly with tumor and meningitis. The ophthalmoscope and 
 various localizing symptoms which will be spoken of hereafter will greatly aid. 
 Hysterical or imitative headaches in children may occasionally closely simulate 
 migraine, particularly in children whose parents are victims of the disease. 
 
 Prognosis. — The prognosis of migraine as to cure is bad. Usually the 
 attacks become more frequent as the child grows older. 
 
 Treatment. — For attacks of migraine in children energetic active treat- 
 ment does not seem as necessary as in adults. As soon as the prodromes 
 appear the child should be placed in a quiet, darkened room, away from sources 
 of irritation and depression. Phenacetin, antipyrin, antifebrin, and caffeine 
 are among the most useful remedies for the abridgement or the mitigation of the 
 attacks. Four or five grains of antipyrin or antifebrin, with two or three 
 minims of tincture of digitalis or tincture of strophantus to protect the heart, 
 
HEADACHE, 721 
 
 mav be given every hour or two until three or four doses are taken. Caffeine, 
 or the citrate of caffeine, in doses of one to two grains every half hour, will 
 sometimes abort an attack if given early. Once an attack has fully developed, 
 it is, as a rule, best to let the patient alone or only to use external applications, 
 as of hot water to the head or feet or menthol or chloral-camphor or mild gal- 
 vanization to the forehead and head. An emetic of ipecacuanha is sometimes 
 efficient, and the administration of a large dose of this drug may afford relief 
 even when it does not produce emesis. 
 
 The treatment of migraine during the intervals of the attacks is of con- 
 siderable importance. Everything should be done to keep the child in the 
 very best general condition. Cannabis Indica has been much praised for adults, 
 giving it in increasing doses, beginning with one-tenth or one- twelfth of a 
 grain three times daily, and continuing the treatment systematically for months ; 
 but its use for children, like that of other narcotics, is not to be encouraged. 
 Arsenic, quinine, iron, hydriodic acid, and the hypophosphites are of benefit, 
 particularly in debilitated cases ; but it is not my experience, as it seems to have 
 been of others, that migraine in childhood is likely to occur in subjects who 
 are weak, anaemic, and sedentary. The most robust and hearty child of a 
 family may be the sole victim of the disorder, although this is not invariably 
 true. Great attention has been paid in recent years to the relief of eye-strain 
 in the treatment of this affection ; and, while the favorable results of ocular 
 treatment have been overstated, measures directed to the eyes should not be 
 neglected. Hypermetropia, myopia, and astigmatism should be corrected if 
 sufficient in degree to clearly cause discomfort or annoyance. The eyes should 
 be examined under atropine, and the correction should be as complete as possi- 
 ble. Tenotomy or partial tenotomy may need to be performed, but too much 
 in a curative way should not be expected from these measures. In particular, 
 children who are going to school and paying close attention to their studies 
 should have their eyes investigated. Imperfectly ventilated and badly-lighted 
 school-rooms and house-rooms probably count for much as exciting causes 
 of migraine. 
 
 Some children suffer from forms of headache which have many of the 
 characteristics of migraine, but cannot be said positively to belong to this type. 
 These children, most commonly young girls at school, have attacks of head- 
 pain, accompanied with nausea or with both nausea and vomiting, which compel 
 them to rest and cause them to be irritable and worrisome. These headaches 
 are often associated with constipation. They are sometimes entirely relieved 
 by a change from a sedentary to an open-air life. They recur so frequently 
 that the term "recurrent headache " has been used in describing them, 
 although this expression has been applied also to other forms of headache. 
 They differ from typical migraine in the absence of prodromes and in their 
 lesser severity. They might perhaps be termed migranoid cases. Like typical 
 migraine, such headaches are often observed in children of neurotic heredity. 
 
 Headaches due to Organic Disease. 
 
 Intracranial tumor, meningitis, abscess, and, in very rare instances, aneu- 
 rism, may be the cause of headache in children. Headache is rarely absent in 
 brain tumor, and sometimes causes extreme suffering, but occasionally a growth 
 may be present without this symptom. The tumors which are most likely not 
 to give rise to pain are the gliomata, probably because these neoplasms are not 
 usually connected with the brain membranes, and also because owing to their soft 
 
 46 
 
722 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 structure, they exert comparatively little pressure. Much of the horrible pain 
 commonly present in intracranial tumor is dependent upon irritation of branches 
 of the fifth nerve in the dura, and this does not always occur in gliomata, 
 because, as has been stated, they may be unconnected with this membrane. In 
 several instances I have observed cases of gliomata of the cerebellum in which 
 pain was unimportant ; but it remains true that in children, as in adults, head- 
 ache is a very common symptom of an intracranial growth. In infants and 
 very young children, the sutures still remaining open, the pressure within the 
 cranium is not increased to the same extent as in adults by a developing tumor. 
 The location of pain in the head is sometimes, although rarely, a guide to the 
 position of the growth, but at the best it is an uncertain guide. A constant 
 occipital pain may indicate a neoplasm in the posterior fossa, but often this 
 will be deceptive. Patients with cerebellar tumor may complain of severe 
 frontal pain. In tumors pain in the head is usually increased by percus- 
 sion, and in some instances this pain will be greatest over the seat of the 
 disease. 
 
 Tuberculous growths or conglomerations are common in tuberculosis in chil- 
 dren, and in these cases more or less tuberculous meningitis is present, so that 
 the diagnosis of the cause of the headache, as between an isolated growth and 
 a meningitis, becomes difficult. The headache of tubercular meningitis is often 
 of great intensity, and this disease may be accompanied, like other affec- 
 tions of the cerebral membranes, and particularly of the dura, with vertigo, 
 nausea, vomiting, and screaming or crying ; but, while this is true, headache 
 is not an invariable accompaniment of cerebral meningitis, and particularly 
 of lepto-meningitis of slow development. 
 
 Occasionally the source of a severe headache is a cerebral or cerebellar 
 abscess, which is usually of rapid development, as long-latent abscesses are not 
 likely to occur in children. Such abscesses are commonly found in association 
 with disease of the middle or internal ear, and the pain will be more or less 
 referred to the location or neighborhood of this organ. 
 
 The diagnosis of tumor, meningitis, or abscess as the cause of a head- 
 ache will be made by a careful study of the accompanying conditions. The 
 most common of these will be, first, such general symptoms as optic neuritis, 
 nausea, vomiting, vertigo, monospasm, or convulsions, mental irritability, or 
 depression, apoplectiform attacks, and paralysis of cranial nerves or of the 
 face or limbs, hyperesthesia, anaesthesia; and, according to the seat of the 
 growth, special phenomena, such as hemianopsia, or cerebellar titubation. As 
 tumors of the cerebellum are somewhat common in children, the particular 
 symptomatology of growths in this location should always be borne in mind. 
 These symptoms, in addition to the headache, vertigo, vomiting, hyperesthesia, 
 optic neuritis, etc., just described, are, or may be, unsteadiness in station or 
 gait; nystagmus; sometimes internal squint ; frequent blindness; sometimes 
 deafness ; enlargement of the head from acquired hydrocephalus ; rigidity of 
 the muscles of the neck with retraction of the head ; loss of knee-jerk, or occa- 
 sionally striking peculiarities of the knee-jerk. Sometimes pain is marked in 
 the neck and back. These symptoms point particularly to tumor of the middle 
 lobe of the cerebellum. 
 
 Among organic headaches may be classed those which are due to inherited 
 syphilitic affections, but which are not necessarily either growths or meningitis. 
 The headache which accompanies the epileptic paroxysm also must not be over- 
 looked in considering this class. As is well known, it may either precede or 
 follow the epileptic fit, or it may be present with slight attacks of petit mal 
 which are scarcely observed. Catarrhal headache of inflammatory origin, 
 
HEADACHE. 723 
 
 according to Allen (Med. JSfews, March 13, 1886), is seen occasionally in acute 
 congestion or inflammation of the frontal sinuses. The pain, which is severe, 
 is usually confined to one side, but it is rare in children. 
 
 Etiological Varieties of Headache. 
 
 The predisposing causes of headache in children are few, the exciting causes 
 are many, and numerous classes or varieties of headaches have been erected, 
 based chiefly upon etiological considerations. These etiological varieties may be 
 indefinitely extended, and it is chiefly for this reason that authors differ so much 
 in their classifications of headache. Even the headaches of children have been 
 subdivided into numerous classes, as into the so-called school-headaches ; the 
 headaches of the period of growth ; anaemic, hyperaemic, and neurasthenic head- 
 aches ; headache of the eye-strain and of genital irritation ; and so on through 
 a long list, according to the inclination or views of the classifier. The causes 
 of organic headaches have necessarily been given in the course of their general 
 discussion. The great predisposing cause of migraine, as has been stated, is 
 heredity ; the exciting causes are those also of headache of any type, as exces- 
 sive fatigue, mental or nervous exhaustion, disorders of digestion, changes in 
 the weather, badly heated and ventilated rooms, lack of exercise, impoverished 
 or altered blood (anaemia, hyperemia, or toxaemia), overwork, excitement, 
 undue exposure to heat or to cold, eye-strain, gastro-intestinal disorders, genital 
 irritation, nasal or pharyngeal catarrhs, or aching teeth. A close consider- 
 ation of the causes or alleged causes of headache in children will show that in 
 addition to migraine and organic headaches we might conveniently erect the 
 following etiological varieties: 1, anaemic headache; 2, reflex headache; 
 3, hysterical headache ; 4, neuritic headache. 
 
 Anemic Headache. — Anaemic headaches sometimes occur in children, 
 although with not nearly the same frequency as in adults, and especially in 
 women. A few children seem to inherit an anaemic diathesis, just as others 
 are congenitally rachitic. These children are pale in skin and mucous mem- 
 branes, sometimes to the extent of being chlorotic; they lack in strength 
 and in nerve energy ; they are neurasthenic as well as anaemic. It is rare, in 
 children, to see a neurasthenic or exhaustion headache not associated with 
 impoverished state of the blood ; and therefore the distinction between a neuras- 
 thenic and an anaemic headache can be more sharply made in the adult. The 
 diagnosis of an anaemic headache is to be made by a careful investigation for 
 the evidences of anaemia, even to the extent, if necessary, of a blood-count. 
 It is well to remember that every pale-faced child is not anaemic, and also that 
 some children who are well supplied with fat may have poor blood. 
 
 Reflex Headaches. — While too much stress is laid upon reflex action 
 as the source of innumerable maladies, it plays an important part in many 
 cases of headache, as in the production of other symptoms. When a child 
 complains of headache after study or use of the eyes at close work, as in 
 drawing, writing, or sewing, the eyes should be investigated. Serious defects 
 of refraction may be present, particularly hypermetropia with astigmatism, and 
 these, if sufficient to cause strain, should be at once corrected. Children who 
 indulge in over-eating or careless eating sometimes suffer in consequence 
 from headaches, which are relieved by spontaneous vomiting or by the use of 
 emetics or cathartics; but it must be remembered that true migraine in children 
 is associated with nausea and vomiting, and that the gastro-intestinal disorder 
 in these cases is a concomitant rather than a cause of the headache. Perhaps 
 too much stress has been laid on sexual irritation as a cause of headaches in 
 children, but that it may be occasionally causative cannot be doubted. Allen 
 
724 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 (Joe. cit.) has presented some points of practical importance in connection with 
 reflex headache, in association with chronic nasal catarrh, which have a bear- 
 ing on the headaches of childhood. These reflex headaches are said by him 
 to be almost entirely restricted to the temple and the vertex. Sometimes nausea 
 is present, and sometimes if a probe, passed into the nose, is made to touch the 
 middle turbinated bone, vertex pain will instantly follow. The inner wall of the 
 orbit is often peculiarly sensitive, and the nasal mucous membrane is in a state of 
 intense inflammation. The reflex headaches of chronic nasal catarrh are sharply 
 separated from the headaches of cerebral disease by the absence of any symp- 
 tom referable to cranial sources, the lack of evidence, as furnished by a history of 
 the case, that the complaint is of central origin, and the complete control of the 
 pain by local treatment. Allen distinguishes reflex catarrhal headache from 
 sick headache of gastric origin by the absence of furred tongue, and from the 
 temple pains of eye-strain by its persistence after the correction of errors of 
 refraction. Such headaches may be the cause of nervous prostration. Reflex 
 headache may also have its origin in the pharynx or even in decayed teeth. 
 
 Hysterical Headache. — A frequent form of headache, even in children 
 of tender years, is the hysterical headache, or what might perhaps be better 
 termed, in most instances, the imitative headache. Most children, and particu- 
 larly those of the precocious and affectionate type, are fond of sympathy and 
 coddling. They are very close observers of the sufferings and peculiarities of 
 others. They have slight pains and aches, and these become headaches appar- 
 ently of very great severity. Often a child who complains of vertical head- 
 ache, or of headache associated with inability to stand the light, or of great 
 pain over the eyes or in the back of the head or neck, will be found on close 
 inquiry to have a father or mother, and especially a mother, who is subject to 
 similar aches and pains. Just as hysterical and hystero-epileptic convulsions, 
 aphonia, paresis of one or more limbs, and even hysterical blindness, may be 
 simulated or mimicked by the child of a neurotic parent, so headache and other 
 pains and aches in children are even more frequently to be traced to the same 
 source. 
 
 Neubjtic Headache. — Some children, usually of neurotic, rheumatic, or 
 arthritic heredity, suffer from pains in the head and face which are accompanied 
 by tenderness and pressure over exposed nerve ends and trunks, and also are 
 commonly increased by pain on movement of the scalp. These mild but annoy- 
 ing head pains are due to forms of subacute or chronic neuritis, which may or 
 may not be associated with slight inflammation of other tissues. Head pains 
 and headaches of this kind are much influenced by the weather. Even when 
 external tenderness is not present, pains in the head may be due to inflamma- 
 tion of the branches of the fifth nerve in the dura, or in the grooves or fora- 
 mina of the skull, or in the scalp. These cases usually yield rapidly to anti- 
 rheumatic or antineuritic treatment. Since the occurrence of the recent pro- 
 longed epidemic of influenza many cases of chronic headache or of chronic 
 head and face pains have been observed, chiefly in adults, but now and then in 
 children. Most of these have been due to a lingering neuritis or to the want 
 of tone in nerve centres, left wounded or vulnerable by the ravages of this 
 disease. 
 
 Diagnosis and Prognosis. — The diagnosis of headache in general relates 
 chiefly to the differential diagnosis of its varieties already considered. When 
 pain in the head is present, the general diagnosis of headache is made, the only 
 point of importance being to distinguish as to whether it is due to intracranial 
 or extracranial causes. The points already given under the general varieties of 
 headache will serve in the main for their differentiation. I would simply lay 
 
HEADACHE. 725 
 
 stress upon the necessity of separating those forms due to pronounced organic 
 disease from migraine and from functional types, such as the hysterical, the 
 neurasthenic, and the rheumatic. Proper but not undue attention should be 
 given to the question of reflexes. The prognosis of headaches has already 
 been sufficiently considered in speaking of its different varieties. 
 
 Treatment. — The treatment of the headaches of children will depend largely 
 upon the special variety. The treatment of migraine has been discussed ; that 
 of organic headache will be largely of the underlying disease.. For the relief 
 of these headaches two classes of remedies should be employed : first, those 
 for the immediate relief of pain ; and, secondly, those to improve the state 
 on which the headache depends. For the immediate relief of pain the best 
 remedies are phenacetin, antipyrin, antifebrin, bromides, chloral, sulpho- 
 nal, chloralamid, codeine, hyoscine, ether, chloroform, and preparations of 
 opium. These remedies should be used in doses proportioned to the age of the 
 child, although it should be remembered that children suffering from violent 
 pain, wherever located, will stand larger doses of hypnotics and narcotics than 
 those in health or those who are suffering from non-painful diseases. In brain 
 tumor and meningitis phenacetin and antipyrin in combination will sometimes 
 afford great relief. 
 
 For the constitutional or the acquired organic conditions on which some 
 headaches depend, mercury, the iodides, hydriodic acid, arsenic, and similar 
 constitutional measures will be found most beneficial. In most cases mercury 
 is best used in the form of minute doses of the bichloride. 
 
 As not a few children who suffer from chronic headache are both anaemic 
 and neurasthenic, it is of great importance first, to pay attention to these 
 conditions, and the best treatment for adults will not always answer in these 
 cases. Preparations of iron and arsenic should be given, but care should be 
 taken in their selection. Among the most useful iron preparations are the 
 malate, the citrates of iron and quinine, the ammonio-citrate of iron, the 
 lactate of iron, powdered iron, and dialyzed iron. Palatable preparations can 
 be readily chosen with a little care. Arsenic alone or in some combination will 
 often be found extremely useful. I prefer small doses of Fowler's solution 
 alone or in combination with the compound syrup of the hypophosphites. In 
 these anaemic children most careful attention should be paid to the quality of 
 the food and to the manner of giving it. Much headache in American chil- 
 dren and in adults is associated with the dyspeptic troubles which are so com- 
 mon in this country, and which are not infrequently due to the use of the fry- 
 ing-pan and to other evil methods of preparing food. Children with their fresh 
 and vigorous digestive organs do not suffer so much in this way as adults, and 
 particularly those who have reached middle age or who have passed into the 
 decline of life ; still, the matter is one of practical importance and should not 
 be overlooked. The diet of children inclined to be dyspeptic and to suffer from 
 headache should be plain, wholesome, nutritious, and easily digested. It is not 
 well to train children to depend upon digestives, such as pepsin and pancreatin, 
 although occasionally their use may be necessary. The stomachs of children 
 are greatly helped sometimes by the administration in small doses, before meals, 
 of bitter tonics, such as chamomile, quassia, columba, gentian, or cascarilla, 
 which are best given in the form of infusion or small doses of the fluid extract. 
 
 The exciting cause of a reflex headache should always be attacked. Eyes, 
 ears, teeth, nose, pharynx, stomach, liver, or genital organs should receive 
 therapeutic attention if necessary. The removal of adenoids has resulted in 
 great benefit to children suffering from headache and inability to study or fix 
 their attention. Some striking instances are also on record of headaches due 
 
726 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 to decayed teeth, writers even going so far as to declare that these and visual 
 defects are the most common causes of headache. 
 
 For hysterical or imitative headaches moral treatment and the improvement 
 of the general condition of the patient by tonics, nutrients, good food, gym- 
 nastics, bathing, and out-door exercise will prove most beneficial. 
 
 Neuritic or rheumatic headaches should be treated with the salicylates, 
 which are often usefully combined with small doses of bromides and iodides. 
 
 Of local applications for the relief of headache in children, the most 
 important are the use of menthol, chloral and camphor, ointments of aconitia, 
 hot, cold, or ethereal applications, galvanism, and head massage. Sinapisms 
 to the back of the neck and hot or stimulating foot-baths are good old-fashioned 
 remedies which may prove of great service. 
 
HYSTERIA. 
 
 By JAMES HENDRIE LLOYD, A.M., M.D., 
 
 Philadelphia. 
 
 Hysteria in children has probably existed always. Peugniez tells us that 
 in an old fresco of Doniinicain the painter represents a saint curing a child 
 possessed of an evil spirit. The patient is not drawn from imagination, but 
 from life, for he is in one of the classical attitudes of the grand attack. With 
 arms extended in the position of the cross, eyes rolled upward, and trunk con- 
 vulsed in opisthotonos, he exhibits the disease in one of its most common forms. 
 It was only because of the ancient Hippocratic definition of hysteria, which 
 attributed the great neurosis to disorders of the womb, that for such a long 
 period it was not recognized or acknowledged before puberty. For two thou- 
 sand years this error ruled the medical world, and had for a kindred error the 
 belief that hysteria is not observed in men. Lepois was undoubtedly the first 
 writer to note the frequency of hysteria in children. After his time scattered 
 references to the subject appeared, but still the old pathology prevailed even 
 to the time (1846) of Landouzy's treatise. Briquet's statistics in his classical 
 monograph on hysteria inaugurated the modern epoch of scientific investigation 
 which secured the recognition of this form of the disease. It is, however, to 
 Charcot and the contemporary school of the Salp§triere that we owe the most 
 light upon this subject. In the masterly demonstration of hysteria in both 
 sexes and at all ages given by this school we recognize for the first time the 
 unity and individuality of this disease. Hysteria is henceforth no longer a 
 vague label, of indeterminate value, for an incongruous mass of phenomena, 
 seen exclusively in women, which most writers have by tacit agreement united 
 to call " protean." Far from being changeable and indeterminable these 
 phenomena are shown to be constant and subject to a strict arrangement : far 
 from being confined to one sex or age or country, they are shown to be dis- 
 tributed well-nigh universally; and far from being typical only in the adult 
 female they are seen probably nowhere to more advantage than in children. 
 
 In addition to the writings of Charcot, we may make special mention of the 
 thesis of Peugniez and the treatise of Grilles de la Tourette, to both of which 
 we are indebted for invaluable information. Other notable theses are those of 
 Clopatt d'Helsingfors and Mile. H. Goldspiegel, quoted by Tourette. The 
 annual contributions of Bourne ville on hysteria, epilepsy, and idiocy are of 
 great value. In the English language the most complete paper on hysteria in 
 children is by Dr. Mills (Keating' % Cyclopaedia of Diseases of Children, vol. 
 iv.). All these papers contain copious references and bibliographical lists, 
 which, combined, bring the whole subject easily within the reach of the student. 
 
 It is our design in this paper to present a concise arrangement of this sub- 
 ject somewhat after the manner of the French school, and to illustrate it with 
 our own clinical observations. We may premise, also, that while we hold 
 hysteria to be a morbid entity, with a well-defined etiology, symptomatology, 
 
728 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and prognosis, we recognize that, as in the cases of so many other diseases, it 
 is modified to some extent in childhood. It shall be our especial aim to empha- 
 size this fact. 
 
 In the statistics of Briquet, hysteria in children occurred as follows in 87 
 cases : 
 
 In childhood (exact age not given) .31 
 
 At 5 years 3 ' 
 
 From 6 to 7 years 6 " 
 
 7 to 8 " 11 " 
 
 8 to 9 " 6 " 
 
 9 to 10 " 9 " 
 
 10 to 11 " 4 " 
 
 11 to 12 " . • 21 " 
 
 Total, 87 cases. 
 
 According to Briquet, this table constitutes one-fifth of his own observations 
 in patients of all ages ; hence 20 per cent, of his cases occurred in patients 
 before puberty. This proportion is probably not exceeded in any other gen- 
 eral nervous disease, unless it be in chorea. Briquet's patients seem to have 
 been girls. 
 
 Cloplatt's statistics are the most complete up to date : 
 
 Girls. Boys. Total. 
 
 In early childhood (exact age not given) 19 
 
 At 3 years 
 
 4 " 
 
 5 
 6 
 7 
 8 
 
 9 
 
 10 
 11 
 12 
 13 
 
 14 
 
 15 
 
 19 
 
 1 
 
 20 
 
 — 
 
 1 
 
 1 
 
 1 
 
 1 
 
 2 
 
 4 
 
 2 
 
 6 
 
 3 
 
 2 
 
 5 
 
 15 
 
 4 
 
 19 
 
 16 
 
 6 
 
 22 
 
 15 
 
 7 
 
 22 
 
 18 
 
 15 
 
 33 
 
 24 
 
 17 
 
 41 
 
 22 
 
 13 
 
 35 
 
 27 
 
 16 
 
 43 
 
 12 
 
 8 
 
 20 
 
 — 
 
 3 
 
 3 
 
 176 96 272 
 
 According to this table, the disease is almost twice as frequent in girls as in 
 boys. It increases almost steadily in frequency from the third year to the 
 thirteenth. 
 
 Etiology, — The most common causes of hysteria in children are heredity, 
 exhaustion and anaemia from acute disease, trauma, disturbing emotions, imi- 
 tation and defective education. 
 
 The subject of heredity has two aspects according as the transmission is 
 between similars or by transformation. By the first is meant transmission of 
 the disease from an hysterical parent to an hysterical child ; by the latter, 
 transmission of hysteria from a parent suffering with some grave nervous dis- 
 ease, as epilepsy or insanity, to the child. The latter aspect, although not the 
 more common, is far the more important of the two. This indirect heredity 
 illustrates the kinship of many of the great neuroses, and demonstrates the 
 necessity for a scientific investigation of remote causes. Briquet was the first 
 to give this subject exhaustive treatment. According to his table, 351 
 hysterical patients had 1103 near relatives whose records were attainable ; 
 among these relatives were found 214 cases of hysteria, 13 of epilepsy, 16 of 
 insanity, 1 of delirium tremens, 1 of paraplegia" 3 of somnambulism, 14 of 
 convulsive diseases, and 10 of apoplexy. This is almost 25 per cent, of 
 
HYSTERIA. 729 
 
 cases of grave nervous disease in the immediate families of the patients. A 
 -•control" table of statistics based upon the cases of 167 non-hysterical 
 women showed less than 8 per cent, of such nervous affections among 704 
 near relatives. Hence the percentage in the first class is more than eight 
 times greater than in the latter. 
 
 Bourneville claims that alcoholism in the father is a not uncommon cause 
 of hysteria in young children. 
 
 Children not infrequently present hysterical symptoms during the prog- 
 ress of, or convalescence from, acute disease. This is so especially in cases 
 of the infectious diseases, and the complication may obscure the diagnosis 
 in some cases not a little. The symptoms then observed are apt to be inter- 
 paroxysmal. Other toxaemias also, such as those caused by lead, mercury, and 
 alcohol, may produce hysteria, but to these causes children usually are not 
 exposed. 
 
 Trauma, next to heredity, is most important as an exciting cause of 
 hysteria, and the symptoms of the grand neuroses which it is especially apt 
 to excite are among the most intractable and simulate most closely organic 
 affections. These symptoms are paralysis, contracture, tremor, and persistent 
 localized pain or tenderness. This cause is often conspicuous in the so-called 
 neuroses following accidents on the railroad and by machinery ; but in children 
 very trifling accidents may cause hysterical phenomena. 
 
 Exciting or depressing emotions may provoke hysteria in children who are 
 predisposed. Fright is one of the most common of these. Disappointment, 
 chagrin, loss of near relatives have all acted thus. Sometimes vexations of a 
 quite trifling character are sufficient. In former ages, more than at present, 
 religious excitement claimed many victims for the grand neurosis. The chap- 
 ters of this part of its history were often written in blood. Demonology, witch- 
 craft, and possession were often but phases of hysteria complicated with super- 
 stition and fanaticism. The revolting epidemic of Salem witchcraft in this 
 country was begun by some hysterical children in the kitchen of a New England 
 parson. Imitation and suggestion were, and are, the potent factors in these epi- 
 demics. Somewhat similar but harmless epidemics, due to these causes, are 
 still seen occasionally in schools and convents. 
 
 Finally, a defective or unwise education has much to do with the produc- 
 tion of hysteria. The child that is constantly indulged, never corrected or 
 controlled, taught to regard itself and its own wishes as always first, allowed to 
 excite the emotions and imagination with fictitious literature, not disciplined 
 to self-control, to self-denial, to duty and to the cultivation of the higher moral 
 and intellectual faculties, is the child that is most apt to display the symptoms 
 of hysteria. It must not be inferred, however, that hysteria is necessarily per- 
 verseness, selfishness, and simulation. This is a too common error, and one 
 which unjustly attaches to hysteria a certain measure of opprobrium and con- 
 tempt. It is true, rather, that in some of the finest minds a defective educa- 
 tion leaves undeveloped the essential qualities of self-knowledge and self-control. 
 This conduces to hysteria. On the other hand, as Briquet has pointed out, 
 excessive severity and cruelty to children, as seen especially among the lower 
 classes, may be the exciting causes of the disease. 
 
 Symptoms. — The symptoms of hysteria divide themselves naturally into 
 two groups — (1) the Paroxysmal, and (2) the Interparoxysmal. We shall con- 
 sider these in turn. 
 
 (1) Just as in epilepsy, so in hysteria, the convulsive phenomena too often 
 attract the attention of the medical observer to the exclusion of even more 
 significant symptoms. The hysterical paroxysm is regarded as in some sort 
 
730 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the essential element of the disease, the acme toward which all the other elements 
 tend. Its bizarre character is no doubt the cause of this. As we shall see, 
 however, the more permanent but less conspicuous symptoms of hysteria are 
 often the more trustworthy, and sometimes the only, signs of the disease. 
 
 The hysteric fit has several grades, but as the less are included in the 
 greater, being but modifications or abortive attacks, it is best to limit the 
 description to the typical spell. This grand attack of hysteria has, rather 
 unfortunately, been called hystero-epilepsy. This is a misnomer, because the 
 fit has nothing of epilepsy about it. The term seems to signify a union of the 
 two diseases, but such is not its true meaning, because such a union does not 
 exist in the grand attack which we call hystero-epilepsy. It is hysteria — 
 nothing more nor less. If a distinctive term were required, it would be better 
 to speak of the attack as hysteria major, just as in epilepsy we distinguish the 
 grand and the petit mal. The term hystero-epilepsy is unfortunate, moreover, 
 because both diseases sometimes occur in the same patient. But in these cases 
 the fits are always distinct. The French speak of these as cases of hystero- 
 epilepsy with separate crises. 
 
 The hysterical paroxysm usually has prodromes. These especially are 
 mental symptoms, and are noted and interpreted rather more easily in children 
 than in adults. The child presents a change in disposition; this change is 
 usually from gay and amiable to moody and choleric. The immediate exciting 
 cause is sometimes evident, but not always. In the latter case the origin or 
 point of departure of the fit may be in some mental state, some auto-suggestion, 
 which we shall study later. In this mental prodrome the child shuns society, 
 appears sad, melancholy, or irritable, and cannot be drawn readily from its 
 self-absorption. 
 
 The paroxysm is preceded immediately by an aura. These aurae, as in 
 epilepsy, are either sensory or motor. The most common is the sense of a ball 
 rising in the throat, causing a feeling of suffocation. This may be quite 
 alarming to the child, who clutches wildly at his throat in evident terror, crying 
 that he cannot get his breath. This aura is called the globus hystericus. 
 Another, equally characteristic, is the cephalic aura. This consists of loud 
 bruits, or beating, throbbing, and hissing sounds in the ears ; of acute pain, 
 sometimes as of a nail driven into the head, hence called clavus ; and of dimness 
 of vision, and even vertigo. Other common aurse are the ovarian and the 
 testicular. Ovarian tenderness not uncommonly precedes the fits. This may 
 be spontaneous in women rather than in little girls. We have observed one 
 case in which the patient called the physician's attention to ovarian pain, which 
 proved to be only the precursor of an hysterical fit. Most frequently this 
 ovarian tenderness may be elicited by pressure, and thus in confirmed cases the 
 attack may be elicited by simply pressing firmly on the ovary. The aura, once 
 started, seems in these cases to set going the whole associated mechanism of 
 the fit. Similar results are claimed in boys by pressure on the testicles. 
 
 Immediately after the aura the fit proper begins. It is customary, for con- 
 venience of description, to divide this into periods. The French school ob- 
 serves four of these : first, the epileptoid period ; second, the period of grand 
 movements ; third, the period of passionate expression ; fourth, the period of 
 delirium. We have convinced ourselves in our own clinical observations of the 
 general accuracy of this division, but think, with Peugniez, that the third 
 period is most likely to be wanting in the cases of children. 
 
 The first (or epileptoid) period may closely simulate true epilepsy, with 
 which, however, it has no identity in any respect. It begins with a tonic stage, 
 in which the patient usually lies supine with the limbs extended and rigid, 
 
HYSTERIA. • 731 
 
 but with fingers and toes flexed. Deviation of the eyes is conspicuous ; usually 
 there is lateral conjugate deviation, the eyes "being rolled slowly either to the 
 right or left ; in some cases, however, as in the one to be reported later in this 
 paper, convergent deviation occurs. The teeth are held forcibly together, the 
 breath is heavy and slow, then rapid, the neck is swollen (more so than in epi- 
 lepsy), and the face is suffused. The heart's action is already becoming rapid. 
 Sensation is usually blunted, and even abolished in some areas. The conjunc- 
 tival reflex, however, is usually preserved in this stage. Consciousness is 
 obtunded, and even lost in some cases, but in our observation consciousness is 
 not affected so profoundly as in epilepsy. The tonic phase gives place rapidly 
 to the clonic. The muscles of the face, trunk, and extremities begin to tremble, 
 and then to be agitated with a succession of shocks. During this, or even 
 during the preceding stage, the patient may turn over on his side or even pre- 
 cipitate himself from the bed. This clonic stage ends usually rather abruptly 
 with a long-drawn breath, and is succeeded by a brief period of repose, during 
 which the patient lies with closed eyes as if asleep. 
 
 The second and third periods of grand and passionate movements have not 
 been observed so commonly by English and American writers, possibly because 
 they have not studied these cases so methodically as the French. We have no 
 doubt of the importance of the second period, especially in the cases of boys 
 and girls. It explains many bizarre co-ordinate movements in children which 
 exist sometimes as unsuspected abortive or atypical cases of hysteria. This 
 period of grand movements begins abruptly. The patient throws himself into 
 many and curious attitudes. Among the most common of these is the position 
 of extreme opisthotonos, in which he rests upon his head and feet, which are 
 at the ends of an arc of a circle. Other movements, too numerous and com- 
 plicated to describe here, occur. Some of these have received special names, 
 as the movement of salaam. Some of these movements are quite complex 
 and apparently purposive, and may be elaborately automatic. These are more 
 common in confirmed cases, and are probably the product of suggestion and 
 auto-suggestion. They may persist, we believe, as isolated phenomena some- 
 times, or as a kind of abortive attack. Charcot calls these phenomena " cloivn- 
 ism." We shall narrate a case briefly in this paper. 
 
 The third, or period of passionate movements, is the least common in chil- 
 dren. We do not, in fact, quite see the necessity for this subdivision, because 
 these movements naturally grow out of those of the second period, with which, 
 in fact, they are sometimes blended and confused. They are still more com- 
 plex movements, or rather expressions of passions, and as such are not common 
 in children, in whom passions are not yet elaborated, and such as do exist 
 receive simple expression. In these passionate moods the patients betray fear, 
 anger, resentment, etc. ; and it is notable that if they attack they usually 
 attack some one whom they dislike. We recall the case of a colored girl (in 
 whose race hysteria major is not uncommon) who in this period of the grand 
 attack struck savagely a fellow servant, with whom she had had a quarrel a 
 short time before. These passionate movements, in fact, are always the expres- 
 sion of some pre-existent mental state, which persists as a mental picture — or 
 "hallucination," as the French say. 
 
 The fourth and closing period of the convulsive attack is the period of 
 delirium so-called. This delirium, well portrayed in children and young per- 
 sons, is also the expression of a mental state, which is usually reproduced in 
 every succeeding fit in the same patient. This mental state is one usually of 
 fear and sadness, so that the period of delirium is characterized by tears, sobs, 
 
732 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cries, incoherent pleading, and appeal. These subside gradually and the attack 
 is finished. 
 
 These grand attacks may be complicated with somnambulism and cata- 
 lepsy, and they may present various atypical and abortive forms, such as 
 choreiform movements. 
 
 Somnambulism has several traits that ally it to the hysterical status. In 
 it we see a profound unconsciousness and abolition of will-power, leaving the 
 patient under the influence of dreams and hallucinations, and extraordinarily 
 susceptible to suggestions from without. A somnambulistic state has been 
 observed sometimes as a complication of the hysterical paroxysm or as a post- 
 paroxysmal phenomenon. Profound lethargy also supervenes sometimes in the 
 fourth period. Catalepsy is another psychosis, which, while not essentially 
 hysterical, has yet something in its nature that affiliates it with hysteria. Cata- 
 leptoid symptoms are not uncommonly seen in various periods of the grand 
 attack, for they are not confined to any one period. They may be elicited 
 sometimes by suggestion. We have done this in the tonic stage of the epilep- 
 toid period by elevating the patient's arms, and thereby have suspended the 
 fit temporarily or even suggested a new turn in it. 
 
 Among the most interesting products of hysteria are the cases of so-called 
 " chorea major." This is another misnomer, for which the Germans especially 
 are responsible. This chorea major has nothing choreic about it ; it is entirely 
 hysterical. To understand its true position among the hysterical symptoms we 
 may recall what was said above — viz. that the grand attacks may present 
 various atypical forms. As Peugniez has shown, the attacks are not always 
 complete. One period alone may appear, having an exaggerated development 
 and leaving the other periods in the shade. Sometimes merely an aura, as the 
 globus, is felt, and the attack aborts. In other cases the period of delirium, 
 with tumultuous emotions, has such a large place as to appear to constitute the 
 whole attack. Thus we believe it is in some cases with the period of grand 
 movements. These movements become stereotyped as it were on the child's 
 brain at the moment of the extreme susceptibility or "suggestibility" that 
 characterizes him at this crisis. They become further developed, in successive 
 fits or even between fits, into most extraordinary combinations of movements 
 and cries. These movements are sometimes apparently purposive, sometimes 
 of the nature of an acquired dexterity or trick, or, again, they may be most 
 elaborately automatic, the patient's will and personality seeming to have noth- 
 ing to do with them. These complex movements may be propagated readily 
 to others, and thus they may give rise to epidemics in schools and religious 
 communities which resemble the dancing manias of the Middle Ages. The 
 writer saw and recorded one such case in a boy, in whom there was an elabo- 
 rate syndrome of spasm, rotation, and catalepsy, undoubtedly hysterical in 
 origin, and which was cured by a slight operation on the foreskin. 1 
 
 (2) The interparoxysmal symptoms of hysteria, which form the second main 
 group, are even more important than those of the paroxysm itself, for upon 
 them must often depend the diagnosis of the disease from grave organic affec- 
 tions. Their study is too often neglected. They are the permanent markings 
 of hysteria, and hence have been called the stigmata. These stigmata are 
 sensory, motor, visceral, mental, and nutritional, and may be considered here 
 in the order named. 
 
 The changes in sensation are varied in hysteria, but some of them are 
 almost always present. Hyperesthesia and hyperalgesia are common. The 
 
 1 For a full discussion of the history of this phase of the subject see Richer' s Etudes Cliniques 
 mr rHystero-Epilepsie, Paris, 1881. 
 
HYSTERIA. 733 
 
 former is usually distributed in a characteristic way, and gives origin to the 
 well-known hysterogenous zones. These zones are points or areas on the skin, 
 pressure on which is usually painful and may excite the manifestation of other 
 hysterical symptoms, especially the convulsion. This acute sensitiveness, how- 
 ever, does not appear to be confined entirely to the skin, but to include the 
 subjacent organs, as for instance, the ovaries. The most common of these 
 hysterogenous points in our observation are over the ovaries and at points 
 along the spine. Others describe them as in the testicles, at the juncture 
 of the ribs to the sternum, and at other points on the trunk. Pressure 
 on a hysterogenous zone is a common means of exciting the convulsion of 
 hysteria major, and when at its height pressure on the same region will often stop 
 it. Hyperalgesia exists as various forms of neuralgia : some of these are the 
 accompaniments especially of traumatic hysteria. We had such a case under 
 observation in which pain at a circumscribed area in the dorsal spine in a girl, 
 following a fall, simulated the early stage of spinal caries. This case occurred 
 in the Home for Crippled Children, and the diagnosis was so uncertain for a 
 time that the child was put in a plaster jacket. This seemed to make a bene- 
 ficial mental impression, and the patient recovered rapidly. Among these 
 traumatic cases that simulate organic disease are those in which the hyperal- 
 gesia becomes fixed in one of the joints, as the hip or knee. 
 
 Anaesthesia is one of the most important stigmata of hysteria. So common 
 is it that it is doubtful if it is ever entirely absent in pronounced cases, and 
 yet so little observed is it that even the patient himself is often ignorant of its 
 presence. It may be very profound, and accompanied with coldness and vaso- 
 motor changes in the part. During the dancing manias and religious crazes of 
 the Middle Ages and later, it was observed that a pin-stick would not bleed. 
 This was a mark of especially evil augury to superstitious minds during some 
 of the witchcraft plagues. It is now one of the best-recognized marks of 
 hysteria. The distribution of the anaesthesia varies. One of the most com- 
 mon types is hemianaesthesia. This extends from the top of the head to the 
 sole of the foot, and is often accompanied with anaesthesia of the special senses 
 — sight, hearing, taste and smell — and of the mucous membranes. Another 
 type is the distribution in geometrical figures, in which case the patient has 
 areas of anaesthesia of various shapes and sizes scattered over the body. Still 
 another is the monoanaesthetic type, in which an area of anaesthesia covers the 
 arm and hand like a gauntlet or the leg and foot like a stocking. This latter 
 distribution is often accompanied with paralysis of the member. This asso- 
 ciation with paralysis and the peculiar sharp demarcation of the anaesthesia at 
 right angles to the long diameter of the limb serve to characterize this form 
 very clearly. The hemianaesthesia of hysteria sometimes displays a peculiar 
 phenomenon called transfer. Under the influence of some external agent, as 
 electricity or a magnet, or even by suggestion or auto-suggestion, the anaesthesia 
 passes from one side to the other. This change, however, is usually of short 
 duration, for, as a rule, the affection soon returns to its first seat. 
 
 The affection of the special senses is often marked in hysterical hemi- 
 anaesthesia. There may be hemianopsia toward the anaesthetic side, and deaf- 
 ness and loss of taste and smell on the same side. The most significant changes 
 are in the eyes. First of these in importance is the concentric narrowing of 
 the visual field. In the normal eye the visual field is not extended equally in 
 all directions, being widest toward the temporal side, next toward the lower 
 segment, next toward the higher segment, and least extended toward the 
 nasal side. In the hysterical patient these relative proportions are apt to be 
 maintained, the centre of the normal field being the centre of the abnormal 
 
734 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 one, but the field itself is very notably contracted. In some cases, however, 
 the relative proportions are not maintained, the contracted field being a round 
 or oval area around the normal centre. This contracted field may be very 
 small in some patients. Another significant change is in the perception of colors. 
 In the normal eye the fields for colors are not the same. The widest field is 
 for blue, then come the fields for yellow, red, green, and violet in the order 
 named, violet having the smallest field. These fields for color are practically 
 concentric. In the hysteric eye the violet field disappears first, being " squeezed 
 out at the centre," as some one has expressed it. Then the other fields con- 
 tract gradually and disappear in the order named, with the important exception 
 that the red usurps the place of the blue field — i. e. it becomes the widest and 
 the last to disappear. In fact, red is a very persistent color-perception in the 
 hysteric, and is supposed by some French observers to play a part in the hal- 
 lucinations and mental states of these patients. Other affections of the eye are 
 amblyopia in various grades, and the curious phenomenon known as monocular 
 diplopia or polyopia, in which the patient sees with one eye two or more 
 images of the same object. 
 
 The motor symptoms of hysteria are of two orders : those that depend 
 upon the absence of function, and those that characterize its perversion. 
 Paralysis is of the first order, and contracture and tremor of the second. As 
 Richer has pointed out, these disorders of motility are very apt to appear as 
 isolated phenomena in juvenile hysteria, and sometimes at a very early age. 
 
 Hysterical paralyses present a variety of forms, but these forms are not as 
 significant as their mode of onset, their clinical history, and their termination. 
 The most common are hemiplegia, paraplegia, and monoplegia. Very fre- 
 quently the paralyzed part is also anaesthetic — a very uncommon phenomenon 
 in similar paralyses due to central nervous disease. In some cases there is no 
 anaesthesia. Paraplegia is more common in children and young persons than 
 hemiplegia. In hysterical hemiplegia the face often escapes ; but if the face 
 be invaded, it is more frequently some of the eye-muscles that are involved, 
 in the form not of a paresis but of a blepharospasm. The paralyzed limbs 
 may be flaccid or spastic. The onset of these paralyses usually is sudden. 
 Their most common causes are trauma, emotion, and the hysterical fit. In 
 the case of a young woman observed by the writer a paraplegia developed 
 brusquely during a highly emotional love scene. In one of Bourneville's 
 cases a paraplegia followed a grand attack of convulsions. During the paralysis 
 the convulsions ceased, but after it disappeared they returned. The duration 
 of these paralyses varies, but not infrequently they disappear as suddenly as 
 they come, and sometimes as a result of mental impression. In the above 
 case observed by the writer the faradic current cured the disease promptly. 
 Sometimes a paralysis suddenly quits one limb or group of muscles and appears 
 in another, as in the transfer scene in hemianaesthesia. 
 
 A peculiar form of hysterical paralysis is loss of power of co-ordination — 
 the so-called astasia-abasia. 
 
 The most common contractures in hysteria in children are as follows : par- 
 tial or complete contracture of a limb, intermittent torticollis, spasm of the 
 orbicular muscle, and paraplegic contracture. The position assumed by the 
 contractured limb varies according as the contracture occurs in the arm or leg : 
 in the case of the arm the limb is usually flexed, while in the case of the para- 
 plegic form the limb is extended, the foot being in' the position of plantar 
 flexion. The hysterical contracture may be very persistent, enduring for years. 
 In childhood, as Richer observes, the contracture may appear, disappear, and 
 
HYSTERIA. 735 
 
 reappear with a sort of periodicity; in other cases it may pass from one seat 
 to another. The causes of contracture are the same as those of paralysis. 
 
 Tremor is a rather rare motor disorder in hysteria, and is more common in 
 adults than in children. It may be caused by trauma, but it occurs sometimes 
 spontaneously. It generally presents the type described by Rendu of a rather 
 fine tremor increased by voluntary movement. 
 
 The visceral and internal disorders of hysteria are numerous and quite 
 important. We prefer to consider them here as a separate class, although 
 some authorities include them under disorders of motility. Among the most 
 common is aphonia, which as an affection of the larynx may be included 
 here. It is caused most frequently by emotion, and is sometimes an isolated 
 symptom. It may be complete, but more frequently the voice is not entirely 
 lost, but only sinks to a whisper. It may appear and disappear suddenly. 
 
 Rapid respiration is seen sometimes in hysteria, and may confuse the dia- 
 gnosis, because it suggests some affection of the lungs or heart. It is a 
 rather rare symptom, and is probably more common in adults than in children. 
 It presents the superior costal type of breathing, and the respirations may be 
 as rapid as seventy to the minute. Dyspnoea is not present, nor any accelera- 
 tion of the heart, as a rule. The only typical case of this affection seen by the 
 writer occurred in a young woman during a long convalescence from a serious 
 surgical operation. 
 
 Hysterical anorexia and vomiting are occasionally seen, and may constitute 
 the most serious symptoms of the disease. They may bring the patient to the 
 verge of the grave ; in fact, in a few cases they have actually caused death. 
 The vomiting is of a peculiar type which may serve to distinguish it. It is 
 caused usually by a spasmodic movement of the oesophagus, by which the food 
 is regurgitated without having entered the stomach. This has been called 
 cesophagismus. In extreme cases this spasm continues at intervals without 
 the ingestion of food, as in a case seen by the writer and reported elsewhere, 
 in which the patient regurgitated only a frothy saliva. She kept a napkin 
 constantly under her chin as she lay in bed, to receive the ejecta. She was 
 emaciated to an extreme degree. In her case the symptom was caused by the 
 shock produced by swallowing supposed poison accidentally. 
 
 Paresis of the intestine, causing immense dilatation of the tube and conse- 
 quent distention of the abdomen, is seen occasionally in hysteria. 
 
 Affections of the bladder are not uncommon. Hysterical ischuria and 
 painful tenesmus are observed, the latter, especially in women, being associated 
 with a vaginismus. In young girls this is rare. 
 
 The consideration of the mental stigmata of hysteria has been reserved for 
 this place, because, while these stigmata are the very first in importance, and 
 constitute really the essentials of the disease, they can best be described after 
 the sensory, motor, and visceral disorders which they serve to interpret. Hys- 
 teria is a psychosis. Without a study of the disease from this standpoint it is 
 futile to attempt to understand it. But this subject is deep, complex, and. to 
 some, repellant. Moreover, we have space here only to indicate its outlines. 1 It 
 is necessary first to reject the idea that the hysterical child is a simulator and 
 a liar. It has been a too common error, due to the writings of Legrand du 
 Saull and others, to confuse the mental stigmata of hysteria with those of 
 imbecility, degeneracy, and moral perversity. Hysteria and degeneracy are 
 distinct, and, while the two may coexist in the same patient, just as may 
 hysteria and epilepsy or hysteria and tabes, it is inexcusable to confound 
 
 1 An early paper by the writer on " Hysteria — A Study in Psychology " was an attempt to 
 state this aspect of the subject. (See Am. Jour, of Nervous and Ment. Dis., Oct., 1883). 
 
736 AMERICAN TEXT- BO OK OF DISEASES OF CHILD BEN. 
 
 them. We must expect and search for distinct and characteristic mental stig- 
 mata in hysteria, and we believe, with Gilles de la Tourette, that such exist 
 and may be recognized. With this author we recognize a mental impression- 
 ability, a proneness to take and act upon suggestions, as the real character- 
 istic of hysteria. But even more than he, we would insist upon the hysterical 
 automatism, in which there seems to be a dissociation of the higher mental 
 faculties, as the will and intellect, from the lower emotional and impulsive 
 states. This dissociation of mental faculties is more apparent than real : a 
 more exact statement would be, that the hysterical child reacts to a morbid 
 association of ideas, which permits it to develop the various physical stigmata. 
 It is of first importance to recognize this, because by the proper use of sug- 
 gestion — i. e., education — much can be done to counteract the effects of this 
 evil "dislocation" of the mental faculties. Suggestions come to the hysterical 
 child either from without or from within ; they doubtless, by the law of asso- 
 ciation of ideas, tend to form in each successive grand attack a more complicated 
 web. Hence it is that many of the physical stigmata — paralysis, anaesthesia, 
 etc. — either originate in or are aggravated by a seizure. Suggestions from 
 
 Fig. 1. 
 
 Case of Hysteria— (Harriet B ). First stage under Hypnotism 
 
 without, as by trauma, moral shock, etc., act often between or independent of 
 the paroxysms. Sometimes in children the paroxysm aborts, and there may 
 be a true "psychical equivalent" (as in epilepsy), in which some of the most 
 astounding of the hysterical combinations may appear. In children, too, the 
 attack may pass off in some of the psychical prodromes, but these prodromes 
 
HYSTERIA. 
 
 737 
 
 may be followed by the dreamlike or delirious states of the fourth period. To 
 these dreamlike states and states of reverie, as well as to their congeners, the 
 nightmares and night-terrors not uncommon in hysterical children, Tourette 
 justly attaches great importance. They influence remarkably the mental state 
 between the attacks, as well as the physical stigmata. The auto-suggestion 
 in traumatic cases is often reinforced by these dreams and nightmares. 
 
 Changes in nutrition are not marked or characteristic in hysteria. It is 
 commonly said that anaemia is observed, but this is not in any sense character- 
 istic, but only a result of the anorexia which is sometimes present. In other 
 words, it is only an anaemia from malnutrition. The normal hysterical patient 
 between paroxysms, unless anaemic, does not present changes in the blood. 
 The observation of the ancient writers, that the blood would not flow freely from 
 an hysterical patient, was correct, but the fact depended upon alteration in the 
 vessels of an anaesthetic limb, and not upon any alteration in the blood. Ac- 
 cording to the table prepared by Gilles de la Tourette, the proportion of red 
 blood-corpuscles, of haemoglobin, and of urea in the blood of hysterical patients 
 is practically normal. During and after the paroxysm it is probable that some 
 transient alteration would be found. 
 
 The following case, from the writer's clinic in the Philadelphia Hospital, 
 illustrates some of the foregoing descriptions : 
 
 Harriet B , aged seventeen, English. The patient has a history from early 
 
 childhood of headaches and fainting-spells. At twelve years she was severely burned 
 
 Fig. 2. 
 
 Fig. 3. 
 
 Anaesthesia in Geometrical Figures. 
 47 
 
 (From author's case of hysteria in a girl, drawn hy Dr. Riesman.) 
 
738 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 about her body and limbs by her dress catching fire. She had her first fit at about 
 fourteen under the following circumstances : A week before the attack she had slept 
 with a very sick relative who was raving in a wild delirium all night. After returning 
 home she constantly talked of this experience, which had evidently made a deep im- 
 pression on her mind. On the night on which the fit occurred her lather had stayed 
 with the same relative until a very late hour, and then, going home, knocked on his 
 daughter's door and awakened her. The child opened the door, was much frightened, 
 and fell to the floor in a violent fit. Thereafter for a while she had as many as from 
 nine to fourteen seizures a day. A physician who saw her in one of these said she was 
 hysterical, and stopped the fit by slapping her in the face with a wet towel. Some of 
 the seizures were nocturnal. . 
 
 On admission the patient was observed to be a tall, well-developed girl, with a 
 marked English accent. 1 She had many scars due to extensive burns. (These happened 
 some years before her first convulsion). On the fifth day after admission she had a 
 grand' attack, lasting about twenty minutes; it came on spontaneously. She uttered a 
 loud wailing cry for a minute or two, then became motionless in tonic spasm, with the 
 eyes rolled up and respiration suspended. Then there was bilateral squint and extreme 
 dilatation of the pupils. The period of tonic spasm was succeeded suddenly by one of 
 slight clonic movements, complicated with spells of crying, sobbing, and choking. The 
 patient was evidently conscious during part of the attack. During subsequent attacks 
 she exhibited grand and passionate movements, and the fit was sometimes followed by a 
 lethargic state. She can be thrown into one of these seizures by causing her to gaze 
 fixedly at an object held before her, as, for instance, a lead-pencil. 
 
 The patient was found to have hysterogenous zones over the ovaries and over the 
 upper dorsal spine. Pressure on these produces an attack as follows : The patient be- 
 comes rigid, with some flexion of the elbows and knees. The eyes become suffused, the face 
 
 Contraction of the Visual Fields in Hysteria. Field of O. S. (From author's case ; drawn by Dr. Riesman.) 
 
 1 This case furnishes a commentary on the claims of some English writers that hysteria, as 
 described in France, does not exist in England. This patient is a typical English girl, born in 
 Birmingham, and drops her h's unmistakably. Yet she exhibits the grand attack as perfectly 
 as though she were in La Salpetriere. 
 
HYSTERIA. 
 
 739 
 
 165V 
 
 Contraction of the Visual Fields in Hysteria. Field of O. D. (From author's case.) 
 
 flushed, and a rapt expression appears. The breathing is hurried and the pulse rapid 
 The eves converge in internal strabismus and the pupils dilate. The arms may be placed 
 in any position, and remain fixed in true cataleptoid rigidity (see Fig. 1). The hysterical 
 symptoms are seemingly interrupted at times by the catalepsy. The tonic stage lasts tor 
 a long time. The clonic stage is of rather short duration, and is marked by tremors and 
 clonic movements of not very wide range. Grand movements are observed in some 
 attacks. The seizure ends in a paroxysm of tears and sobs. A lethargic state follows. 
 Between the paroxvsms the patient has marked anaesthesia, both in geometric areas 
 and in islets (see Figs. 2 and 3). Sensation is blunted in the buccal and lingual mucous 
 membranes. There is no thermo-ansesthesia. There is some vasomotor weakness, shown 
 by a bright erythematous flush extending for an inch or two around the mark of the 
 sesthesiometre. The visual fields are narrowed concentrically (see Figs. 4 and 5), but 
 the color fields are not modified in a typical way. . „,..■,,. 
 
 It is to be noted finally that this patient has had a few seizures strikingly like true 
 epilepsy in which she is unconscious, froths at the mouth, and bites her tongue. These 
 have occurred mostly at night, and their exact nature therefore is difficult to be deter- 
 mined. But it is possible that the patient has " separate crises," i. e., both hysteria and 
 epilepsy. 
 
 Diagnosis. — In general terms it may be said that in the diagnosis of doubt- 
 ful cases of hysteria the main reliance must be placed upon the presence of 
 some of the permanent stigmata. It is frequently said that hysteria simulates 
 all diseases, but the truth is that it simulates none exactly. The stigmata of 
 the disease, if it is present, can usually be found. 
 
 Epilepsy is the disease most closely counterfeited by the grand attack. But 
 this resemblance is seen in the first period only, the periods of grand move- 
 ments and passionate attitudes not being seen in epilepsy. When the attack 
 aborts in the first period, the likeness to epilepsy may be striking, and it may 
 be necessary to base the diagnosis upon the stigmata. The possible asso- 
 
740 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ciation of the two diseases in one patient ("separate crises") must not be 
 forgotten. 
 
 Paralysis due to organic disease may be simulated by hysteria. Para- 
 plegia especially may be so simulated. The history of the case and the detec- 
 tion of other hysterical signs can usually determine the diagnosis. The same 
 may be said of hysterical joint-disease. 
 
 The so-called " traumatic neuroses " are in large proportion hysterical, as a 
 proper study of the stigmata will usually demonstrate. 
 
 The most common error is to confuse hysteria with degeneracy and moral 
 perversity. It is commonly said that the hysterical patient has one or more 
 of such syndromes as folie du doute, morbid scruples, mysophobia, agaro- 
 phobia, impulse to set fire, to commit suicide, to make murderous assault, or 
 that he is guilty of sexual perversions. It is needless to say that these are the 
 stigmata of degeneracy, not of hysteria. The hysterical child is not a moral 
 imbecile. While hysteria may coexist with degeneracy, as with numerous 
 other morbid states, it is not part of it. 
 
 The various internal and visceral disorders, as hysterical breathing, anor- 
 exia, vomiting, phantom tumors, etc., may usually be diagnosticated by a pro- 
 cess of exclusion, the history of the case, and the presence of one or more 
 hysterical stigmata. 
 
 Treatment. — The treatment of hysteria in children must be partly moral 
 and partly physical. Among the first we include especially education, and 
 secondarily isolation. We have not space to discuss the subject of education, 
 but after what we have said already of defective education as a cause of hys- 
 teria, and of the peculiar impressibility of the hysterical brain, it is enough 
 simply to indicate the sovereign necessity for a sound moral and intellectual 
 regime for these cases. Unfortunately, it is often difficult to procure it. In 
 some cases, if a good training cannot be obtained permanently, the influence 
 of an evil one may be combated temporarily by isolation. To remove the 
 patient from unwholesome domestic surroundings is the first requisite for a 
 cure. 
 
 Among the physical agents the most important for children are gymnas- 
 tics, hydrotherapy, and vigorous tonic treatment. Gymnastics and hydro- 
 therapy are much used by French practitioners, and with signal success. 
 They probably act partly by their moral effects, both direct and indirect, as, for 
 instance, by substituting wholesome impressions for morbid ones, and by divest- 
 ing the mind of the unhealthy complexus of ideas which underlies the hys- 
 terical state. This vigorous restorative treatment, unless contraindicated by 
 special conditions, is better adapted for hysterical children than is treatment by 
 rest and by measures adapted to pamper and enervate them. 
 
 In anaemic states, secondary to anorexia, forced feeding and iron may be 
 indicated. But anaemia, being a secondary condition, will usually improve, 
 even without drugs, on the hygienic plan above suggested. As a rule, few if 
 any drugs are indicated, but as it may be necessary to use some of them for 
 their moral effect, the least injurious ought to be carefully selected. Bromides 
 and sedatives ought to be avoided. 
 
 To abort or control the paroxysm a cold douche, pressure on a hysterogen- 
 ous zone, a hypodermatic injection of morphine, or an emetic, have all been 
 recommended and tried. Morphine, however, is not proper for these cases. In 
 the cases of children suggestion skilfully used will sometimes abort paroxysms 
 and diminish their frequency. The suggestion of an operation will sometimes 
 act thus. Too much solicitude and too persistent holding and controlling the 
 patient should be avoided. 
 
CONVULSIONS. 
 
 By FREDERICK PETERSON, M. D., 
 
 New York. 
 
 Eclampsia is a term often used synonymously with convulsion. Eclampsia 
 is a series of violent contractions of a limited number or of many muscles, 
 clonic generally, sometimes mingled with more or less tonic spasm, paroxysmal 
 in character, and accompanied, when severe and general, by loss of consciousness. 
 Convulsions are to be looked upon not as a separate and distinct disease, but as 
 merely a symptom of a great variety of morbid conditions affecting the most 
 divers portions of the animal economy. The constant repetition of convulsive 
 seizures at irregular intervals is often considered as a distinct disease, but, in 
 the light of recent research, epilepsy too is now regarded merely as sympto- 
 matic of many pathological states which give rise to katabolic discharges in 
 epileptogenetic centres. 
 
 But while eclampsia is only a symptom, it is one of so pronounced a char- 
 acter that it merits, and indeed requires, special consideration as regards its 
 point of origin, etiology, nature, and treatment. 
 
 Convulsions occur at all periods of life, but are so common in infancy and 
 childhood as a symptom of disturbance in nervous centres that, as West says, 
 convulsions in children correspond with delirium in adults ; and Trousseau 
 goes even farther in saying that there are some children who have convulsions 
 as easily as some persons have delirium or dreams. They are more common 
 under the age of two years than at any other period of early life. Males are 
 more frequently affected than females. 
 
 Seat of Origin of Eclampsia. — Convulsions, whether local or general, 
 have their origin in katabolic discharges of nerve-cells, either in the cortex or 
 at the base of the brain. J. Hughlings Jackson has taught that there are 
 three levels from which such discharges may occur : from the cells of the ponto- 
 bulbar region ; from the Rolandic area ; and from a level (purely speculative 
 on his part) which he conceives to exist in the frontal lobes and to represent 
 the highest control of sensory-motor functions. Whatever may be the merits 
 of his highest-level theory, I believe that from a practical point of view we 
 may consider eclampsia as originating either in the ponto-bulbar region or the 
 Rolandic cortical area, and generally the latter. Jackson thinks laryngismus 
 stridulus is a convulsive discharge from the ponto-bulbar region, while Semon 
 believes it to be cortical. The former would also classify as ponto-bulbar con- 
 vulsions the respiratory fits induced in animals by asphyxia, the seizures pro- 
 duced by convulsant poisons (such as nitrous oxide, curare, absinthe, camphor, 
 and uraemia), and those resulting from injuries to the cord and sciatic nerve in 
 guinea-pigs. Lately he has been modifying his earlier views, for now he inti- 
 mates that, though the primary discharge in these cases occurs from the ponto- 
 bulbar level, the higher centres may also at the same time be implicated by 
 intermediation of the ascending sensory fibres. For my own part, I see no 
 
 741 
 
742 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 reason why poisons, for instance, circulating in the blood may not discharge 
 cortical centres simultaneously with ponto-bulbar centres. Whatever may be 
 the ultimate idea attained as to the different levels, the seat of the discharge in 
 convulsions is undoubtedly in the ganglion cells of the brain, and the molecular 
 disturbance in these cells necessary to the discharge is determined either by 
 direct irritation at these centres (from morbid states of the blood or vascular 
 apparatus, trauma, neoplasms) or by indirect irritation (reflex). 
 
 I submit a diagram of the two chief epileptogenetic centres. (Fig. 1). There 
 is no form of eclampsia generated from the ganglion cells in the spinal cord. 
 
 Fig. 1. 
 
 Left Hemisphere. 
 
 Bight Hemisphere. 
 
 Muscles of trunk 
 arms and legs, etc 
 
 Reflexes from 
 
 peripheral nerves and 
 
 viscera. 
 
 Showing, schematically, the two convulsive centres— one the cortical, the other the ponto-hulbar, and 
 their relations and connections. They may he acted on directly hy lesions of the centres themselves, 
 or by vascular or blood states. They are more commonly acted upon reflexly by irritations conveyed 
 along sensory fibres from remote parts. 
 
 Etiology. — Infants are always particularly liable to present the convulsive 
 symptom, because of the incomplete state of development of the nervous system. 
 An infant is a bundle of nerves and nerve-centres and reflexes in a state of 
 great activity, prepared to receive, store up, and re-energize a worldful of new 
 
CONVULSIONS. 743 
 
 impressions suddenly thrust upon it. While the nervous system of the adult 
 has acquired the steadiness of long habit and has but to repair waste, that of 
 the infant has all the delicacy and instability of newly-formed and highly- 
 impressionable protoplasm, and, besides having to preside over the processes of 
 repair, it must govern the growth of the whole organism. The lower centres 
 at birth are more developed than the higher ones, and control is therefore much 
 more imperfect ; yet at the same time the healthy child rarely suffers from 
 eclamptic seizures. It is the child with a hereditary neurotic and unstable 
 nervous system, or with acquired nervous instability, that is prone to fall a 
 victim to convulsions. Most authors are united in the belief that there is an 
 inherited convulsive tendency, that some families are more predisposed to the 
 development of convulsions in infancy than others, and that various neurotic 
 conditions in the parents, such as drunkenness and epilepsy, may give origin 
 to this tendency in their offspring. Rickets is one of the strongest predis- 
 posing causes, and the rickety condition is exceedingly common in children that 
 suffer from convulsions, the coincidence occurring in 30 to 40 per cent. (Gee, 
 Morris J. Lewis, and others). Anaemic conditions and exhaustion or general 
 debility from any cause predispose to eclampsia. 
 
 The exciting causes are chiefly reflex, either from irritation in the fifth 
 nerve (dentition) or in the visceral sensory distribution (gastro-intestinal dis- 
 orders). Many of the exciting causes act directly upon the convulsive centres 
 (febrile and toxaemic conditions). These are given as typical exciting causes. 
 Whether the purely physiological condition of dentition is the sole exciting 
 cause in the cases usually ascribed to that period, or whether there may not be 
 other causes operative during this important epoch of early life, cannot always 
 be definitely determined. 
 
 Improper feeding, over-feeding, and disturbances of digestion are very 
 frequent causes of convulsions. Instances of improper feeding are not often 
 so remarkable as one that came under my observation lately, where an infant 
 of nine months was given a dinner of corned beef and cabbage. This was 
 promptly followed by convulsions lasting seven hours, and these by a hemi- 
 plegia from a meningeal haemorrhage. Gastro-intestinal disorders of all kinds 
 are frequent precursors of convulsions. Worms no doubt often give rise to 
 eclamptic symptoms, but not so commonly as is popularly believed. Convul- 
 sions complicate many of the acute infectious diseases, and are probably due to 
 toxines of bacterial origin circulating in the blood. In the intermittent fever 
 of children convulsions usually take the place of the chill. In certain districts 
 it is common to speak of malarial eclampsia as a very fatal disorder. Convul- 
 sions complicate pneumonia occasionally, but rarely after the age of two years 
 (Holt). Fever from any source is a prolific cause. Infants seem to be very 
 susceptible to the influence of lead, convulsions sometimes following the thera- 
 peutic administration of this metal (Eustace Smith). The so-called "uraemic" 
 conditions frequently give rise to convulsions, though it is well to remember 
 that we do not know what poison in the blood is the exciting cause, and that 
 we do know that urea itself is innocuous. In 3 to 5 per cent, of cases of 
 whooping-cough eclampsia is a complication. Fright, terror, anger, burns, 
 scalds, morbus caeruleus, earache, laryngeal irritations, and organic diseases of 
 the brain and spinal cord are to be borne in mind as more or less frequent) 
 causes of infantile convulsions. 
 
 Pathology. — Often after death from convulsions no morbid changes are to 
 be found at all in the central nervous system. Usually there are signs of death 
 by asphyxia, such as engorgement of the meningeal and cerebral veins with dark 
 blood. Sometimes the passive hyperaemia is so intense that effusion of blood 
 
744 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 takes place, or oedema may be present. Some authors have described anaemic 
 conditions of the brain after death from convulsions. The pathology is of 
 course not obscure when actual organic foci of disease are discovered. 
 
 Outside of the central nervous system the most various pathological condi- 
 tions are found at times in the heart, lungs, and abdominal viscera, this depend- 
 ing naturally upon the varying nature of the exciting cause. 
 
 Symptoms. — The simplest form of spasm is the respiratory spasm, known 
 by several names, such as laryngismus stridulus, spasmodic croup, spasm of the 
 glottis, child-crowing, and inward spasm. It is a local spasm, affecting gener- 
 ally the glottis, but in severe cases all of the respiratory muscles may take part 
 in the morbid movement. In mild cases there is a slight stridulous or crowing 
 sound made by the infant during inspiration through the spasmodically con- 
 tracted glottis ; in severe forms this sound becomes more intense, and the child 
 may become pale or blue before the obstruction gives way. The paroxysms 
 mav appear at any time without warning, sleeping or waking, when being fed, 
 or when laughing or crying ; but the usual onset is at night. The attacks last 
 from a few seconds to a few minutes, and terminate in a coughing or crying 
 spell. Sometimes rigidity of the limbs, opisthotonos, or even general convul- 
 sions may accompany the laryngeal spasm. These seizures may occur once 
 or several times in one night, and be repeated on following nights, the child 
 being apparently well in the intervals. 
 
 In general convulsions there are at times prodromal symptoms, but more 
 often none. The prodromal signs are restlessness, starting and crying in sleep, 
 grinding of the teeth, twitchings of the face or extremities, flexions of the 
 thumbs, and the like. These are often, however, unimportant. There is con- 
 siderable variation in the extent and severity of eclampsia in children, from 
 slight jerky movements of the head and face and carpo-pedal contractions, to a 
 condition not differing from epileptic fits. Then in some of the graver cases there 
 may be a cry ; consciousness is lost ; there is at first a tonic contraction, often 
 not so long as in epilepsy ; then follow vigorous clonic movements of the face, 
 eyes, tongue, jaw, arms, hands, thighs, and legs, which gradually diminish in 
 extent as the nerve-storm abates, until the child becomes wholly quiet, and 
 remains dazed or in a deep sleep or stupor for some minutes or a half hour 
 afterward. There may be frothing at the mouth. The tongue is sometimes 
 caught between the teeth and bitten. The pupils maybe contracted or dilated, 
 and the face cyanosed or pale. There may be a single such attack, or the 
 seizures may be repeated daily or innumerable times during a day or two, 
 resembling the status epilepticus. Sometimes the convulsions may be limited to 
 one side or one extremity, or to some particular part, as in respiratory spasm. 
 The repetition of convulsions continuously limited to one side or one extremity 
 would lead one to suspect a localized organic lesion in or about the motor cor- 
 tex. Consciousness is not always lost in the milder types of infantile spasm. 
 The temperature is generally normal in laryngismus stridulus, but more or less 
 fever may accompany general convulsions, especially when prolonged and fre- 
 quently repeated, as in the condition resembling status epilepticus (Morris J. 
 Lewis suggests the term status eclampticus for this condition). Death may occur 
 during a paroxysm, either from asphyxia or from unknown influences on cere- 
 bral centres. It is important, too, to remember that haemorrhage may take place 
 from the turgid meningeal vessels, as I have pointed out in another article in 
 connection with the causation of the cerebral palsies of early life. 
 
 Prognosis. — Convulsions in children are always a symptom of great gravity. 
 Life may be terminated in a single seizure. Yet many children become robust 
 and healthy after passing through successive series of attacks. Naturally, our 
 
CONVULSIONS. 745 
 
 prognosis must be governed by a knowledge of the exciting causes, and these 
 are often very obscure. In children afflicted with convulsions during the first 
 few days of life the probability of meningeal haemorrhage from instrumental 
 delivery or tedious labor is strong, since eclampsia is rare from other causes in 
 infants under the age of one month. Hyperpyrexia is a very grave concomitant 
 symptom. General convulsions associated with respiratory spasm, whooping- 
 cough, and toxaemia of any kind are of serious import. The same is true when 
 they follow upon wasting diseases, such as cholera infantum and diarrhoea. In 
 the exanthemata convulsions at the onset are not so ominous as in the later 
 stages, though in scarlatina they are dangerous indications at all times. The pos- 
 sibility of the recurrence of spasms in the form of epilepsy in later life should be 
 borne in mind, for in nearly 10 per cent, of epileptics a history of infantile convul- 
 sions is found. It is probable that the convulsions are a symptom, more often 
 than is generally supposed, of organic lesions in the brain, and that associated 
 conditions, such as hemiparesis, hemiplegia, and mental defects, often escape rec- 
 ognition until later development of the child brings them into prominence. It is 
 therefore well to remember that eclampsia*may be associated with such states, as 
 well as occasionally produce them, as noted above. When convulsions are 
 ascertained to depend upon dyspepsia or other mild disorders of the alimentary 
 canal, or to be symptomatic of rachitis, the results may not be so serious as 
 under other circumstances, but the prognosis should always be guarded. 
 
 Diagnosis. — Convulsions occurring in children shortly after birth are 
 probably due to injuries received during labor or to congenital pathological 
 conditions (like heart disease or atelectasis), though reflex digestive disturbances 
 are to be considered if organic causes can be excluded. In infants above six 
 months of age gastro-intestinal troubles or disorders of dentition are to be 
 regarded as most commonly the exciting cause, particularly in such cases as are 
 predisposed by rickets or general debility. The temperature and pulse should 
 be taken, for these often furnish indications as to the possible onset of some of 
 the exanthemata. Symptoms of meningitis, pneumonia, and bronchitis, and 
 eruptions should be looked for. The urine should be examined for albumin. 
 The manner of origin and of onset, the order of the attack, and the presence 
 of paresis or paralysis should be carefully inquired into. 
 
 Treatment. — The treatment of the convulsions of infancy and childhood 
 depends, of course, to a great extent, upon the cause. But this cannot always 
 be ascertained. Where there is reason to suspect organic brain disease, such 
 as haemorrhage, the treatment is much the same as in the adult — perfect quiet, 
 cold applications to the head, relief of the bowels by injection, and the relief 
 of the convulsions by chloroform inhalation and later by small doses of bromide 
 of potassium. Should there be fever, the tepid half-bath, with cold ablutions 
 and rubbing, should be frequently employed. When the eclampsia is due to 
 some reflex disturbance, the warm bath is useful (96°— 97° F.), and if there be 
 colic or abdominal disorder a warm bath containing mustard should be employed. 
 An overloaded stomach or an alimentary canal containing indigestible food may 
 be relieved by one or two grains of calomel. A good emetic is a teaspoonful of 
 syrup of ipecacuanha mixed with alum. Tickling the fauces should not be for- 
 gotten. If the child be at the age of dentition, and there be actual evidence 
 of painful and swollen gums, these should be incised. 
 
 If called to a case of infantile convulsions where the cause seems to be 
 wholly obscure, it may be laid down as a safe rule to give a warm (not a hot) 
 bath, if, indeed, this has not already been done by the family, and to give an 
 enema of five grains of chloral in a little warm starch-water, using a few drops 
 of chloroform for inhalation while the chloral injection is being prepared and 
 
746 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 while awaiting its effects. In recurrent convulsions medicines may be given in 
 the intervals, and among these the bromide of potassium in doses of 3 to 5 
 grains for an infant six months old, and chloral 2 to 3 grains, stand pre- 
 eminent as antispasmodics. The bromide should be continued for a few days 
 after the convulsions have ceased, in order to prevent their repetition. 
 
 In laryngismus stridulus chloroform inhalation will always stop the par- 
 oxysm, though simpler means should be resorted to at first — viz., ammonia to 
 the nose, slapping with a cold wet towel, tickling the fauces, and the like. In 
 the interim between attacks the treatment of special exciting conditions should 
 be carried out, as in infants suffering from general convulsions. 
 
 In all cases the diet should be regulated, and morbid states, such as rickets, 
 diarrhoea, worms, dyspepsia, earache, and the like, be given appropriate treat- 
 ment. 
 
EPILEPSY. 
 
 By JAMES HENDME LLOYD, A. M., M. D., 
 
 Philadelphia. 
 
 Epilepsy is not a disease ; it is a syndrome. By this is meant that it is a 
 collection of symptoms or a comprehensive symptom-group. It was among the 
 earliest recognized so-called diseases, because of its abrupt onset and dramatic 
 features. Like many other symptom-groups of which the morbid anatomy was 
 unknown, this one was made to include phenomena of a variety of distinct 
 affections due to widely varying causes. With the growth of modern pathology 
 these various disease-processes have been more and more carefully studied and 
 differentiated. Hence one by one independent classes of epileptic, or epileptoid, 
 affections have been separated from the main group. Thus the convulsions of 
 hysteria major were first set aside. Later puerperal convulsions, or eclampsia, 
 were defined. So, too, the convulsions of uraemia, of certain toxaemias, of 
 infectious diseases, of degenerative processes such as general paresis, and those 
 occurring in infancy, were demarcated. No one now would think of speaking 
 of these fits as epileptic, and yet, except in hysteria, the convulsive crises, as 
 well as some of the attendant sensory and psychic phenomena, are practically 
 identical with those of epilepsy. Later still it was observed that in some cases 
 the fits began always in one particular muscle or muscle-group, whence they 
 radiated to a variable extent, sometimes persisting in only a few muscles or 
 spreading to one limb or to one side, but in some cases extending to the whole 
 body, involving consciousness only partially in the milder cases. These local 
 fits were found to be due to a " discharge " from a limited area in the brain- 
 cortex, determinable now by the principles of cerebral localization. This area 
 of discharge is oftenest in the motor zone, but not always, because sometimes 
 the first or "signal" symptom is sensory. This species of epilepsy is called 
 "focal," or, after the writer who first described it, Jacksonian epilepsy. Not 
 unfrequently such focal epilepsy is found to be due to a distinct local lesion, 
 such as may be caused by trauma, by a neoplasm, or by some point of irritation 
 or inflammation. Again, a large class of epileptics is associated with idiocy, 
 arrest of development, or atrophy of the brain. The pathological processes 
 underlying these are numerous, and some of them have not yet been clearly 
 demonstrated. 
 
 Thus it is seen that the tendency of modern research is to demonstrate dis- 
 tinct pathological processes for the various diseases or conditions which have 
 among their symptoms an occasional epileptic spasm. Hence there is left only 
 a constantly narrowing group of epilepsies, of Avhich the pathology is as yet 
 unknown, and to which some writers illogically apply the terms "true" or 
 "essential " epilepsy, or, still worse, idiopathic epilepsy. The author does not 
 believe that epilepsy or any other disease is truly idiopathic, but he thinks, 
 with Fere, that this group of essential epilepsies is one, not in which there is 
 no pathology, but in which the pathology is unknown. But so long as this 
 
 747 
 
748 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 group stands he recognizes that it will be desirable, even necessary, to give a 
 clinical description of it in a text-book on practice, to state briefly the advances 
 that have been made in its pathology, and especially to describe its proper 
 treatment. 
 
 Etiology. — It follows from what has been said that the causes of the 
 various forms of epilepsy differ. Focal epilepsy is usually dependent upon a 
 local lesion, such as a trauma, a tumor, or a syphilitic or tubercular process. 
 •The causes of " essential " or vulgar epilepsy are often very problematical. It 
 is the custom now to regard it as a manifestation of a degenerative process in 
 the brain, dependent largely upon heredity or congenital imperfection. In this 
 aspect it has its alliances with insanity on the one hand and with idiocy on the 
 other. It is possible that some cases are the results of intra-uterine mishaps or 
 diseases, or of injury, unobserved and unsuspected, at the time of birth. 
 Others, again, may date from the insidious process of some infectious disease. 1 
 Alcoholism is an occasional, not a common, cause of confirmed epilepsy. It may 
 act in the parents, however, to contribute to degenerative processes in the chil- 
 dren, among the symptoms of which may be epilepsy. 
 
 Pathology. — Epilepsy, in its motor aspect, is an explosion of nerve-force 
 from the brain-centres. But this is a crude and inadequate explanation of the 
 disease-process. It does not explain all the phenomena, especially the loss of 
 consciousness and the various psychical disorders. Bevan Lewis believes that 
 the cells of the second layer of the brain-cortex undergo degeneration or " vacu- 
 olation" — that these cells are the sensory pole of a true sensori-motor arc, the 
 motor pole being the large cells of the deeper layers. Hence the normal inhi- 
 bition exerted by the sensory cells being destroyed, a periodical explosion of 
 the motor cells occurs. It is needless to say that this is a mere theory. 
 
 Morbid Anatomy. — The gross lesions of focal epilepsy are usually easily 
 recognized. Among the most common are tumors, especially in the motor 
 region of the cortex. Next are wounds, causing either depressed fractures of 
 the skull or localized inflammatory products, or both. Such wounds may be 
 caused by blows on the head and by gun- and pistol-shots. Syphilitic lesions, 
 as a localized pachymeningitis, may cause a focus of discharge. So may a 
 tubercular deposit, often called massive tubercle. Focal discharges are some- 
 times, as the author has seen, among the earliest symptoms of tubercular men- 
 ingitis. The gross deformities, such as porencephalon, and diffused processes, 
 such as lobar sclerosis, which manifest themselves by idiocy and arrest of 
 development, and are not unfrequently provocative of epileptic seizures, are 
 not properly to be described here. 
 
 A number of diffused lesions have been reported as found in cases of chronic 
 epilepsy. These are, as a rule, scleroses of different parts of the brain or bulb. 
 Sclerosis of the Ammon's horn has attracted much attention and caused much 
 debate. According to some, it is found in only 6 per cent, of brains examined, 
 but, according to others, it is much more frequent. The facts of motor local- 
 ization, as Fere' says, do not lend countenance to the theory, and experiment 
 shows that lesions of this part do not cause epilepsy ; nevertheless, the obser- 
 vations are rather too frequent to be mere coincidents. With this author we 
 may suppose that the induration of the cornu Ammonis is only a predominant 
 localization of a more diffused lesion. Fe>6 reports also plates of induration in 
 various parts of the cortex and induration of the olivary bodies similar to that 
 of the Ammon's horn. Chaslin claims to have found in brains of some of Fe^'s 
 
 aa\ \ The * nfec | ious ori g in of epilepsy has lately been claimed by Marie (Prog. Med., 1887, No. 
 44), Lemoine (Ibid., 1888, No. 16), and by Veysset (Thesis, 1889, Be V influence des maladies inf&y 
 tieuses sur le developpement de Vepilepsie). 
 
EPILEPSY. 749 
 
 patients a diffused neuroglias sclerosis, a real gliosis — in other words, a pro- 
 liferation of the neurogliar tissue of the brain, as distinct from a sclerosis of 
 connective tissue. 1 The claim of Bevan Lewis that the distinctive lesion of 
 epilepsy is a vacuolation of the cells of the second layer of the cortex has already 
 been referred to. It still remains a vital point to be decided whether these 
 various lesions are the causes or the effects of confirmed epilepsy. 
 
 Symptoms. — Adopting Fare's plan, we may divide the symptoms of epi- 
 lepsy into four groups : (1) Sensory, (2) Motor, (3) Psychic, (4) Visceral. 
 These blend in various ways in different cases ; in fact, it may be said that no 
 two cases of epilepsy are alike. 
 
 Sensor*y symptoms may precede or follow the fit, or both. The sensory 
 aura is a very common signal or initial symptom. It may be a sense of numb- 
 ness or tingling in one of the extremities, as in a finger or toe, or it may be a 
 peculiar, indescribable sensation starting from the epigastrium and mounting 
 to the head. This epigastric aura is perhaps the most common. When it 
 reaches the head or neck, the patient usually loses consciousness and falls in 
 the fit. Sometimes the aura is in one of the special senses, as flashes of light 
 in the eyes or rumbling or other sounds in the ears. Auras of taste and smell 
 are more rare. Occasionally hallucinations of sight are described, as an image 
 of some person or thing, either agreeable or terrifying, appearing and advancing 
 to the patient. The aura, whatever it is, is usually unvarying ; that is, the 
 same patient always experiences the same aura in succeeding fits. The sensory 
 symptoms following the attack are less striking and variable. The most fre- 
 quent is headache, which may persist for some hours or even a day. Some- 
 times the sensory symptoms constitute the w r hole of the attack, and may consist 
 in a crisis resembling migraine. In fact, some authors teach that all migraine 
 is an epileptoid affection, but of this there is not satisfactory proof. Certainly, 
 ordinary migraine does not show a tendency to pass into motor epilepsy. 
 
 The motor symptoms of epilepsy are by far the most conspicuous, and so 
 dominate the scene that they are apt to be regarded as the most important; but 
 this is an error. They present great variety, and, for the sake of brevity, can 
 best be described in some of their typical forms. The first visible motor 
 symptom may be in the form of an aura; that is, a signal symptom recognized 
 by the patient. This may coexist with or immediately follow a sensory aura, 
 such as has already been described. It is usually a tonic or clonic movement 
 of the muscles of one of the fingers or toes, or of the external muscles of the 
 eyes, or of the muscles of the face or neck. This motor aura is especially 
 likely to occur in the focal epilepsy referred to above. This slight initial 
 spasm soon radiates to other muscles, then to the proximal parts if in a limb, 
 then to the whole limb, then to the limbs of one side, and then, in severe cases, 
 to the whole body. The first movement of the convulsed muscles is nearly 
 always tonic or spastic, rapidly giving way to vibratory and clonic movements. 
 In some milder cases or attacks of this focal epilepsy the movement may consist 
 of merely a slight spastic, followed by a jerky, clonic convulsion in a very 
 limited muscle-group. In the most severe of all forms of epilepsy, known as 
 vulgar epilepsy or grand mal, the motor phenomena are about as follows : 
 Almost instantly, with a very brief aura, or even without any warning whatever, 
 the patient utters a peculiar startling cry and falls convulsed. This cry is 
 probably part of the motor symptom-group, being rather the result of the 
 forcible expulsion of air from the chest by the vice-like spasm of the respiratory 
 muscles than the expression of emotion or other psychic states. When he falls 
 
 1 For an exhaustive discussion of this whole subject see Fern's treatise, Les Epilepsies et les 
 epti-eptiques, Paris, 1890, chap, xxx, p. 437. 
 
750 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the patient is in a general tonic or spastic stage. The pupils are dilated. The 
 face, at first pale, rapidly becomes congested and cyanosed. The teeth are 
 firmly set, the tongue probably caught between them. The fists are clenched, 
 the limbs extended, the head often drawn forcibly to one side. In a few mo- 
 ments vibratory movements begin in the muscles of the eyes, face, and extrem- 
 ities. These vibrations soon increase in range, and they pass into clonic spasms, 
 which gradually diminish and usually terminate in wider shock-like movements. 
 While they endure bloody or unstained froth escapes from the mouth ; the urine, 
 and rarely the faeces, may be expelled. The patient often injures himself in 
 his fall, besides biting his tongue. He is unconscious from the first moment, 
 and sleeps heavily for many hours afterward. Exhaustion, even paralysis, of 
 the convulsed muscles may follow the fit. Exhaustion and abolished knee- 
 jerks are seen after these severe attacks especially. Paralysis in the previously 
 convulsed muscles is more apt to occur after focal epilepsy, especially when 
 this depends upon a destructive focus, such as trauma or tumor, in the brain. 
 
 The psychic symptoms of epilepsy are of the very first importance. It is 
 too often the custom, unfortunately, to regard epilepsy as a mere motor dis- 
 order characterized only by a fit. There is nothing wider from the truth than 
 this. Epilepsy, or that for which it stands, is much more than a fit. Its essen- 
 tial factor is probably a widespread degenerative process which involves not 
 only the motor and sensory cortex, but also the higher intellectual spheres of 
 the brain. Hence, as was recognized long ago, epilepsy has important rela- 
 tions to the mental health. The transient psychic disorders usually attending 
 the convulsion, or following it, have already been noted. They consist of very 
 fleeting mental states, which accompany the aura, such as confusion, possibly 
 in some cases terror, or even rage, and which soon pass into unconsciousness. 
 This unconsciousness lasts for a variable time, usually persisting as a deep sleep 
 for some hours after the fit. But there are other and more important psychic 
 phenomena. Not only loss of consciousness, but also stuporous and confusional 
 states, as well as various forms of mental derangement, attests how comprehen- 
 sive may be this degeneration. Among the most common of these derange- 
 ments are episodes of fury with forgetfulness, mania, substituting or following 
 the paroxysm, delusional ideas, moral perversions, coma, and chronic deteriora- 
 tion of the brain-faculties. Many years ago Morel, a French writer, described 
 masked epilepsy (epilepsie larvee), in which the motor crisis is not apparent, 
 but is replaced by an explosion of maniacal fury. This is perhaps an extreme 
 doctrine if applied to the cases of persons who have never been known to have 
 any of the motor disorders of epilepsy. But this variety is very similar to the 
 now well-recognized substitutional attacks. These are episodes of confusion, 
 forgetfulness, automatism, and even violence, taking the place of a motor seizure 
 in a confirmed epileptic. They are called also psychical equivalents. Another 
 mental disorder is mania, a dangerous complication. It may appear as a sub- 
 stitute for, or as a sequel of, a paroxysm. Delusions sometimes persist in the 
 epileptic, which appear to have had their birth in the disordered brain just 
 before or after a convulsion. Homicidal and suicidal impulses are sometimes 
 displayed. The terminal dementia of epilepsy is a state of degeneration of the 
 mental faculties. As was said above, no two epileptics are alike. Hence it is 
 futile to attempt to classify this great array of psychoses into " prodromal," 
 "post-paroxysmal," etc., as some have done. Each case must be studied by 
 itself. Commonly, mental symptoms appear just before or after or substituting 
 a paroxysm; in other words, they are part of the epileptic discharge. Where 
 they seem to come independently of a fit, it is well to recollect that the motor 
 discharge may have been so slight as to have been overlooked. 
 
EPILEPSY. 751 
 
 The great viscera are variously affected in epilepsy. Death has resulted 
 from asphyxia due to the spasm of the chest-muscles, or even from rupture of 
 the heart occurring during the tonic stage. Crises resembling angina pectoris, 
 also peculiar spasmodic affections of the larynx, are sometimes epileptic in 
 character. Nocturnal incontinence of urine, especially if persisting after early 
 childhood, may excite a reasonable suspicion. Disorders of digestion not unfre- 
 quently persist for some days after a convulsion ; these are chiefly nausea, vom- 
 iting, anorexia, constipation, or diarrhoea. Jaundice even has been seen. 
 Post-paroxysmal albuminuria has been observed, but not constantly, as some 
 have claimed. Glycosuria is exceptional. Visceral symptoms are quite prom- 
 inent in some cases of petit mal; thus with slight dizziness and confusion there 
 may be nausea or palpitation of the heart. In a very few cases haemorrhage 
 into the brain has been found as a result of a fit. 
 
 The nutrition is variously affected by the epileptic seizure. Loss of weight 
 and alterations in the blood, such as diminution in the quantity of oxyhsemo- 
 globin, have been observed and studied by Fe'rd, Henocque, and others. 
 
 Epilepsy leaves its marks or stigmata upon the body of the patient. These 
 are most conspicuous in chronic cases that have begun early in life, and hence 
 in cases that are most distinctly degenerative in origin and course. Some of 
 these somatic signs, in fact, are identical with those that are now well recog- 
 nized in constitutional or hereditary types of insanity, or even in arrest of 
 development. Among them are cranial and facial asymmetry ; also other cra- 
 nial and skeletal deformities. Such epileptics, on the whole, are of poor or 
 even stunted development, although many exceptions to this rule occur. Defec- 
 tive development of teeth, external ears, and genital organs is sometimes 
 noted. The epileptic facies has been described, but it is too often the evidence 
 of bromidism rather than of disease. 
 
 Varieties. — There are many varieties of epilepsy. Focal epilepsy has 
 already been described. Petit mal is often only a minor form of this : it consists 
 in a momentary dazed or confusional state, with or without localized muscular 
 movements. Grand mal also has been described. Nocturnal epilepsy is not 
 distinct, except for the fact that the attacks occur during sleep: somnial epi- 
 lepsy would be a better term, because the attacks occur really during sleep, 
 whether this be during the day or night. Cases have preserved this type for 
 many years. Procursive epilepsy derives its name from the fact that the 
 patient runs for some distance before falling in the fit. Masked epilepsy, 
 already referred to, is the type in which the sensory and motor symptoms are 
 replaced by a psychosis. A very grave complication is the epileptic status. 
 In this the patient passes rapidly from one convulsion into another. He is 
 comatose, with high temperature, a weak pulse, and a stertorous respiration. 
 In this condition he may die. 
 
 Diagnosis. — Epilepsy is to be distinguished especially from hysteria, from 
 the convulsions of uraemia, and from those due to gross organic brain disease. 
 It can be distinguished successfully from hysteria by the absence of the hys- 
 terical stigmata, which cannot be described here ; by the histoiy of the case, 
 and by a careful comparison with a typical grand attack as described elsewhere. 
 It can be distinguished from uraemia by the history of the case and by the 
 absence of evidence of organic kidney changes. In gross brain disease the 
 symptomatic epilepsy is often focal, although not always, and other symptoms, 
 such as various forms of paralysis of motion and sensation, changes in the optic 
 disks, vomiting, vertigo, and acute mental symptoms, together with the history of 
 the case, assist in the diagnosis. In children a grave question sometimes arises 
 as to the exact nature of a convulsion, especially if it has been repeated after 
 
752 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 a comparatively long interval without apparent cause. Reflex epilepsies in 
 children from teething, worms, constipation, etc., are not nearly so frequent as 
 has been supposed. The great majority of infantile convulsions are caused by 
 some infection of the blood, such as the poisons of scarlatina, measles, whooping- 
 cou^h, etc., or the products of indigestion. Where no such cause exists, and 
 especially when the convulsions are repeated at comparatively long intervals, 
 the case ought to be recognized as serious, as threatening the formation of the 
 epileptic habit, and it ought to be treated accordingly. 
 
 Prognosis. — In early exceptional cases, not caused by gross brain disease, 
 it is possible that a cure may be obtained. For chronic epilepsy there is no 
 cure. The more inveterate and severe the fits, the greater is the chance of 
 mental complications and ultimate deterioration. This rule is not universal, 
 however, because mental symptoms are due to obscure causes and may appear 
 in mild cases. Patients with severe, if infrequent, attacks often lead a long 
 and even useful life. The epileptic status is always dangerous to life. Brain- 
 surgery has relieved focal cases due to gross lesions, but even in these cases 
 relapses have occurred. 
 
 Treatment. — The treatment of epilepsy must be both hygienic and spe- 
 cific. It has long been observed that over-eating, over-sleeping, and a slothful 
 life are especially injurious to epileptics. In young patients, who do not yet 
 show the marks of chronicity and deterioration, it is important to regulate the 
 habits and the daily life. Attention ought to be paid to the gastro-intestinal 
 tract ; over-eating and constipation must be guarded against. Radcliffe of 
 England also cautions against over-sleeping as provocative of more frequent 
 seizures. An overloaded bowel will undoubtedly act injuriously upon the 
 epileptic. This is a matter of common observation in the Philadelphia Hospital 
 among the epileptics and the epileptic insane. An idle life is, unfortunately, 
 often forced upon the epileptic ; he both shuns and is shunned because of his 
 affliction. It were far better if he could be kept busy at some light and agree- 
 able task. In private patients this need can and ought to be met. Finally, 
 the well-recognized rules of personal hygiene, which cannot be given here in 
 detail, ought never to be relaxed. 
 
 The indications for treatment supplied by the advanced pathology of epi- 
 lepsy, given above, are several. Drugs which have, or are supposed to have, 
 a restraining effect upon connective tissue or neurogliar proliferation ought to 
 have a thorough trial. Iodide of potassium is the first of these in importance. 
 The mercurial drugs may have a somewhat similar effect, as may also nitrate 
 of silver. Arsenic and zinc salts are of doubtful utility. It is but reasonable 
 to suppose that the peculiar action of these medicines will be exerted best in 
 recent cases and in young persons. Certainly, every such case ought to have a 
 thorough trial of the iodide of potassium. If time shall prove that this latter 
 drug exerts a true alterative action upon the sclerotic processes seen in epilepsy, 
 it will deserve, rather than the bromides, the title of a specific. 
 
 The bromides are undoubtedly the surest remedy for epilepsy, especially 
 for controlling the fits in confirmed cases. That they are ever curative, even 
 when given early in young patients, is at least doubtful. The writer has never 
 seen them effect a cure. Some authorities advise heroic doses given until the 
 patient is " bromidized." It is well to try this plan in early cases in the hope 
 of eradicating the disease. In chronic cases bromide in any doses cannot cure, 
 but it can reduce the number of seizures. It does this, however, at the cost 
 of much depression, and in advanced cases, if given in large doses for a long 
 time, it probably promotes some deterioration of the brain. Children bear 
 large doses of the bromides well. Of the various salts, the potassium is rather 
 
EPILEPSY. 753 
 
 the most reliable, the sodium is least likely to disturb the stomach, and the 
 ammonium is stimulating to an insignificant degree. The iodide of potassium 
 can be given with any bromide salt. 
 
 Antipyrin has been tried with apparently good effect in epilepsy. It 
 belongs strictly to the same class as the bromides — i. e. it is palliative rather 
 than curative. Chloral hydrate may assist the bromides, especially in urgent 
 cases like epileptic status. 
 
 Of other drugs, none deserve special mention except belladonna and nitrite 
 of amyl. The former has value, but its unpleasant physiological action is much 
 against it. The nitrite of amyl is of use in some case of petit mal to abort the 
 crisis. 
 
 Surgery offers relief in many cases of focal epilepsy due to gross lesion of 
 the brain or skull, such as tumor and fracture. The seat of an old fracture, or 
 even suspected fracture, ought to be trephined if epilepsy supervenes. The 
 principles of cerebral localization may indicate the seat of a lesion in obscure 
 cases. Even in cases where no organic lesion has been discovered, excision of 
 that part of the cortex which contains the focus of discharge has done good. 1 
 Trephining in cases of epileptic idiocy caused by brain atrophy, porencephalon, 
 and other gross defects, should be condemned. It is not based upon scientific 
 principles, and the results in the cases in which it has been done are disap- 
 pointing, and they have often been fatal. 
 
 1 See cases by Lloyd and Deaver, Am. Jour. Med. Sei. f Nov. 1888, and Intern. Clinics, voL 
 iii., 2d Ser. 1892. 
 48 
 
CHOREA. 
 
 By M. ALLEN STARR, M. D., Ph. D., 
 
 New York. 
 
 Chorea minor, Chorea of Sydenham, or St. Vitus' Dance, is a functional 
 nervous disease characterized by sudden rapid twitchings of any or all of the 
 muscles of the body, by slight deficiency in the control of the muscles which 
 twitch, and by mental irritability. 
 
 Description. — The movements produced by chorea are spasmodic, unex- 
 pected, and inimitable. They cannot be arrested by will for any length of time, 
 but are much increased by attention, by excitement, or by any effort either to 
 restrain them or to exercise the muscles involved. In the majority of the cases 
 the movements are momentary and slight, and do not exhaust the patient. In a 
 few most severe cases they are extended, violent, and continuous, endangering the 
 patient's safety and even his life. These movements interfere greatly with 
 voluntary acts, rendering them imperfect, awkward, excessive, or even impos- 
 sible. When chorea is slight, such acts as dressing, writing, or playing the 
 piano may reveal irregular motions not noticeable in a state of rest ; and often 
 it is this unusual awkwardness in the performance of these acts or nervousness 
 which first attracts attention to the condition. When the disease is fully devel- 
 oped any movement involving fine co-ordination is impossible. While any muscle 
 of the body may be involved in the choreic movements, it is more common to 
 notice them in the extremities and face than in the muscles of the trunk. The 
 facial muscles are frequently affected, and the child makes queer faces, espe- 
 cially while talking. The eyes are suddenly closed or opened ; the mouth 
 pouts ; the tongue if protruded is seen to be affected, and may be suddenly 
 withdrawn, or even be cut by an unexpected snapping together of the jaws; 
 occasionally the laryngeal and respiratory muscles are affected, and noises are 
 made in the throat. The neck is not as frequently affected as the shoulders, 
 but the arms below the elbow are almost always involved, and irregular, 
 awkward motions of the fingers are always seen or felt if the hands are held. 
 While the trunk-muscles do not often appear to swell out in contraction, yet 
 the entire body is uneasy, and frequent changes of posture are always to be 
 seen. The legs below the knees are affected as often as the arms, but the 
 thighs do not often twitch, and the patient is rarely seen to fall, though he may 
 stagger in walking. These motions cease during sleep. 
 
 The weakness in the muscles affected may occasionally amount to paralysis, 
 but this is rare. The awkwardness or ataxia is always noticeable. The disease 
 might be supposed to be entirely muscular in its origin, were it not for the facts 
 that it is very often unilateral and almost always associated with mental irri- 
 tability. Hemichorea is about one-third as common as general chorea. In 474 
 cases of my own 169 were unilateral. It occurs on either side, and if the 
 disease begins as a hemichorea it rarely becomes general. If it has once 
 occurred as a hemichorea, it usually recurs as such. 
 
 The mental irritability is usually noticeable early in the disease. It may 
 
 754 
 
CHOREA. 755 
 
 be accompanied by inability to exert the mind continuously and by enfeebled 
 ability and depression of spirits. The child frets and is easily irritated, is 
 quarrelsome when previously of good temper, cannot be amused, and is said to 
 be naughty when in reality it is unable to exercise self-control in a normal 
 manner. It may act in a semi-imbecile manner, laughing too easily. It is 
 always incapacitated for study. This mental excitement may interfere with 
 sleep. 
 
 A child who is suifering from chorea is unusually pale, badly nourished, has 
 little appetite, is constipated, passes but little urine, and that of high specific 
 gravity, loaded with phosphates and urates. Very frequently, if examined, it will 
 be found to have a loud systolic heart-murmur, which may be either functional 
 and due to anaemia or organic and due to endocarditis. There is often obtained 
 a history of muscular pains or of an attack of rheumatism preceding or coincident 
 with the appearance of the chorea, and also of headache. There is usually 
 diminution of the tendon reflexes and a hyperexcitability of the muscles to 
 electrical stimulation. Temperature, pulse, and respiration are normal. 
 
 The disease appears suddenly sometimes after a fright, increases during the 
 first two weeks, lasts for several weeks (ten is the average), and gradually sub- 
 sides, but will probably recur after a year at the same season at which it first 
 appeared. 
 
 This description applies to the majority of cases of chorea. There are 
 exceptional cases which require mention. 
 
 In a few instances the motions are constant, excessive, and violent, so that 
 the patient will be thrown oif a chair or out of bed, and is liable to injure 
 his limbs by their violent contact with objects. Unless these patients are 
 kept asleep, they are soon worn out and may die of exhaustion. 
 
 In a few cases the mental irritation rises to the pitch of mania, and 
 active delirium occasionally occurs in this form of the disease. 
 
 In some the weakness is so much more apparent than the twitching that 
 the case impresses the observer as one of paralysis : this has been named the 
 paralytic form. I have known a case of chorea to be mistaken for infantile 
 spinal paralysis. Occasionally the twitching is less noticeable than the awk- 
 wardness, and were it not for the age of the patient and the absence of other 
 symptoms the case might be thought to be one of locomotor ataxia. 
 
 In a few instances speech becomes affected early, and may be so indistinct 
 that it cannot be understood : it is in these cases that grunting noises may be 
 made. Sometimes nervous patients affected with twitching motions give vent 
 to loud words unexpectedly, usually of a profane or obscene kind. This con- 
 dition, known as coprolalia, is not choreic, but hysterical. So, too, is echolalia, 
 in which the patient repeats the last word heard. Such patients often mimic 
 motions and show other signs of hysteria. 
 
 Subcutaneous nodes, which are small, round, hard nodules appearing in 
 many parts of the body, notably on the back and along the flexor surfaces of 
 the extremities, are occasionally seen in choreic patients. They are to be 
 regarded as evidence of rheumatism, and have no special relation to the 
 chorea. 
 
 Duration of the Disease. — The duration of an attack of chorea is very 
 variable in different cases. Sometimes the disease runs a rapid course, and 
 terminates in recovery within a month ; again it may continue for a year or 
 more with varying degree of severity; occasionally it becomes chronic and 
 lasts for years. 
 
 The large majority of cases of chorea last from six to ten weeks, and ter- 
 minate in recovery; but there is always danger of a relapse, and the greater 
 
756 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 number of the patients suffer from a second or third attack, which attack usu- 
 ally occurs at the same period of the year at which the first seizure occurred. 
 I have treated a patient for seven successive years every spring, and have many 
 cases on my books of fourth and fifth recurrences. 
 
 Death only occurs as an exception in children, though fatal cases in adults, 
 especially when chorea complicates pregnancy, are not very rare. When a child 
 dies of chorea it is because of exhaustion on account of the severity of the 
 motions. 
 
 Etiology. — Sex. — Males are less liable to the development of chorea than 
 females, the proportion being about 1 to 3. Of 466 cases of my own, 136 
 were males and 330 were females ; of 436 cases collected by the Collective 
 Investigation Committee of the British Medical Association in 1887, 1 114 were 
 males and 322 were females. 
 
 Age. — While chorea may occur at any age of life, instances having been 
 reported both at birth and at the age of eighty-six, yet the large majority of 
 cases appear between the fifth and fifteenth years of life. Table I. shows the 
 age of onset in 467 cases under my own observation and in 436 cases tabulated 
 in the report of the B. C. C. : 
 
 Table I. — Age of Incidence of Chorea. 
 
 Cases. 
 
 CO 
 
 u 
 <s 
 
 a 
 P 
 
 4. 
 
 5. 
 
 6. 
 
 7. 
 
 8. 
 
 9. 
 
 10. 
 
 11. 
 
 12. 
 
 13. 
 
 14. 
 
 15. 
 
 16 
 to 
 20. 
 
 21 
 to 
 25. 
 
 26 
 to 
 30. 
 
 31 
 to 
 35. 
 
 36 
 to 
 40. 
 
 3 
 u 
 
 9 
 
 6 
 
 B. C. C. cases . . 
 Personal cases . 
 
 2 
 3 
 
 1 
 7 
 
 3 
 
 19 
 
 15 
 
 22 
 
 37 
 
 25 
 34 
 
 59 
 
 20 
 55 
 
 75 
 
 43 
 44 
 
 87 
 
 46 
 43 
 
 89 
 
 49 
 35 
 
 84 
 
 42 
 42 
 
 84 
 
 41 
 42 
 
 83 
 
 39 
 35 
 
 74 
 
 20 
 22 
 
 42 
 
 71 
 
 56 
 
 127 
 
 10 
 10 
 
 20 
 
 2 
 
 
 2 
 
 1 
 2 
 
 3 
 
 1 
 1 
 
 2 
 
 6 
 5 
 
 11 
 
 J 5 
 
 8 
 
 22 
 
 Classes. — While children in all classes of the community may be attacked 
 by chorea, a large majority of the cases are found to develop among the lower 
 classes, especially among children living in tenement-houses under bad hygienic 
 surroundings and subsisting upon poor and badly cooked food. 
 
 Season. — Several interesting investigations have been made with regard to 
 the relation between atmospheric and climatic conditions and the development 
 of chorea. An attempt has been made by Lewis to trace some relation between 
 the occurrence of storms, between barometric changes, between changes in 
 humidity of the atmosphere, and the occurrence of the onset of chorea. While 
 it appears from the tracings upon his table (see Table II.) that there is some 
 connection between the conditions of the weather and the development of rheu- 
 matism, and while there is undoubtedly a distinct tendency for chorea to pre- 
 vail in certain climates at certain seasons of the year, yet no precise statements 
 in regard to the influence of climatic changes upon the production of chorea 
 can be made. 
 
 Weir Mitchell and Sinkler have called attention to the fact that chorea 
 appears with greater frequency at certain periods of the year, notably during the 
 spring. Table III., which compares the months of onset of 170 cases of Weir 
 Mitchell and 409 of the author's, clearly shows that the largest number of cases 
 begins in the spring. 
 
 Relation of Rheumatism and Chorea. — For many years it has been 
 admitted that there is an intimate relation between chorea and rheumatism. 
 Many cases of chorea develop immediately after an attack of acute rheumatism, 
 with or without accompanying endocardial complications. In many instances 
 
 1 The results of this investigation are valuable, and will be referred to in the course of this 
 article as the B. C. C, British Chorea Committee. (See British Medical Journal, Feb. 20, 1887.) 
 
CHOREA. 
 
 757 
 
 rheumatism and chorea appear alternately, one succeeding the other in some 
 patients; in many cases they appear simultaneously. In Table IV. the relation- 
 ship or coincidence of these diseases is displayed, and the large percentage 
 of cases of chorea in which rheumatism has existed (26 per cent.) can not be 
 ignored. The statement may be made that a certain poison in the blood, either 
 of extraneous origin or internal development, under certain conditions, produces 
 rheumatism or chorea or endocarditis. This poison may affect the joints or the 
 nervous system or the heart, probably in accordance with the varying suscepti- 
 bility of these organs in different individuals, and in many subjects it produces 
 all three diseases at once. 
 
 Some authors regard the existence of "growing pains" of an indefinite 
 muscular character as sufficient evidence of rheumatism, and in the statistics 
 here collected it has not always been possible to determine whether the pains 
 called rheumatic were of this character. In my own cases I only consider 
 those rheumatic in which a history of acute articular rheumatism occurring 
 within three months of the onset of the chorea has been obtained. 
 
 PHILRDELPHIR. 
 
 Table II. 
 
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 barometer ; 4. Mean relative humidity ; 5. 674 separate attacks of acute inflammatory rheumatism.— (Lewis, 
 Trans. Assoc. Amer. Phys., 1892). 
 
758 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Table III. — Showing Month of Onset of Chorea. (409 cases of author, black line; 170 cases of 
 
 Weir Mitchell, dotted line.) 
 
 65 
 60 
 55 
 50 
 45 
 40 
 35 
 30 
 85 
 20 
 15 
 10 
 . 6, 
 
 Jan. 
 
 Fet. 
 
 Mar. 
 
 Apr. 
 
 May. 
 
 June 
 
 July: 
 
 Aug. 
 
 Sept 
 
 Oct. 
 
 Nov. 
 
 Dec. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 A 
 
 
 
 
 
 
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 -x 
 
 
 
 
 N»^' 
 
 
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 *~" 
 
 *>^_— 
 
 -• 
 
 » 
 
 Relation of Chorea to Endocarditis. — In a large percentage of patients suf- 
 fering from chorea examination of the heart reveals the existence of a murmur. 
 
 Table IV. — Showing the Relationship of Chorea, Rheumatism, and Endocarditis. 
 
 Author. 
 
 Reference. 
 
 No. 
 Cases Chorea. 
 
 Rheumatism. 
 
 Cardiac. 
 
 Groendal 
 
 Wien. med. Woch., Mar. 26, 
 1891 
 
 52 
 
 121 
 
 267 
 
 30 
 
 196 
 
 80 
 20 
 80 
 80 
 84 
 
 439 
 
 100 
 
 70 
 
 130 
 
 279 
 
 448 
 
 37 
 
 11 
 
 48 
 
 14 
 
 134 
 
 5 
 3 
 
 37 
 36 
 62 
 
 116 
 
 24 
 8 
 
 7 
 
 37 
 
 83 
 
 Majority. 
 
 15 
 
 37 
 
 6 
 
 5 
 
 8 
 20 
 45 
 
 141 
 40 
 12 
 
 8 
 
 82 
 83 
 
 Meyer 
 
 Berl. Min. Woch., July 14, 
 1890 . 
 
 Koch 
 
 Peiper 
 
 See 
 
 Leroux 
 
 Dale 
 
 Herringham 
 
 Garrod 
 
 Cheadle 
 
 Brit. Col. Invest. Com. 
 
 Arch. Jclin. Med., 1886 . . 
 Deut. med. Woch., July, 1888 
 La Med. moderne, Oct., 1891 
 Rev. Mens, des Mai. de I'Enf, 
 
 June, 1890 
 
 Lancet, Oct. 31, 1891 . . . 
 Lancet, Jan. 12, 1889 . . 
 Lancet, Jan. 12, 1889 . . 
 Lancet, May 4, 1889 . . . 
 Brit. Med. Jour., Feb. 26, 
 
 1887 .... 
 
 Gowers 
 
 Sachs 
 
 Dana 
 
 Sinkler 
 
 Starr 
 
 Bis. Nerv. System, vol. ii. 
 
 p. 550 
 
 Keatintfs Cyclo. Child. Bis., 
 
 vol. iv. p. 843 .... 
 Arch, of Pediatrics, Apr., 
 
 1888 . 
 
 Pepper's System of Med., vol. 
 
 iv. p. 442 
 
 
 
 
 2476 
 
 662 
 26 per cent. 
 
 502 + 
 
CHOREA. 759 
 
 This murmur is usually a mitral systolic murmur, heard at the apex, only occa- 
 sionally being aortic or double. In many of the cases the murmur heard 
 appears with the beginning of the attack of chorea, and ceases after the attack 
 is over. Such murmurs are usually considered as blood-murmurs, owing to 
 their association with anaemia, and are not thought to indicate any actual disease 
 of the valves. A certain proportion, however, of patients who have chorea con- 
 tinue to have a cardiac murmur after the chorea has passed away, and just as 
 rheumatism may leave a diseased heart, so chorea may leave a diseased heart ; 
 and this is true whether the chorea has been associated with rheumatism or not. 
 It is true that the rheumatic cases of chorea are more liable to develop endo- 
 cardial murmurs than the non-rheumatic cases, but it is not true that the 
 development of a true endocardial murmur is evidence of the existence of 
 rheumatism in a given case of chorea. 
 
 In my own records I have distinguished between cases in which a murmur 
 has been present and has passed away after the chorea has ceased (65 cases), and 
 cases in which the murmur has remained for a period exceeding six months 
 after recovery from the chorea (83 cases). There were 300 cases in which the 
 heart was carefully watched, and in which no murmurs, either functional or 
 organic, appeared. Osier has shown that in a considerable proportion of cases 
 of chorea the complicating endocarditis is independent of rheumatism, but 
 lays the foundation of organic heart disease — an opinion which my experience 
 confirms. 
 
 Other Etiological Facts. — It is well known that chorea occurs as a sequel 
 of scarlet fever and measles, whooping-cough and varicella. It is possible that 
 the original infectious agent producing these diseases acts as an irritant to the 
 nervous system. The chorea which occurs during pregnancy need not be con- 
 sidered here as it is not a disease of childhood. 
 
 A large majority of the patients suffering from chorea present evidences of 
 anaemia in greater or less degree. It cannot be stated, however, that anaemia 
 is a cause of chorea. It is probable that the same conditions which give rise 
 to anaemia conduce to the development of chorea. The anaemia is frequently 
 so severe as to require treatment simultaneously with the chorea. 
 
 While it is possible that local twitchings of the muscles of the eyes or face 
 or neck may be produced by eye-strain or by irritation in the naso-pharynx, 
 true chorea is never, in my opinion, produced by these causes, and treatment 
 directed to the relief of so-called muscular insufficiencies in the eye-muscles is 
 useless. 
 
 The exciting causes of chorea are not fully determined, but a certain pro- 
 portion of the cases develops after sudden mental excitement, such as fright or 
 grief. Thus in 87 cases out of 490 of which I have records, a fright was 
 assigned as the exciting cause, and in the B. C. C. report it is assigned as a 
 cause in 96 cases out of 222. In order to be considered as an actual cause of 
 chorea the mental shock must precede the development of chorea by not more 
 than a week, for it is hardly to be supposed that the effects of any mental 
 shock can appear after a longer interval. 
 
 Certain authors have called attention to hereditary influences acting as pre- 
 disposing causes to chorea, and it is a fact that if the family history be carefully 
 investigated, rheumatism, various nervous disorders, alcoholism, and tubercu- 
 losis are frequently discovered. 
 
 Pathology. — According to our definition, chorea is a functional disease. 
 This implies that there are no organic changes constantly present as its patho- 
 logical cause. That all functional diseases are undoubtedly due to disturbance 
 in the nutrition or in the molecular structure of tissues is admitted, and that 
 
760 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 in 
 
 chorea such changes are present in the nerve-cells of motor function is highly 
 probable; but inasmuch as the very large majority of patients suffering from 
 chorea recover entirely, and inasmuch as in many cases of chorea there are no 
 permanent objective symptoms which indicate a loss of any function, it must 
 be admitted that a constant pathological condition visible by the microscope is 
 not to be expected. 
 
 Nevertheless, numerous cases of chorea have been examined post-mortem, 
 and many changes have been described in the nerve-cells, in the neuroglia, and 
 in the blood-vessels as characteristic lesions of chorea. The statements made 
 by some authors regarding hyperemia of the nervous system as a cause of 
 chorea may be dismissed without consideration, for, aside from the question 
 whether hyperemia or anaemia during life leaves any evidences in the nervous 
 system after death — an open question — these appearances are described in 
 other diseases besides chorea. 
 
 Some authorities have described minute haemorrhages and capillary emboli 
 as the lesions of chorea, but other equally good observers have failed to find 
 these conditions. 
 
 Vacuolization of the nervous tissue and of the nerve-cells has been assigned 
 as the lesion of chorea, as have also dilatations of the spaces around the blood- 
 vessels ; but this condition has also been described as the lesion of diabetes and 
 of various functional nervous diseases, and cannot be accepted as characteristic 
 of chorea alone. 
 
 Hyaline degeneration in the nervous cells of motor function in the cortex 
 and in the basal ganglia has been described, but this is known to be present 
 in epilepsy and in many organic lesions not attended by the twitchings of 
 chorea. 
 
 Hyperplasia of the neuroglia has been seen, but this, too, cannot be con- 
 sidered as a necessary accompaniment of chorea, inasmuch as it is permanent, 
 while the disease is temporary. 
 
 It is to be remembered that in the majority of cases which have come to 
 autopsy other diseases than chorea have caused the death of the patient, or else 
 the patient has succumbed to a condition of exhaustion which in itself might 
 be sufficient to produce many of the changes described; therefore I do not 
 believe that the pathological anatomy of chorea can be said to be known. 
 
 It is not positively determined whether the portion of the motor nervous 
 system affected in chorea is the spinal cord, basal ganglia, or cortex. Probably 
 various cases present various conditions. In the cases in which the mental 
 symptoms are prominent the cortex is undoubtedly involved, and in the unilat- 
 eral cases the lesion is undoubtedly cerebral. There is little ground for posi- 
 tive statement regarding the situation of the lesion in chorea, and writers too 
 often indulge in theoretical argument. 
 
 Diagnosis. — There are many diseases in which the chief and most promi- 
 nent symptom is a twitching of the muscles. These should not, however, be 
 mistaken for chorea. Tic convulsif, which is a unilateral twitching of the mus- 
 cles of the face, is usually a reflex spasm due to some irritation in the domain 
 of the trigeminal nerve; which irritation, being conveyed inward to the pons, 
 gives rise to a sudden impulse outward through the facial nerve, just as a bit 
 of dust in the eye gives rise to a wink. The limitation of this spasm to the 
 face, and the fact that in the majority of cases it can be arrested by pressure 
 exerted upon some branch of the trigeminal nerve upon the face, will prevent 
 its being mistaken for chorea. 
 
 There is a similar disease, called general convulsive tic or maladie des 
 tics convuhifs, first described by Gilles de la Tourette, consisting of a sudden 
 
CHOREA. 761 
 
 twitching of any or all of the muscles of the body. This resembles chorea 
 closely, but should not be mistaken for it. It is not attended by any weakness 
 of the muscles or by any awkwardness of voluntary movement ; the twitchings 
 do not occur during voluntary movements, but only appear during rest. The 
 disease is a chronic one, appearing as a rule about the fifteenth year and remain- 
 ing during life. The twitchings are more sudden than those of chorea, and 
 there is no mental irritability. The disease does not appear as early in life as 
 chorea, and it does not yield to arsenic. 
 
 Habit-spasm has been mistaken for chorea, but should not be confounded 
 with it. All children have a tendency toward mimicry, and a child who is 
 afflicted by habit-spasm makes movements which have the character of volun- 
 tary movements, such as winking, pouting the lips, turning the head, shrugging 
 the shoulders, or moving the extremities : such habit-spasms are not as quick 
 and sudden as the spasms of chorea ; after a time they are not easily controlled 
 voluntarily, as they are in the early stage of the affection. Voluntary control 
 can, however, be increased by forcing the child's attention to the necessity of 
 it, and in this condition moral treatment and general hygienic measures, such 
 as baths and proper exercise, are of more service than medicines. 
 
 Paramyoclonus multiplex is a spasmodic affection of the muscular system 
 which resembles chorea. In this disease it is the muscles of the body and of 
 the proximal portions of the limbs which are affected ; the face and arms and 
 hands and legs do not participate in the spasm. The spasms are bilateral and 
 symmetrical ; they occur at intervals, and are rapidly repeated, as many as 
 ninety contractions of the muscles occurring in a minute. The movements 
 during the attack of spasm are very violent, so as to throw the patient down 
 if walking or to hurl him off a chair if seated. The spasm can be brought 
 on by tapping the patellar tendon. During the interval between the spasms 
 fibrillary tremor of the affected muscles may be seen. The disease may 
 occur at any age ; it usually develops after some mental or physical strain in 
 patients of an hysterical temperament, and recovery generally takes place after 
 a time. It will be seen from this description that the disease should not be 
 mistaken for chorea. 
 
 The hemichorea which follows hemiplegia is characterized by slow, irregu- 
 lar ataxic movements on voluntary motion, and does not consist of twitchings 
 in individual muscles. It should be regarded as hemiathetosis rather than as 
 a species of chorea. 
 
 Multiple sclerosis may be the cause of irregular movements, but these never 
 occur when the patient is at rest, and this is not a disease of childhood. 
 
 Prognosis. — In view of the facts stated it is evident that the prognosis 
 given to the parents in any case of chorea should be a hopeful but also a 
 guarded one. For while the chances are all in favor of a speedy recovery 
 within three months, they are also in favor of a recurrence of the disease, and 
 in no case is it possible to promise a cure, because of the fact that a few of the 
 cases which cannot at the outset be distinguished from the ordinary cases 
 become chronic and do not recover at all. 
 
 Another fact should be mentioned which should lead to a guarded prog- 
 nosis — namely, that certain children are exceedingly susceptible to the effects 
 of arsenic, which, as we shall see in the section upon Treatment, is the only 
 remedy of value. These children either cannot take arsenic in sufficient doses, 
 or if they take it develop arsenical poisoning or even arsenical multiple neuri- 
 tis, both of which conditions hamper the treatment exceedingly. 
 
 The development of rheumatism during the disease does not necessarily 
 make the prognosis very grave, for few children die of rheumatism. Nor does 
 
762 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the development of endocarditis with organic murmurs in the heart lead 
 to any great anxiety as to the life of the patient : such murmurs may remain 
 through life, and in later years the heart disease may give rise to much trouble ; 
 but it is very rare to find in children suffering from chorea and endocarditis 
 any evidence of insufficiency of the heart's action, as demonstrated by oedema 
 of the extremities or oedema of the lungs. Nor have I ever seen hemiplegia 
 develop in the course of chorea as an evidence of cerebral embolism. 
 
 Treatment. — The first endeavor of the physician who is called upon to 
 treat a case of chorea should be to direct such an arrangement of the patient's 
 life and surroundings as will remove him from the bad hygienic influences 
 which have conduced to the development of the disease. If the patient 
 remains in a damp or ill-ventilated room, if he be not properly bathed and fed, 
 and if he cannot be kept quiet and without excitement, the prospect of success 
 in treatment is not good. The child should always be removed from school. 
 Nutritious diet of varied character, the digestion of which should be aided, if 
 necessary, by the use of digestants and of laxatives, is important. Long-con- 
 tinued baths are to be recommended, the child being allowed to play in the 
 the water for half an hour twice a day. The bath should be tepid, between 
 95° and 100° F., and no sudden shock of cold is to be used. The object of 
 the bath is to have a soothing influence as well as to dilate the vessels of the 
 surface, and the sharp contraction of the vessels produced by cold applications 
 is to be avoided. Rest in bed or upon a bed or couch is very essential during 
 the first two weeks of the disease. It is difficult to keep a child who is irri- 
 table in bed ; therefore it is best for the child to be warmly clad in merino 
 underclothing, but not fully dressed, and to be allowed to play about upon a 
 large bed, but not allowed to run about upon the floor. Gentle massage to the 
 entire body for an hour daily or for half an hour twice a day, the body being 
 anointed with cocoa butter, is of decided benefit. It is better for a child with 
 chorea to see but one or two members of the family, so as to be kept free from 
 all mental excitement. After the child is kept at rest in this manner, being 
 amused in every possible way, being fed frequently, bathed and massaged, a 
 very marked improvement will be noticeable within two weeks. 
 
 The improvement can be hastened materially by the use of medicines. The 
 treatment of a case of chorea will depend somewhat upon the mode of its onset. 
 If the child has had an attack of acute articular rheumatism just preceding 
 the chorea or associated with it, and if he has pains in the limbs and a rise of 
 temperature in the evening, it is much more important to treat him with salicyl- 
 ate of sodium or salicin or salophen than with arsenic. These remedies may 
 be used in connectioD with antipyrine, phenacetin, or exalgin, the latter drug 
 being of considerable service in the early stage of an acute attack. In the 
 use of these remedies the condition of the heart must always be taken into 
 account, and heart stimulants added if necessary. I prefer camphor and caf- 
 feine to other heart stimulants in this condition. The dosage of these remedies 
 must depend entirely upon the severity of the symptoms and upon the age of 
 the child. It may be necessary to give to a child of eight years ten grains of 
 the salicylate of sodium every two hours for several days ; it may not be neces- 
 sary to give more than ten grains three times a day. Exalgin is to be given 
 in three-grain doses every four hours in a severe case, and three times a day in 
 a mild case. With children I prefer to use these remedies in capsules, as the 
 disagreeable taste is then avoided. 
 
 If there be no history of rheumatism, it is well to think of the possibility 
 of malarial infection as a cause of chorea. If there be a daily periodical rise 
 of temperature, with or without a chill, or if an examination of the blood 
 
CHOREA. 763 
 
 reveals the presence of the malarial plasmodium, a dose of calomel, followed 
 by Warburg's extract in capsules, or quinine in capsules, kept up for a week, 
 will be efficacious in cutting short an attack of chorea. 
 
 Arsenic is the chief remedy for chorea not complicated by rheumatism or by 
 malaria. Fowler's solution is the best preparation to use, being tasteless. It is 
 to be begun in three-drop doses three times a day, the number of drops being 
 increased daily one drop until physiological effects are produced. These are a 
 puffiness of the eyelids noticeable on waking in the morning, and slight nausea 
 or griping pains with diarrhoea. It is possible in some children to reach a dose 
 of fifteen drops of Fowler's solution three times a day without the production 
 of these effects ; many children take ten drops three times a day without dis- 
 comfort. It is my rule to keep on increasing the dose until the physiological 
 effects appear. When this occurs the medicine is to be stopped for twenty-four 
 hours, and then resumed at the dose just below that which produced poison- 
 ing ; and this dose is to be kept up regularly so long as treatment is needed. 
 Arsenic should always be given after eating and well diluted with water. There 
 are some children who cannot take it in efficient doses without producing 
 poisonous effects. In these reliance must be placed upon the hygienic rules 
 already laid down, and if the chorea is very severe chloral may be given, the 
 condition of the heart being carefully regarded during its administration. In 
 some cases which do not yield readily to arsenic it is well to employ chloral in 
 combination with it, giving from five to ten grains three times a day. In some 
 cases tincture of cimicifuga is of service. 
 
 A few cases of chorea present very severe symptoms, the spasms being so 
 extensive and violent as to throw the patient about in bed and even to prevent 
 sleep. In these the use of a combination of bromide of potassium and chloral 
 (bromide 30 grains, chloral 15 grains), given two, three, or even four times a 
 day by the rectum, is advisable, while at the same time arsenic is used by the 
 mouth, being given in eight-drop dose in milk. A few patients are kept 
 awake by the movements and rapidly become exhausted: in these cautious 
 administration of chloroform by inhalation may be necessary in order to secure 
 the needed sleep. The hypodermatic use of hydrobromate of hyoscine in 
 dose of 2-J-q grain for a child of eight years, once in twelve hours, may be 
 tried in very violent cases. Sulphonal and chloralamide are valuable hyp- 
 notics in such cases. 
 
 In addition to the foregoing treatment of the disease, it is usually necessary 
 to remove the condition of anaemia which is present in the majority of cases, 
 and therefore iron must be given in any form which may be preferred. The 
 solution of the albuminate of iron is perhaps the best form to use for children, 
 although the chocolate lozenges containing iron may also be given freely. 
 Every form of nutritious food, especially milk and cream, and cod-liver oil, if 
 the child can be made to take it, is also indicated. 
 
 When medicinal treatment appears to be of little service, a change of air, 
 especially a change to the sea-shore, is often of very great benefit. The sea 
 air is much more conducive to recovery than mountain air, though sea-bathing 
 is not to be recommended. In any case a certain amount of open-air life should 
 be enforced during the treatment. 
 
TETANY 
 
 By HENRY M. LYMAN, A. M., M. D., 
 
 Chicago. 
 
 Tetany is a functional disease of the nervo-muscular apparatus, charac- 
 terized by the occurrence of paroxysmal tonic spasms that involve certain 
 groups of muscles, and that in severe cases may extend to nearly all of the 
 voluntary muscles of the limbs and body. The nerves that are concerned in 
 the production of these contractions exhibit a considerable increase of elec- 
 trical and mechanical excitability. 
 
 The functional character of the disease has led many observers to doubt 
 the propriety of dividing it from other functional spasmodic disorders. The 
 infrequency with which it is encountered in certain localities and among cer- 
 tain races has also created a degree of scepticism regarding the disorder as 
 a separate entity. But this lack of unanimity is principally due to the fact 
 that tetany prevails chiefly among women and children who belong to neurotic 
 families and are subject to unfavorable conditions of living. It will be observed 
 more frequently by physicians in general practice than by those whose expe- 
 rience is limited to office and consultation practice. 
 
 Etiology. — Tetany occurs most frequently among children during the 
 period of first dentition ; it is especially connected with gastro-intestinal dis- 
 orders which interfere with nutrition, and is associated with an exaggerated 
 excitability of the nervous system at the period of life when those tissues are 
 naturally more unstable than during later years. For somewhat similar 
 reasons it is not infrequent among young people near the age of puberty. 
 The influence of sex is not very decided ; it is less conspicuous than are the 
 influences that are derived from ancestral sources. The children of nervous, 
 weakly parents are particularly liable to the disease. Constitutional causes 
 and diathetic influences which favor the development of scrofula, arthritism, 
 and rickets are powerful predisposing causes of tetany. The disease is, in 
 fact, closely allied to those spasmodic tendencies that are so commonly wit- 
 nessed among rachitic children. It is undoubtedly due to insufficient diet and 
 to the other predisposing causes of rickets that the disease is so often encoun- 
 tered among children in orphan asylums, foundlings' homes, and similar con- 
 gregations of ill-conditioned infants. 
 
 Among the exciting causes of tetany, exposure to cold exhibits great 
 prominence. The disease is more often experienced during cold weather than 
 in summer. Exposure to cold and wet has been noticed as an antecedent of 
 the disease, and its manifestation is sometimes accompanied by articular swell- 
 ings that are highly suggestive of rheumatism. 
 
 When a predisposition to tetany exists, almost any irritation of the cuta- 
 neous or mucous surfaces of the body may excite an attack of the disease. 
 It is therefore frequently observed during the course of infantile diarrhoea 
 764 
 
TETANY. 765 
 
 and other irritative disorders of the alimentary canal. Among female patients 
 its occurrence is closely connected with menstrual disorders, pregnancy, and 
 lactation. It has been observed as a sequel of various infective diseases, but 
 it is probable that in such cases the infection merely lowers the resistance of 
 the nervous system, so that morbid manifestations of various character are 
 more easily excited. When a predisposition has been established, almost any 
 active disturbance of a peripheral character, or even of a psychical origin, 
 may suffice to arouse a paroxysm. 
 
 Symptoms. — The occurrence of an attack of tetany is usually preceded 
 by certain premonitory symptoms of nervous disturbance. Occasionally the 
 patient complains of dizziness, determination of blood to the head, humming 
 sounds in the ears, and flashes of light before the eyes. Various perversions 
 of sensation in the limbs may be also experienced. When, finally, the attack 
 is matured, it is upon the fingers and toes that the force of the paroxysm is 
 usually expended. The muscular spasms are generally bilateral, and in ordi- 
 nary cases they are limited to the flexor muscles of the fingers, wrists, and 
 toes ; the extensor muscles escape more frequently than the flexors ; sometimes 
 the muscular groups of the forearm, upper arm, leg, and thigh are involved. 
 In certain rare instances the muscles of the abdomen, thorax, neck, face, eyes, 
 tongue, pharynx, diaphragm, and bladder may participate in the tonic spasm. 
 The tips of the fingers and thumbs are frequently drawn together into the 
 conical position assumed by the accoucheur when about to introduce the whole 
 hand into the vagina. The great toe is flexed and bent laterally under the 
 other toes, which are also drawn down into the position of plantar flexion. 
 Occasionally the toes and fingers are spread apart, instead of being tightly 
 drawn together. The upper arm is drawn against the side of the thorax, 
 while the forearm is partially flexed and crossed over the front of the body. 
 The legs are usually extended, but the thighs are adducted, and are sometimes 
 flexed upon the body. When the muscles of the trunk and of the neck are 
 invaded respiration becomes difficult, and suffocation sometimes appears immi- 
 nent. When the paroxysms succeed one another intermittently, the phenomena 
 of tetanus are closely counterfeited, though, fortunately, the comparative brevity 
 of the attack and the rarity of a fatal termination mark a decided difference 
 between the two diseases. 
 
 During the course of the paroxysm the peripheral nerves of sensation 
 exhibit various disorders. Sensations of cold, heat, numbness, and formica- 
 tion are not uncommon. Neuralgic pains and a feeling of soreness in the con- 
 tracted muscles are often experienced, together with headache, dizziness, and 
 other cerebral symptoms of sensory disorder. 
 
 Three cardinal symptoms deserve notice: Trousseau many years ago 
 remarked that pressure exerted upon the large arteries and nerves of the 
 limbs of a patient would be often followed by the development of a paroxysm 
 of tetany. In this way a latent predisposition may be aroused to active mani- 
 festation of the disease. This phenomenon is more easily produced in the 
 upper extremity than in the lower. Occasionally the paroxysm may be 
 excited by pressure upon the carotid artery and the sympathetic ganglia in 
 the neck. 
 
 A second characteristic depends upon the increase of electrical excitability 
 in the motor nerves of the body and limbs. When applied to the nerves, 
 very weak faradic currents are sufficient to excite muscular contractions. The 
 application of galvanic currents also indicates great increase of excitability, 
 so that tetaniform contractions of the muscles can be aroused by currents 
 which ordinarily would scarcely be noticed. This inordinate sensitiveness to 
 
766 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 electrical excitation is frequently manifested in latent cases where the fully- 
 developed paroxysm has never been experienced. 
 
 The increased excitability of the motor nerves is further indicated by their 
 behavior under the influence of mechanical stimulation. A slight tap upon 
 the trunk of a nerve is often sufficient to arouse a paroxysm, even though the 
 muscles themselves cannot be thus thrown into contraction by direct percus- 
 sion. When the facial nerves are involved the muscles of the face may be 
 easily brought into a state of spasmodic contraction by tapping upon the 
 trunk of the nerve at its point of emergence from the bony canal, or by draw- 
 ing the point of the fingers across the face from the external angle of the 
 orbit to the styloid foramen. 
 
 Besides the various disturbances of sensation that have been already 
 noted, painful pressure-points are sometimes discovered over the spinous pro- 
 cesses of the vertebrae. 
 
 The duration of a paroxysm may vary from a few minutes to many hours, 
 or even two or three days. In cases of such long duration muscular spasm 
 persists even during sleep, though its intensity is considerably diminished. 
 The number of paroxysms during the course of an attack is also subject to 
 great variation. A single paroxysm sometimes terminates the attack, while 
 in other cases the spasms follow one another at brief intervals, almost like the 
 paroxysms of genuine tetanus. 
 
 Pathological Anatomy. — Since tetany rarely proves fatal, the oppor- 
 tunity for investigation of its pathological anatomy is seldom offered. It is 
 probably a functional disease of the whole nervous system, but many of the 
 morbid processes that have been described are the results of predisposing dis- 
 eases, or of the convulsive paroxysms to which the patient has been subjected, 
 rather than causes of its phenomena. Among these, undoubtedly, are the 
 slight haemorrhages that have been noted in the membranes of the cord and 
 in the cord itself. The various conditions of hyperaemia and actual inflamma- 
 tion that have been sometimes remarked are also of the same accidental or 
 complicating character. The reflex nature of the symptoms and their produc- 
 tion by irritation of the peripheral nerves render it probable that the disease 
 has its principal seat in the spinal cord, though the reflex arcs in which the 
 cranial nerves are included sometimes display evidence of disturbance in a 
 way that indicates an extension of disorder throughout the entire length of the 
 nervous axis. The occurrence of the disease after diarrhoea and other wasting 
 discharges suggests the idea that this inordinate excitability of the nervous 
 centres is in some way connected with malnutrition and with the exaggerated 
 irritability that is thus induced. It is not impossible that these conditions 
 are dependent upon an infection that has invaded the tissues of the spinal 
 cord. The occurrence of the disease after extirpation of the thyroid gland 
 has aroused a suspicion that tetany, like myxcedema, may be due to an auto- 
 intoxication with mucin. But these speculations have not yet emerged from 
 the realm of hypothesis. 
 
 Diagnosis. — Tetany may be easily recognized by the occurrence of 
 paroxysmal tonic contraction in particular groups of muscles, usually the flex- 
 ors of the extremities, and by the increased reaction that takes place after 
 electrical or mechanical excitation of the peripheral nerves. By attention to 
 these phenomena the disease may be readily distinguished from tetanus, a dis- 
 order which, moreover, usually commences with trismus — a symptom that is 
 rarely observed in tetany. Similar facts of dissimilarity serve to distinguish 
 tetany from the convulsive paroxysms of hysteria, and from the spasmodic 
 movements that are sometimes witnessed in writer's cramp and the allied pro- 
 
TETANY. 767 
 
 fessional neuroses. The spasmodic attacks that sometimes occur as a conse- 
 quence of ergotism very closely resemble tetany, and should probably be 
 considered as belonging to the same class of toxic disturbances of the nervous 
 system. 
 
 Prognosis. — The disease is seldom fatal, but sometimes it persists for 
 a considerable period of time. In such lingering cases a certain degree of 
 muscular contracture and weakness is occasionally evident on careful examina- 
 tion, even after the cessation of spasmodic attacks. Mechanical or electrical 
 excitation of the nerves may then suffice to arouse a more or less complete 
 paroxysm. 
 
 Treatment. — In the management of tetany special reference must be made 
 to the underlying causes of the disease in each individual case. Disorders of 
 the alimentary canal require appropriate treatment ; all exhausting discharges, 
 such as haemorrhage, diarrhoea, excessive menstruation or the opposite condi- 
 tion, prolonged lactation, inordinate perspiration, etc., demand attention. 
 Rheumatic and tuberculous patients require the treatment that is appropriate 
 to such diathetic conditions. 
 
 Electricity has been employed with but indifferent success. Counter-irri- 
 tants of all kinds have been applied to the spine, and hydropathic treatment 
 has also been prescribed with varying degrees of benefit. For the relief of 
 the paroxysm the various narcotics are generally recommended. Bromide of 
 sodium, cannabis Indica, hyoscyamus, belladonna, chloral, ether, chloroform, 
 valerian, oxide of zinc, and the opiates have been exhibited with temporary 
 advantage. In severe attacks it is advisable to administer ether by inhalation 
 and to employ non- volatile remedies by hypodermatic injection. Calabar bean 
 and curare are too powerful and uncertain for administration in this disease. 
 The principal object of treatment should be the improvement of the general 
 health of the patient and the removal of all unfavorable conditions that inter- 
 fere with nutrition. For this reason hygienic measures and dietetic manage- 
 ment are more important than specific medication for the palliation of symp- 
 toms. 
 
PSEUDOHYPERTROPHIC MUSCULAR 
 PARALYSIS. 
 
 By FRANCIS T. MILES, M. D., 
 
 Baltimore. 
 
 The essential feature of this disease is a progressive loss of power in certain 
 definite muscles and groups of muscles, and its most characteristic and distin- 
 guishing symptom (from which it has received its name) is the increase of 
 volume and apparent hypertrophy in some of the weakened muscles. 
 
 Symptoms. — It is a disease of early childhood, the great majority of cases 
 occurring before the tenth year. It is but seldom that its invasion appears to 
 begin about or after the time of puberty, and it is probable that the eye of one 
 accustomed to the disease would have discovered indications of it long before 
 that time. As a rule, the first symptom that arrests the attention of the 
 parents or nurse is the seeming clumsiness manifested by the child in 
 using his legs. A slight trip or jostle causes him to fall, and then he gets up 
 slowly. He walks with a straddling, inelastic gait, ascends steps laboriously, 
 clinging to the banisters and pulling himself up. Sooner or later (in some 
 cases it is the first thing to attract attention) certain muscles begin to develop 
 out of proportion to the rest, and are hard and elastic to the touch. Usually 
 the first muscles to show this increase of volume are those of the calves of the 
 legs, with which are generally associated the glutei, one or more of the divisions 
 of the quadriceps extensor, and the erector spinae in the lumbar region. But 
 the hypertrophy affects other muscles than those of the lower limbs. Thus the 
 infraspinatus is very commonly much enlarged, frequently the deltoid, and even 
 the biceps and triceps are sometimes involved. The escape of the muscles of the 
 hand and forearm, which have been but very rarely described as implicated in 
 this affection, gives a distinctive peculiarity to this form of muscular paralysis. 
 The neck and face do not show an absolute immunity, and cases of hypertrophy 
 of the sterno-mastoids, temporals, masseters, and even of the tongue, have 
 been recorded. In a case of Bergeron's all the muscles except the pectorals 
 and sterno-mastoids were increased in volume, thus giving to the child an 
 appearance of great athletic development. 
 
 In marked contrast to the Herculean proportions of the muscles is their 
 strength, which is almost always so greatly diminished that they are incapable 
 of performing their required functions. After a time these muscles cease to 
 increase in size, and then begins a diminution of their volume, which may go 
 on to complete atrophy, with corresponding absolute loss of power. But by the 
 side of these enlarged and feeble muscles we observe others whose power is 
 diminished more or less while they retain their normal size, or are from the 
 first involved in a process of atrophy. In the lower extremity this loss of 
 power is manifested in the flexors of the hip, which, though out of reach of 
 direct observation, are thus evidently invaded by the disease. The extensors 
 
 768 
 
PSE UD O- HYPER TP OPHIC PAPAL YSIS. 
 
 769 
 
 Fig. 1. 
 
 of the hip and knee may be under-sized or atrophied, and always much 
 weakened. The flexors of the knee are but rarely affected. Of the muscles 
 of the upper extremity, those of the shoulder-girdle are generally more or 
 less atrophic, especially (indeed, almost without exception) the costal portion 
 of the great pectoral and the latissimus dorsi. Less 
 frequently, but not uncommonly, the biceps and triceps 
 are small and weak. If we attempt to lift the child 
 by placing the hands under its arms, we find that the 
 shoulders yield against the weight of the body, and 
 are dragged almost to the back of the head. 
 
 This mixed and variable picture of hypervolumi- 
 nous and atrophied muscles would seem to indicate 
 that the pseudo-hypertrophy is, as it were, an acci- 
 dental factor, and that the intrinsic nature of this 
 disease is the progressive loss of power in certain 
 muscular groups. Indeed, cases have occurred in 
 which all the motor symptoms of pseudo-muscular 
 hypertrophy were present, but in which the diseased 
 muscles that caused these symptoms presented no alter- 
 ation of volume. In the words of Charcot : " The 
 hypertrophy is not, all things considered, an essential 
 element in the constitution of the affection called 
 pseudo-hypertrophic paralysis." We will return to 
 this point farther on. 
 
 On account of the weakness of the muscles involved, 
 the attitude in standing and the manner of walking 
 in this disease are peculiar and characteristic. In a 
 state of health, while standing erect the centre of 
 gravity of the body falls slightly in front of the point 
 of support, and the hip- and knee- joints are not in 
 a position of complete extension ; so that to maintain 
 the equilibrium and to prevent the flexion of those 
 joints a sustained action of the erector spinse and 
 the extensors of the hip and of the knee is demanded. In the disease 
 under consideration an involuntary effort is made to relieve these en- 
 feebled muscles by throwing the centre of gravity very far back. To do 
 this the lumbar concavity is increased as much as possible, so as to throw the 
 weight of the head and shoulders behind the hip-joint, thus producing a marked 
 lordosis, with a corresponding protrusion of the chest and belly. The knee- 
 joints are fully extended (locked), so that the weak quadriceps extensors are 
 at rest, while the base of support is broadened by the wide separation of the 
 feet. The lordosis disappears when the child is seated ; but in an advanced 
 stage of the disease, when the erectors of the spine are greatly weakened, a 
 kyphosis may for the time take its place. When standing the patient 
 may be able to raise himself on his toes, but cannot spring from the floor. In 
 ordinary natural walking, while one foot is off the ground and is being pro- 
 pelled forward the centre of gravity of the body falls much nearer the median 
 line than the supporting foot, and, indeed, it continues to move toward the 
 opposite side until the advancing foot reaches the ground and receives the 
 weight of the body. During this time the weight of the body is sustained 
 ijpon the head of the fixed femur, principally by the glutei muscles. In pseudo- 
 hypertrophic paralysis, these muscles being too weak to perform their task, the 
 patient relieves them by throwing the body far over to the side of the susrain- 
 
 Pseudo-hypertrophic Muscu- 
 lar Paralysis. 
 
 49 
 
770 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ing foot, thus bringing the weight over the point of support, while the other 
 leg swings forward. This manoeuvre, being repeated alternately for the two 
 limbs, gives a peculiar and characteristic swaying motion of the body from side 
 to side in walking. This false position of the trunk and the weakness of the 
 extensors of the knee hinder the foot being projected forward to the length of 
 a full step, and, instead of the heel touching the ground first, as is usual in 
 walking, the ball of the foot or the toes first descend, giving the appearance of 
 an attempt to step softly. This stepping on the toes is sometimes caused by a 
 contraction of the muscles of the calf, which may occur early in the disease. 
 
 Very characteristic and almost pathognomonic of this disease are the 
 manoeuvres executed by the child in getting into the erect from the recumbent 
 position. They were first and with great clearness described and explained by 
 Gowers. The weak extensors of the hip and knee are not equal to the work 
 of extending these joints and giving the erect position to the body against the 
 
 Fig. 2. 
 
 Postures in rising to the Erect Position (Gowers). 
 
 weight of the head and shoulders. The child, therefore, unable to assume the 
 sitting position, takes that of "all fours," thus throwing the weight upon the 
 hands and arms, while the legs are being straightened. He then works his 
 hands backward along the floor until he gets to a position from which with an 
 effort he can grasp the legs above the knee, and then, by alternately clasping 
 them at a higher level, he thrusts the trunk into a more and more erect posi- 
 tion, until by a final push he jerks the spine into the position of lordosis already 
 described. To use the common and appropriate phrase, he " climbs up his 
 legs." 
 
 We have already said that the hypertrophied muscles after a time lose their 
 volume and become atrophied. This may not take place until after many (ten 
 to fourteen) years, and does not affect all of the hypertrophied muscles at the 
 same time. Those of the upper extremity are generally the first to undergo 
 the change, the muscles of the calf being the last to lose their volume. In- 
 creasing weakness more and more circumscribes the movements of the patient, 
 until at last he can no longer walk or stand, although the movements of the 
 arms and hands may still, in a measure, be retained. Now contractions of the 
 wasted muscles set in, and joints, as the knee and elbow, are fixed in the posi- 
 tion in which they are usually maintained. The ankle-joint takes the position 
 
PSEUDO-HYPEBTBOPHIC PABALYSIS. Til 
 
 of pronounced talipes equinus, partly from fixation in the position in which un- 
 supported it hangs, and partly from contraction of the muscles of the calf. 
 From loss of power in the spinal muscles there may result lateral curvature. 
 
 The tendon reflexes, as a rule, show no change, except that they grow more 
 feeble as the muscles become weaker, until they are finally lost. 1 The sphinc- 
 ters are unaffected. 
 
 Fibrillary contractions have been observed so rarely as to make it presum- 
 able that they are caused by some intercurrent trouble, such as neuritis. While 
 the electric reactions are gradually diminished and lost, they are qualitatively 
 normal, and in the very few cases in which degenerative reaction has been 
 described it is probably due to some secondary cause similar to that which 
 causes the fibrillary contractions in certain reported cases. Sensation is nor- 
 mal, and mental impairment, although occurring in some instances, does not 
 seem to be a consequence of the disease. A symptom which might be referred 
 to an affection of the vaso-motor nerves is the bluish mottling or marbling 
 of the skin of the lower limbs which is sometimes seen. There is no evidence 
 of any disturbance of the sympathetic nerves. 
 
 The disease runs a chronic course, it may be of ten or twenty years' dura- 
 tion, and does not itself directly cause the death of the patient. This termina- 
 tion is usually the result of some intercurrent respiratory trouble, to which the 
 enfeebled condition of the patient gives force. 
 
 Etiology. — Hereditary influence can be traced in a large majority of cases, 
 and exclusively through the mother, who, without being herself a subject of 
 the disease, may nevertheless transmit this developmental defect to her off- 
 spring. Males are much more frequently affected than females, and in the 
 latter it tends to develop later in life and progress more slowly. The disease 
 may be considered as a congenital affection, for even when it develops after the 
 period of childhood, as it sometimes, though rarely, does, there is reason to 
 assume that the defect of muscular development has merely lain dormant 
 during the earlier years of life. No other etiological factors, as syphilis or alco- 
 holism, have been recognized in the causation of the disease. For a long time 
 after pseudo-muscular hypertrophy had been observed and fully described clin- 
 ically, it was considered a disease of spinal origin, a myelopathy. But more 
 recently the opinion that it is a primary disease of the muscles, an idio- 
 pathic myopathy, has received a very general sanction from pathologists. It 
 is recognized as one (and the most frequent) form or type of a group of myo- 
 pathic atrophies, or muscular dystrophies, of which Erb's juvenile type, the 
 facio-scapulo-humeral or infantile type, and it may be Leyden's hereditary type, 
 are the most distinctively marked forms : " The infantile type is characterized 
 by the early facial paralysis, the juvenile type by the time of its development 
 (early youth) and localization of the atrophy (in the muscles of the shoulder- 
 girdle) ; the pseudo-hypertrophic type by its development in early childhood 
 and the predominance of the lipomatous condition of the muscles ; the heredit- 
 ary type (Leyden's) by its heredity." 
 
 While these forms of muscular atrophy are fairly separable clinically when 
 well marked, there are numerous transition forms which cannot be easily clas- 
 sified. Not infrequently the different types occur in members of the same 
 family, and arise presumably from the same inherited defect. 
 
 As Erb has shown, there are no greater differences amongst these varie- 
 
 x The writer has recently seen a case of pseudo-muscular hypertrophy in a boy nine years 
 old, in which the knee-jerk was abolished, although he could still walk, and the partly hyper- 
 trophied quadriceps extensor could extend the knee almost completely when the patient wan 
 seated. 
 
772 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 ties than there are amongst the individual cases of any one variety. Thus 
 in the pseudo-hypertrophic form we have fairly constant atrophy of the 
 muscles of the shoulder-girdle and arm — i. e. those characteristically affected 
 in the juvenile type; and in some cases described by Erb there was atrophy 
 of the muscles of the face, the mark of the infantile type. Indeed, Erb sug- 
 gests that many cases having the clinical aspect of the pseudo-hypertrophic 
 form, afterward, as the adipose matter is absorbed, take on the appearance of 
 the juvenile type of muscular atrophy. 
 
 Pathological Anatomy. — The essential feature of the pathological anat- 
 omy in this disease is a degenerative change in the muscular tissue itself; and 
 this change is probably the first which takes place. Pieces cut from the living 
 muscles (which are much to be preferred to morsels extracted by the " har- 
 poon"), and properly prepared, present the following microscopic appearances: 
 The muscular fibres in cross-section are seen to have lost their polygonal out- 
 line, to have become rounded in contour, even to be complete circles. Amongst 
 fibres of normal size there are those which are hypertrophied, and others which 
 show atrophy in varying degree, even to the point of complete disappearance. 
 The abnormal increase in volume of the muscular fibres would, from recent 
 observations (Erb), appear to be an essential feature in the muscular atrophies, 
 and it may be that it is a condition of the fibres which very generally precedes 
 their atrophy. At any rate, such hypertrophied fibres are rarely, if ever, 
 wanting in preparations of muscular tissue taken from these diseases. This 
 increased volume of the fibres cannot be explained by their contraction after 
 excision, since it is seen when precautions are taken to counteract this. In 
 addition, the fibres show a splitting in the longitudinal direction and the for- 
 mation of vacuoles in their interior. The muscle-nuclei are sometimes more, 
 sometimes less, but always considerably, increased. 
 
 The alteration of the connective tissue must follow very closely, if it is not 
 coincident with, that of the muscular fibres. A proliferation with increase of 
 its nuclei goes on pari passu with the muscular atrophy, until finally it becomes 
 excessively developed. In pseudo-hypertrophic muscles the connective tissue 
 is not only increased, but is crowded with fat-cells. It is this condition, in- 
 deed, to which they owe their increased volume and hardness. In muscles 
 primarily atrophied, and in the pseudo-hypertrophic muscles after they have 
 undergone atrophy, there is little or no adipose matter, only a greater or less 
 amount of connective tissue (connective-tissue cirrhosis of Erb). In muscle 
 preparations from the dead body the microscopic appearances are practically 
 the same as those seen in pieces from living muscles. It is of great importance 
 to observe that the microscopic appearances in muscles taken from the different 
 types of muscular dystrophy do not differ more from each other than do those 
 in preparations obtained from different cases of the same type, nor, indeed, 
 than those in different specimens from the same individual. Not only do the 
 pathological changes in the muscles bear a very close resemblance in all the 
 types of muscular dystrophy, but these changes as closely resemble those found 
 in other forms of muscular atrophy, as, for instance, the spinal atrophies and 
 those attending arthritic disease. " The proof for or against the pure myopathic 
 nature of the progressive muscular atrophies cannot at present be furnished by 
 histological research." 
 
 Investigations of the nervous system, both central and peripheral, have in 
 such a large majority of cases given a negative result that the reports of lesions 
 of the spinal cord, though made by competent observers in recent cases, will 
 scarcely change the generally accepted opinion that the muscular dystrophies 
 do not depend on discoverable nerve lesions. The question, however, has 
 
PSEUDO-HYPEBTROPHIC PARALYSIS. 773 
 
 arisen, and still awaits its answer, as to whether the muscular dystrophies are 
 absolutely myopathic, or whether functional disturbances ("dynamische 
 Storung '") in the trophic mechanism of the cord, too subtle to be ascertained 
 by our present methods of investigation, may not set up at first hand nutritive 
 changes in the muscles. Some considerations certainly point in the direc- 
 tion of classing these diseased conditions of the muscles with the tropho- 
 neuroses. 
 
 Diagnosis. — When the disease has advanced to a point where the athletic 
 proportions of the hypertrophied muscles stand in strong contrast to their 
 weakness, and where, moreover, along with these over-developed muscles, we 
 have others which are atrophied, there can be little difficulty in making the 
 diagnosis. Gowers claims diagnostic importance for the "condition, which is 
 seldom absent," "of enlargement of the infraspinatus, with a wasting of the 
 latissimus and lower part of the pectoralis." In cases where the enlargement of 
 the muscles is slight, or, as in some instances, where they retain their normal 
 size, the difficulty may be greater. The peculiar position in standing, and, 
 still more, the makeshift movements of the patient in rising from the recumbent 
 position, are almost positive evidence of the disease, whose main characteristics 
 depend on the invasion and weakening of the muscles employed in these acts. 
 
 From a progressive chronic neuritis, which might cripple these muscles, the 
 diagnosis would most likely be made by the absence of fibrillary contractions 
 and of degenerative reactions, both of which symptoms belong to neuritis. A 
 history of other members of the family having suffered with atrophy of the 
 muscles would be strong confirmation. Congenital spastic paraplegia, in which 
 the muscles sometimes exhibit a considerable volume, is distinguished from 
 pseudo-muscular hypertrophy by the muscular spasms and the increased myo- 
 tonus, which shows itself in an exaggerated knee-jerk, and often in ankle-clonus. 
 The different types of muscular dystrophies may be distinguished among them- 
 selves by marks already given. 
 
 Prognosis. — In this disease no hope can be entertained of recovery, and 
 very little of delay in its progress, which in children is infallibly to utter help- 
 lessness, with all the intercurrent risks incidental to that state. The best 
 cared-for will generally live longest, but the great majority never attain adult 
 years. In girls the outlook is somewhat more favorable as to length of life. 
 Cases where the disease has not developed till later years have been seen to 
 progress more slowly, and even to come to a standstill before the power of 
 standing and walking was lost. 
 
 Treatment. — It is in vain that we look for any drug which will exert 
 direct influence on the diseased processes in the muscles. Tonics, arsenic, cod- 
 liver oil, etc., can only benefit indirectly by improving the general nutrition. 
 In children, as soon as the disease is suspected, or, indeed, in all the children 
 of a family in which any one of the muscular dystrophies has shown itself, a 
 scrupulous and untiring enforcement of all the rules of health with regard to 
 diet, fresh air, and exercise should be observed. Gowers argues with con- 
 vincing force on the probable benefit of judicious exercise of the affected 
 muscles. The cold mottled limbs would indicate the employment of massage. 
 Electricity, so far, seems to have exerted no beneficial influence. For the con- 
 tractures so marked in the last stage of the disease, tenotomy is unhesitatingly 
 to be employed. This is especially demanded in the contractures of the calf- 
 muscles, which sometimes occur early in the disease and render walking or 
 standing impossible. 
 
FACIAL PARALYSIS AND PROGRESSIVE FACIAL 
 
 HEMIATROPHY. 
 
 By CHARLES W. BURR, M. D., 
 
 Philadelphia. 
 
 I. Facial Paralysis. 
 
 Facial Paralysis, Bell's palsy, or mimetic paralysis, is due to injury or 
 disease of the motor portion of the seventh cranial nerve or its nucleus. 
 
 Etiology. — Cases occurring at birth are due frequently to pressure of the 
 forceps upon the nerve at its point of exit from the skull ; or even if forceps 
 are not used and the labor is normal, though much prolonged, paralysis may 
 ensue. In the latter case it is due to pressure exerted either by the promontory 
 of the sacrum or by the ischiatic spines. A few cases have been reported which 
 were caused by the pressure of intrapelvic tumors. 
 
 The causes acting after birth are the same as those which occur in adult 
 life, but the affection is not nearly so common in infants as in older people. 
 The most common cause is cold, which acts by setting up a neuritis — the so- 
 called rheumatic palsy. Ear disease, especially if caries of the bone and sup- 
 puration be present, is a common causative factor. It is undoubtedly true, 
 however, that the affection may develop when only the lining membrane of the 
 tympanum is inflamed, without accompanying bone disease. Tumors, meningi- 
 tis, or fracture of the base of the skull are occasional causes. Surgical opera- 
 tions in the region of the ramus of the jaw are quite frequently followed by 
 palsy due to division of the nerve. A blow in the same region may have a 
 like effect. Certain acute infectious diseases — as, for example, diphtheria — may 
 be causative. Very rarely it occurs in acute infantile spinal palsy. Non-trau- 
 matic cases, in which the onset is sudden and the palsy complete, and in which 
 there is no evidence of cerebral disease, must be due to haemorrhage in the 
 nerve-sheath or Fallopian canal. Gowers has seen two cases, and Wilks and 
 Moxon have found the haemorrhage after death. 
 
 Symptoms. — Often there is preceding pain in the ear or over the entire 
 side of the head, and a slight swelling may be present in the region of the 
 parotid gland. The onset is rapid — rarely, as stated above, sudden. The 
 child may be put to bed well and wake up affected. Usually in from a few 
 hours to a few days the palsy reaches its height. There is ordinarily little or 
 no constitutional disturbance. 
 
 In very young children the signs of palsy may be very slight, on account 
 of the greater quantity of adipose tissue, the greater elasticity of the skin, and 
 the smaller muscular development. There may be when at rest only a slight 
 drooping of the angle of the mouth. When, however, the infant cries or 
 laughs, the deformity becomes marked. The affected side remains motionless, 
 the eye cannot be closed, the cheek and ala of the nose fall in and out with 
 inspiration and expiration, and the mouth is drawn strongly toward the sound 
 
 774 
 
FACIAL PARALYSIS AND HEMIATROPHY. 775 
 
 side. Most often the tongue and soft palate are unaffected, and the child 
 experiences no difficulty in nursing. Taste may be lost in the anterior half of 
 the tongue on the affected side. The reaction to electricity depends upon the 
 severity of the attack and the time which has elapsed since the onset. In a 
 typical case reaction of degeneration appears after a time. After some months 
 in severe cases, but not in those in which the palsy remains complete, contrac- 
 tures develop on the affected side, making it on first view appear to be the 
 sound side. Examination during movement, however, reveals that the diseased 
 side moves much less. The contracture causes, furthermore, a wrinkle which 
 has no analogue on the sound side. It must be remembered that in some cases 
 only a part of the nerve may be palsied — only the mouth or only the orbicularis 
 palpebrarum — and also that both nerves may be affected. 
 
 Diagnosis. — The palsy is unmistakable, and the only question is whether 
 the lesion is central or peripheral. If the lesion be situated above the nucleus, 
 there is never lasting, but sometimes transient, palsy of the eyelid. Emotional 
 movement is less impaired by central disease than voluntary movement. Re- 
 action of degeneration is never present in central disease, and is never absent 
 in peripheral disease unless the palsy be very slight. In the former the reflexes 
 are present, in the latter they are lost. If taste be lost, the lesion is within 
 the Fallopian canal. In disease of the nucleus the orbicularis oris is not 
 affected. 
 
 Prognosis is excellent in the cases due to pressure at birth and in those 
 from diphtheria. Gowers justly lays great stress on the prognostic value of the 
 electric excitability of the nerve. If, he says, it is not below normal at the 
 end of ten days, recovery will probably follow in a few weeks. If at the end 
 of a fortnight it is absolutely lost, the palsy will certainly last several months. 
 
 Treatment. — The first indication is, of course, to remove the cause if pos- 
 sible. In recent cases, due to cold, hot fomentations should be placed in front 
 of and below the ear. Blisters should be applied over the mastoid process or 
 occiput. Hot baths and free purgation are very useful. 
 
 Galvanism is useful when the condition has become chronic. The positive 
 electrode should be placed below the zygoma, and the negative moved gently 
 over the muscles. The least amount of current sufficient to produce muscular 
 response should be used. But little can be done to influence contracture. 
 Daily gentle massage of the face is at least harmless. 
 
 II. Progressive Facial Hemiatrophy. 
 
 Progressive Facial Hemiatrophy — also called Neurotic facial atrophy, 
 Facial trophoneurosis, Prosopodysmorphia — is a chronic progressive disease 
 characterized by wasting of the skin, fat, connective tissue, bone, and some- 
 times, but to a less degree, the muscles of one or very rarely both sides of the 
 face. 
 
 Etiology. — The disease, while absolutely rare, is far more frequent in 
 females than in males. Of 92 cases collected by Hermann Steinert, 60 occurred 
 in the former, 30 in the latter, and in 2 the sex was not mentioned. It 
 is most apt to occur in early life. In 29 cases the onset was before the tenth 
 year, 24 began between the tenth and twentieth years, while only 22 occurred 
 between the twentieth and fiftieth years ; in 1 the onset was at sixty years. 
 Traumatism seems to exert a positive causal influence, as in quite a number 
 of cases injuries to the face, the jaw, or the head preceded but a little while the 
 first symptoms. It sometimes follows an acute infectious disease. 
 
 Symptoms. — The major symptom, wasting, may begin either diffusely or 
 
776 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 in one spot, spreading thence slowly, and involving skin, subcutaneous tissue, 
 the muscles mayhap, and the bone. The atrophy is most marked in the bone 
 if the disease begins during the period of active growth. Usually the process 
 stops abruptly at the middle line, making the face look as if it were made up 
 of halves from different people, but it may involve both sides, and even extend, 
 it is alleged, to the shoulder and arm. The skin on the wasted side is thinner 
 and paler. The hair may become simply gray, finer, and smoother, or it may 
 fall out. The alveolar processes waste and the teeth are shed. The lower jaw 
 becomes both thinner and shorter. The orbital fat disappears and enophthal- 
 mos develops, but the eyeball is not affected. There is sometimes an associated 
 hemiatrophy of the tongue. Pain and numbness are not uncommon, but anaes- 
 thesia is rarely present. Anidrosis, weakness of the carotid pulse, and loss of 
 the power to blush are occasional symptoms. There is never marked difference 
 of the surface temperature of the two sides of the face. The special senses are 
 never affected. There are no changes in the electrical reactions of nerves or 
 muscles. The diseased side in well-advanced cases may produce an expression 
 mimicking the drawn features of old age. 
 
 The disease follows a slowly progressive course, sometimes extending over 
 many years, or it may, after reaching a certain stage, cease to progress. 
 
 Pathology. — The pathology of the condition remains as yet almost entirely 
 theoretical. Mendel has made one autopsy in which he found an interstitial 
 neuritis of the trifacial from its origin to the periphery. In an atypical case 
 of Horner a tumor was found pressing on the Gasserian ganglion and the 
 trifacial nerve. Taking all things into consideration, it is probable that the 
 future will show that disease of this nerve stands in close causative relation to 
 the affection. 
 
 Diagnosis in a well-developed case is easy. The only conditions with 
 which it can be confounded are congenital facial asymmetry due to torticollis, 
 facial paralysis, and facial hemihypertrophy. These need only be named to 
 avoid error. 
 
 Treatment has so far been absolutely valueless. On theoretic grounds 
 Dercum in 1891 recommended section of the various branches of the trifacial. 
 He holds that the condition depends not upon failure of trophic nerve stimulus, 
 but upon a radical perversion of that stimulus. 
 
INFLAMMATORY DISEASES OF THE SPINAL 
 MENINGES AND SPINAL CORD. 
 
 By ARCHIBALD CHURCH, M. D., 
 
 Chicago. 
 
 I. SPINAL MENINGITIS. 
 
 Spinal Meningitis is an inflammation of the covering membranes of the 
 spinal cord. 
 
 The varieties of meningitis ordinarily described have been somewhat arbi- 
 trarily based upon anatomical considerations. As the dura or the softer mem- 
 branes are principally involved, the terms pachymeningitis and leptomeningitis 
 are respectively employed, but a sharp division is impossible clinically, and is 
 not found post-mortem. 
 
 For purposes of description we may consider — 1st, Pachymeningitis, or 
 external and internal inflammation of the dura; and 2d, Leptomeningitis, 
 or inflammation of the pia. But inflammation of the inner surface of the dura 
 must from contiguity involve the leptomeninges more or less, so that the con- 
 ditions are usually associated, and meningitis originally external may finally 
 invade the pia. Association with myelitis is hardly less frequent ; mixed 
 forms, therefore, or meningo-myelitis, are common, and are to be classed as 
 the thecal or cord symptoms may predominate. 
 
 Pachymeningitis Externa. 
 
 Pachymeningitis externa, or external dural meningitis, is due to chronic 
 irritation and inflammatory conditions invading the spinal canal, and is there- 
 fore secondary to other morbid states. Thus, vertebral tuberculosis, Pott's dis- 
 ease, abscesses and new growths near the spine, inflammation and purulent col- 
 lections in the pleurae, mediastinum, peritoneum, and pelvis, may be the source 
 of the meningeal thickening, which gives rise to symptoms mainly by irritation 
 of the sensory and motor nerve-roots which pass through the area of disease. 
 When the thickening becomes extreme, as it rarely does, it may be sufficient 
 to compress the cord itself and give rise to pressure symptoms and the spastic 
 paraplegia of a cross-myelitis. There is local tenderness over the spine, shoot- 
 ing or constant pains in the distribution of the irritated nerves, twitching of 
 their muscles, hyperesthesia in their cutaneous areas, which may go on to anes- 
 thesia and muscular palsy if the nerves be sufficiently compressed or inflamed 
 to cause their complete degeneration. 
 
 Anatomically, the dura is found hyperplastically thickened, with much 
 adventitious fibrous tissue, and is frequently covered by a caseous or purulent 
 deposit or involved in a new growth. The various findings, of course, depend 
 upon the nature of the primary disease. When the thickening is extreme, the 
 soft membranes are adherent to the dural tumescence and may be indistinguish- 
 able. The cord then shows a constriction, and may, in severe cases of long 
 
778 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 standing, be very considerably reduced in size at the place of disease, with, 
 inflammation and degeneration. 
 
 The diagnosis is usually not difficult if the primary disease is recognized. 
 It may be confounded with a myelitis, with which late in the case it is often 
 associated ; but the clinical history shows a preponderance of pain, spasm, and 
 irritation, a chronic course, and an early absence of paralysis ; while in myelitis 
 the japid onset, the absence of pain aside from the girdling sensation, and the 
 promptly developed paralytic state with early bladder and bowel symptoms, are 
 distinctive. 
 
 Owing to the serious nature of the causal conditions, the prognosis is bad 
 and treatment is practically surgical. The pachymeningitis externa associated 
 with Pott's disease is perhaps the least grave, as the proper orthopaedic and 
 surgical management of such cases frequently, in very marked instances, is 
 followed by practical recovery, even when the cord has been notably com- 
 pressed. 
 
 Pachymeningitis Interna. 
 
 Pachymeningitis interna, or internal inflammation of the dura, is described 
 as hypertrophic and hemorrhagic. In reality, these forms are but stages of 
 one and the same process, the thickening and hypertrophy following upon the 
 organization of the hemorrhagic exudate ; and the term hematoma of the 
 spinal dura mater has been sometimes used. The condition is a rare one, and 
 usually the cerebral meninges are similarly affected. It is most commonly 
 found in general paralysis of the insane, and consequently is practically 
 unknown in childhood. 
 
 The portion of affected dura presents on its inner surface a very consider- 
 able thickening, which may be a layer of reddish-brown exudate or consist of 
 a lamination of fibrous tissue, the apparent result of the organization of suc- 
 cessive hemorrhagic exudations, and may attain sufficient size to constrict the 
 cord. The softer, more recent, and reddish or brownish layers consist of fibrin 
 and blood. Its distribution is frequently extensive, but in some instances it is 
 confined to a comparatively short vertical extent of the spinal envelope, and is 
 then more frequently situated in the cervical region. This circumscribed cer- 
 vical form was first described by Charcot and Joffroy. 
 
 Syphilis, trauma, alcoholism, and exposure are regarded as competent 
 causes, and hence it occurs, as a rule, in adult males, though some cases in 
 children are recorded. 
 
 The condition is essentially chronic and of slow onset. At first, irritation 
 of nerve-roots gives rise to local pain and hyperesthesia over the spine and in 
 the peripheral distribution of the spinal nerves of corresponding origin. This 
 is followed, months or years later, by gradual loss of power, atrophy, and anes- 
 thesia in the corresponding parts, and, as compression upon the cord is pro- 
 duced, spastic symptoms appear below, with increased reflexes, rigidity, and 
 paraplegia leading to exhaustion and death. Some cases present stationary 
 periods, and a few recoveries are claimed. 
 
 The diagnosis is difficult when a general distribution and cerebral symptoms 
 are wanting. Diseases of the spine, progressive muscular atrophy, cross-mye- 
 litis, tumor, and external pachymeningitis must be excluded. An operation 
 may be required to do this, and as it presents, except in syphilitic cases, the 
 best chances of favorably influencing the condition and preventing destruction 
 of the cord, in the desperate situation that is presented and with the courage 
 given by asepsis, it may the more reasonably be resorted to early. Where 
 syphilis is strongly suspected specific treatment should be persistently tried. 
 
INFLAMMATION OF SPINAL MENINGES AND CORD. 779 
 
 Acute Leptomeningitis. 
 
 Acute leptomeningitis, or inflammation of the spinal pia mater, is due to 
 infection, usually involves the inner surface of the dura, and extends to the 
 substance of the cord. 
 
 Etiology. — The infection of cerebro-spinal meningitis in epidemics of the 
 disease falls sometimes only on the cord, and the infective nature of the attack 
 is obvious. In those cases, however, that are attributed to exposure, " insola- 
 tion," rheumatism, and other occult conditions, the infection is less readily 
 comprehended, but in all probability is equally in operation, being favored by 
 the physical conditions mentioned. The association of cases with septicaemia, 
 pyaemia, and other infectious blood-states points to the same conclusion, and in 
 the lymph and spinal fluid of these cases abundant pathogenic organisms have 
 been observed. In some instances the spinal trouble is an extension from the 
 cerebral meninges, the cervical portion of the cord being usually the only part 
 involved. Injuries resulting in traumatism of the membranes by vertebral 
 dislocations, strains, and severe concussions may incite a leptomeningitis over a 
 limited area, from which it may extend or in which an infection may find a suit- 
 able field for development. Surgical operations upon the spine and penetrating 
 wounds may afford access to and furnish the infection. Tuberculosis is a com- 
 mon cause, but the resulting meningitis is rather less acute, as is the case to 
 a greater degree in syphilitic inflammation, which has a marked tendency also 
 to remain localized. 
 
 Pathology. — The disease is usually of wide extent, the infection travelling 
 rapidly through the arachnoid spaces, and finding in the spinal fluid an excellent 
 medium for its propagation and extension. Congestion of the pia, of the adj oining 
 inner surface of the dura, and of the cord, marked by increased vascularization 
 and an increase of spinal fluid, passes into inflammation, with dulness of the mem- 
 branes, opacity, thickening, and an exudation of large quantity, varying in 
 color from an opalescent to a puriform, and of corresponding consistency. The 
 microscope shows the diapedic elements of inflammation and often numerous 
 bacteria, including at times those closely resembling the pneumococcus of Fried- 
 lander. Tubercles here correspond to their histological and bacterial characters 
 on other serous surfaces. For a time the somewhat resistent pial covering of the 
 cord and nerve-roots protects these structures, and especially in the purulent 
 form of the disease ; but usually the periphery of the cord and the roots show 
 the inflammatory invasion, with corresponding changes in the nerve-fibrils, neu- 
 roglial framework, and vessels. In cases reaching a convalescent or chronic 
 stage adhesions form betAveen the cord and the dura, obliterating the arachnoid 
 space over more or less extensive areas, distorting the nerve-roots, and some- 
 times changing the outlines of the cord itself, which, if softening in its substance 
 has taken place as a result of the meningo-myelitis, presents degenerations of 
 its conduction tracts and localized destruction of its gray matter. Large quan- 
 tities of spinal fluid usually mark these late cases, causing, with the irregular 
 adhesions, a sacculated condition of the dura. 
 
 Symptoms. — The abrupt onset of the disease may be preceded by a day 
 or two of malaise and slight anorexia ; but sometimes no invasive period is 
 present, and a sharp chill is followed or attended by great pain in the back and 
 darting pains around the body or down the limbs. In children, vomiting or 
 convulsions may be present, and the former is a common symptom. Tenderness 
 is at once developed over the spine, easily detectable, when not prominent, by 
 the use of a sponge dipped in hot water or by sharp percussion with the finger. 
 Spasm and rigidity of the muscles appear at once, causing stillness of the neck 
 
780 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and back, sometimes notable retraction of the head ; fixation of the limbs upon 
 the body more or less marked, with a tendency to flexed attitudes ; retraction 
 of the belly from implication of the abdominal muscles ; and sometimes difficulty 
 of breathing, by involvement of the chest musculature aside from the dyspnoea, 
 Cheyne-Stokes' respiration, and cardiac symptoms of medullary implication. 
 The cramps in the muscles are painful, and yet tenderness and hyperesthesia 
 in the limbs prevent manipulations and passive movements. The rectum and 
 bladder are the seat of similar spasms which may cause constipation and reten- 
 tion of urine, with frequent annoying and ineffectual expulsive contractions of 
 these viscera. 
 
 Pulse and temperature are fickle, sometimes being subnormal, sometimes in- 
 creased, and more often divergent ; for instance, a subnormal temperature with 
 an accelerated pulse. The lack of uniformity in their range is especially valu- 
 able in diagnosis, even when the cerebrum is apparently not involved. A tem- 
 perature of 103° F. is not uncommon. Vaso-motor paralysis is usually shown by 
 the vivid, persistent, but slowly-developed line which follows every stroke of 
 the finger-nail or similar object upon the skin, and from the same cause the 
 limbs may be congested and even slightly oedematous. At first, for a day 
 or two, reflexes are inclined to be increased, and later may be wanting. 
 
 Cases which outlast the acute symptoms develop paralysis, anaesthesia, 
 atrophy, and contractures in proportion as the cord and nerve-roots are affected. 
 Paraplegia may result, presenting the features of a cross-myelitis with bladder 
 paresis, bed-sores, increased reflexes, and spasticity. Symptoms vary with the 
 location of the disease, but its tendency to involve the entire spinal apparatus 
 is marked, and indications of its effect upon all spinal segments are to a greater 
 or less degree present in a majority of instances. Some regions situated in the 
 focus of the inflammatory action show early and emphatic involvement; those 
 at a distance may be disturbed very little ; and yet in some purulent cases, 
 where the dural sheath is greatly distended through its entire length with the 
 large accumulation, the pia protects the cord and nerve-roots from infection, so 
 that pressure symptoms alone may be present. 
 
 Course. — Some cases terminate fatally within a day or two ; others last a 
 fortnight, and may then end fatally or recover. The nature and virulence of 
 the infection are a determining factor, as is the location of the disease — exten- 
 sion upward or early involvement of the high levels of the cord tending to an 
 early fatal issue. Complete recovery is rare, and the conditions resulting from 
 myelitis are of long duration, and may even last a lifetime. The tubercular 
 and syphilitic varieties, as already indicated, less rapidly run their course, and 
 the latter is capable of material modification by treatment. 
 
 Diagnosis. — The diagnosis depends upon the rapid onset, the pain in the 
 back, the radiating pains, the rigidity, the increase of pain on voluntary move- 
 ment, the hyperesthesia, and the fickle temperature and pulse. From myelitis 
 it is distinguished by the paralysis and lack of pain which characterize the cord 
 lesion, but the frequent association of the two is to be always kept in mind. 
 Haemorrhage into the subdural space, from the irritation of the nerve-roots, pre- 
 sents very similar symptoms, but is extremely rapid in the onset, usually follow- 
 ing traumatism or a strain, and develops meningitis in a short time thereafter. 
 Haemorrhage into the spinal cord gives instantaneous symptoms and immediate 
 paralysis, and is practically devoid of pain. The rigid form of tetany may 
 present a very close counterfeit, but its long duration, remissions, and amen- 
 ability to spinal sedatives, with absence of spinal tenderness and shooting 
 pains, and with the possible history of previous attacks and the usual irritability 
 from pressure upon nerve- trunks and arteries, should differentiate it. Tetanus 
 
INFLAMMATION OF SPINAL MENINGES AND CORD. 781 
 
 may be mistaken for spinal meningitis. The early trismus, the excessive 
 hyperesthesia, the fever of onset, the paroxysms of spasm, and the frequent 
 history of traumatism point the way to diagnosis. Muscular rheumatism and 
 strain present a very superficial resemblance. 
 
 Prognosis. — The outlook as to life is always serious and grave in propor- 
 tion to the acuteness of the onset, to the virulence of the infection, to the 
 implication of the upper portion of the cord, and to the height of temperature. 
 The estimate is also to be guided by the previous condition of health and the 
 age of the patient, children and the aged quickly yielding to the disease. 
 Traumatic and surgical infection is less serious than auto-infection by leuco- 
 maines. The possibility of the removal of sources of infection cuts some 
 figure as to ultimate results, providing the patient survives the acute stage. 
 The late results, due, for the most part, to permanent changes in the cord, are 
 usually beyond the hope of marked improvement. 
 
 Treatment. — Complete and absolute quiet is to be insisted upon, and the 
 patient maintained upon the side or face, if possible to do so without increasing 
 the cramps. The partial knee-elbow position over a mound of firm pillows 
 will often be found very comfortable, and at the same time will afford the 
 best opportunity for local applications. These at first should be strongly 
 counter-irritant, as the thermo-cautery, blisters, or detergents like leeches, 
 vigorous dry-cupping, or wet-cups in robust or plethoric individuals. Should 
 myelitis be associated, less active measures are indicated, and the skin must not 
 be broken or highly irritated, owing to the tendency to bed-sores. A hot bath 
 and pack at the onset with active catharsis have seemed to do good. Seda- 
 tives, especially spinal sedatives, are frequently required to control the spasms, 
 and anodynes to relieve the pains. A thorough course of mercurial inunc- 
 tions over the spine has strong advocates, the quantity used being sufficient to 
 produce slight ptyalism. Owing to the reflex irritability, these rubbings must 
 often be impossible, and the therapeutic value of mercury in the acute stage 
 of non-luetic cases is open to question. Iodide of potassium and ergot are 
 also at this time of little or no value. The ice-bag to the spine is one of the 
 most serviceable measures, but is rarely tolerated long by the patient, and its 
 intermittent application is useless. It should always be tried. As the active 
 stage subsides, light cauterizations with the Paquelin apparatus, mild sinapisms 
 applied for six or eight hours, and the hot spray douche seem to assist the 
 reparative efforts of nature. Cerebral symptoms usually mean the implication 
 of the brain coverings, the spinal features become of secondary importance, 
 and the treatment is that of cerebro-spinal meningitis. The paralysis, con- 
 tractures, and other late results of the myelitis are to be managed in accord- 
 ance with the rules of practice in that disease. 
 
 Chronic Leptomeningitis. 
 
 The chronic form of inflammation of the soft membranes is usually the 
 sequential stage of an acute attack, but may follow alcoholism, syphilis, or 
 tuberculosis. Its origin as a primary affection is open to some doubt, but a 
 very slowly-developed leptomeningitis may follow concussion, though it is 
 impossible in such a case to exclude immediate slight histological injuries of 
 which the later inflammation is a natural development. The formerly much- 
 used term " chronic meningitis," which was given to every group of obscure 
 subjective symptoms referable, however remotely, to the spine, only needs 
 mention to be condemned. 
 
 The symptoms are practically those of the acute form much reduced in in- 
 
782 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tensity, and are dependent upon similar causes. Pain in the back predomi- 
 nates, and spasm is insignificant or absent. The radiating neuralgic pains are 
 especially pronounced, and paresthesia are prominent. Their distribution de- 
 pends upon the nerve-roots involved and the location of the inflammation, 
 which is much more circumscribed than in the acute form. The late manifes- 
 tations are those due to neuritis originating in the roots, and myelitic symptoms 
 are comparatively infrequent. 
 
 The anatomy of the disease is very little known, as opportunity for post- 
 mortem examination rarely occurs, but a more or less extensive fibrous thick- 
 ening may be found, and adhesions between pia and dura which constrict the 
 nerve-roots and may girdle the cord. Degeneration of the spinal nerves travers- 
 ing the lesion is not rare, and this accounts for the herpetic and other cuta- 
 neous symptoms of neuritis which are occasionally noted. 
 
 The prognosis will be guided mainly by the effect of treatment, but a com- 
 plete recovery is very rare. Each case must be carefully estimated by itself. 
 
 The treatment in syphilitic cases consists in the heroic management of that 
 disease, and iodides and mercury are also the most efficient drugs in non-luetic 
 cases. General measures are of avail, and persistent counter-irritation over 
 the spine is the most valuable local measure. Sometimes rest in bed and the 
 ice-bag to the spine are of distinct value. Sedatives and analgesics are often 
 required. 
 
 n. MYELITIS. 
 
 Myelitis, or inflammation of the spinal cord, is a generic term covering a con- 
 dition presenting many varieties of a more or less arbitrary character, depend- 
 ing upon the mode of onset, the portion of the cord involved, the duration of 
 the disease, and the exciting cause. Thus it is acute, subacute, or chronic ; 
 transverse, diffuse, focal, disseminated, central, or annular ; parenchymatous or 
 interstitial ; and compressive, traumatic, secondary, syphilitic, infectious, etc., 
 the adjectives sufficiently describing the modifications. The forms of myelitis 
 constituting the so-called system lesions, poliomyelitis, locomotor ataxia, and 
 other circumscribed scleroses, are described under separate headings. The 
 clinical variations of the disease are multiform. So widely do the several 
 tracts and segments of the cord vary in function that their implication gives 
 rise to the most diversified symptomatology, for the comprehension of which a 
 fair knowledge of the anatomy and physiology of the cord is requisite. 
 
 Acute Myelitis. 
 
 Acute Myelitis, acute softening of the cord or transverse myelitis, is the 
 most ordinary form, and not a rare disease. 
 
 Etiology. — While the disease may appear at any age, it is very rare in 
 children ; males from eighteen to forty years furnish the large majority of cases, 
 syphilis, exposure, and muscular effort playing an important part in precipitating 
 the malady. Next to trauma, syphilis is the most frequent cause. Benedict 
 and Erb, indeed, are disposed to assign to the syphilitic cases a clinical entity ; 
 but the only variations are those attributable to the infection, the nature of 
 the syphilitic process, and its partial response to treatment in some cases. 
 Lead, mercury, and other chemical poisonings are at times provocative of 
 myelitis. Acute infections, sapraemic and pyogenic conditions, may lead to it, 
 the last sometimes producing an abscess of the cord. Pressure from hsemor- 
 
INFLAMMATION OF SPINAL MENINGES AND COBB. 783 
 
 rhage, pachymeningitis, tumors, fractures, dislocations, and from Pott's disease, 
 very rarely from a thoracic aneurism, may incite it, and it has been attributed 
 to sexual excesses. Wounds of the cord or in the neighborhood leading to 
 infection, minute haemorrhages in the cord from strains, violence, concussion, and 
 arterial disease, thrombosis or embolism, may originate the softening. Whether 
 concussion unattended by immediate histological injury to the cord is capable 
 of producing myelitis or not is a mooted question, but the growing tendency is 
 to look upon the material and anatomical factors as requisite to its develop- 
 ment. The annular form, and sometimes other varieties, are due to extension 
 from a meningeal inflammation. 
 
 Pathology. — The inflammatory process may be very slight or absolutely 
 destructive in intensity. If the lesion be examined early, there will be found 
 hyperemia and swelling of the adjacent pia mater and of the affected portion 
 of the cord. Later, the condition depends largely upon the amount of blood 
 effused ; in some instances the disintegration of the cord is such, and the ex- 
 travasation of blood so considerable, that the gross characters of a clot only 
 are found. In other cases softening is so pronounced that the cord is diffluent 
 and of a creamy consistence and appearance. From the hemorrhagic element 
 "red softening," comparable to that in the brain, may be found, and this, by 
 the resorption and change of the coloring matter, later becomes yellowish. In 
 time the affected area, through the removal of the fat and the deposition of 
 adventitious fibroid elements, looks grayish and translucent and is shrunken 
 in outline. Thus, after some lapse of time, the cord may be reduced to a 
 narrow filament. In these prolonged cases upward and downward, secondary, 
 sclerotic degenerations in the white columns ensue. 
 
 Peripherally, the muscles innervated by the involved cord-segments rapidly 
 waste and degenerate, and dystrophic bed-sores are common even at an early 
 stage. Implication of the nerves controlling the bladder frequently results in 
 cystitis, leading to nephritis and uraemia. 
 
 Microscopically, the findings vary greatly with the intensity, form, and dura- 
 tion of the disease. When the cord has become entirely disintegrated and dif- 
 fluent such examinations are of little value. In the mildest forms the vascular 
 changes are the most noticeable, the blood-vessels being widened, crowded with 
 the formed elements of the blood, and the perivascular spaces greatly distended 
 with leucocytes. Minute extravasations are common. The gray substance 
 of the cord is more granular than in health, its cells distorted, swollen, and 
 devoid of processes when the condition is marked. Corpora amylacea and 
 globules of myelin are common. In the white portions increase and alteration 
 in the neuroglia are found. Spider-cells are frequent. The fibres show swell- 
 ing of the axis-cylinder, and the myelin has a tendency to break up. At 
 points of pressure the fibres are shrunken and may entirely disappear. In the 
 parenchymatous forms the nerve-cells present the principal changes, the inter- 
 cellular substance and interstitial material showing practically no change, and 
 the vascular condition is less marked. 
 
 In cases of long duration both fibres and cells give place, in large part or 
 completely, to an actual increase in the fibrous elements of the interstitial 
 structure, and new fibroid tissue is deposited. The resulting ascending and 
 descending degenerations show sclerotic features similar to those in the system 
 lesions, and sometimes a more active inflammatory process extends a short dis- 
 tance up or down the cord, occasionally following the central canal, which may 
 show dilatation, proliferation of the epithelial lining, and more or less dis- 
 tortion. 
 
 The distribution of the inflammation in the cross-section of the cord is 
 
784 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 subject to no rule. In some cases it is scattered in random foci, in others 
 confined to a few principal points ; or the entire cross-section may be involved, 
 and the gray matter does not, relative to its proportions, seem to be especially 
 selected. 
 
 Symptoms. — The onset, except in traumatic cases, is gradual, but in the 
 course of a few hours or days or weeks paraplegia may become complete. 
 Very rarely, and usually only in syphilitic forms and those due to slowly-devel- 
 oped pressure, there are prodromata for weeks or months before the attack, con- 
 sisting in temporary weakness, tingling and radiating pains ; but ordinarily a 
 feeling of numbness and weakness in the legs is experienced, the lower extrem- 
 ities feel heavy and unmanageable : in a few hours they refuse to bear the 
 weight of the body, and in a few days may become completely paralyzed. 
 During the first week the temperature may be elevated a degree or two, but very 
 rarely attains a height of 104° F. Delirium and convulsions have been seen 
 occasionally in children, and more rarely in adults. The reflexes, where directly 
 related anatomically to the affected segments, are lost early and permanently, 
 and below that level are increased after a few days, unless the cord has been 
 entirely destroyed at the inflammatory focus, when they are abolished. Pro- 
 vided the posterior roots and meninges are involved, pain in the back and limbs 
 is a prominent symptom, but rarely is of an excruciating character at the 
 onset. At the upper level of the inflammation some pain is the rule, which gives 
 rise to a band or girdle sensation and a zone of hyperesthesia about the abdo- 
 men or chest. This sign, with the paralysis, definitely localizes the upper limit 
 of the lesion, but if it be in the lower cervical region this sensation passes down 
 the arms and is not so sharply defined. Lesions in the cervical region are also 
 marked by implication of the cilic-spinal centre, with consequent dilatation of 
 the pupil. Continuous priapism is then, too, a usual occurrence, and the inter- 
 costal muscles and heart may be affected. Below the lesion, and depend- 
 ing upon its intensity, there are variations in sensibility to all forms of stimu- 
 lation, from slight blunting to the usually complete anaesthesia. Sensations of 
 drowsiness and aching in the paralyzed and anaesthetic limbs are sometimes 
 mentioned ; and cramps and drawing up of the limbs frequently occur early, and 
 later are the rule. Distinct muscular atrophy related to the portion of the cord 
 
 Fig. 1. 
 
 Showing Flexion, Cross-leg from Adduction, Contractions causing Drop-foot 
 and Bed-sores. 
 
 affected takes place, but in the trunk is not readily discernible. The paralyzed 
 limbs during the first few days are abnormally warm, but soon present a sub- 
 normal temperature : sluggish circulation and emaciation ensue, with oedema 
 of the feet and legs if the limbs are left any length of time in a pendent posi- 
 tion. If the lesion is low down, the atrophy is a marked feature and the re- 
 
INFLAMMATION OF SPINAL MENINGES AND CORD. 785 
 
 action of degeneration is present. Under the influence of pressure bed-sores 
 form on prominent portions of the body and limbs, and this very early. In 
 some cases within the first week immense sphacelization may take place over 
 the sacrum, which cannot be explained by pressure and the moisture from the 
 urine, but implies a dystrophic condition of cord origin. Bed-sores of this 
 nature are especially liable to form when the lumbar cord is the seat of 
 the disease. 
 
 Course. — The onset, as already indicated, is moderately rapid, as a rule, 
 and in the course of a few days the complete picture of paraplegia is presented. 
 Although the case may stop short of this at any point, it may, on the other 
 hand, rapidly progress to the formation of bed-sores, the development of 
 cystitis, and rapidly progressive exhaustion, often terminating in a fatal issue. 
 Non-fatal cases come to a standstill after two or three weeks, and if nutrition 
 and strength are maintained improvement slowly takes place, sensation and 
 motion gradually reappearing and increasing for a year or two. A complete, 
 or apparently complete, recovery is rarely seen. For the most part, secondary 
 degenerations, upward in the posterior columns of the cord and downward in 
 the lateral tracts, cause inco-ordination on the one hand and spastic symptoms 
 on the other — a combination suggestive of ataxic paraplegia, and no doubt 
 sometimes confused with that disease. The implication of the pyramidal tracts 
 leads to the spasms, tremors, and cramps which form such prominent features 
 of these late cases, and gives rise to the spastic gait when walking is pos- 
 
 Fig. 2. 
 
 Fig. 3. 
 
 Chronic Myelitis, showing station and rigidity, with partial flexion and 
 adduction of thighs. 
 
 sible, and to the flexed limbs, adducted thighs, and crossed legs of the bed- 
 ridden cases, as shown in Figs. 1, 2, and 3. In these later stages the condi- 
 tion is often spoken of as chronic myelitis. 
 
 50 
 
786 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Diagnosis. — Regarding the location of the lesion, the best guide will be 
 the upper level of anaesthesia and the hyperaesthetic girdle. After a few 
 weeks increased superficial and deep reflexes occur below the disease, while 
 those reflexes whose arcs are involved in the softening disappear. Thus, if 
 the umbilical or mid-abdominal reflex is absent, those below being present 
 and exaggerated, and a girdle sensation is present just above the navel with 
 anaesthesia below, the lesion is at the tenth dorsal segment and opposite the 
 body of the ninth dorsal vertebra, the guide to which is the eighth dorsal 
 spine. With this the distribution of paralysis should also agree. 
 
 The intimate and usual association with myelitis of some more or less local- 
 ized meningitis is to be constantly in mind, as the obtrusive symptoms arising 
 therefrom may serve to very much embarrass the diagnosis, especially in the 
 beginning, and mislead the judgment as to the future of the case. The nature 
 of the lesion must be determined by a careful study of the clinical history and 
 a careful clinical examination of the patient for spine disease, for neoplasmata 
 in other locations, for tuberculosis, for syphilis, and for injuries. 
 
 Prognosis. — While the prognosis is always grave as to ultimate recovery, 
 and early in a given case must be carefully guarded as to the probability of 
 a fatal termination, there are certain facts which modify the estimate. A 
 dorsal myelitis is less serious than a lumbar, and very much less than a 
 cervical involvement. The more sudden and complete the onset, the greater 
 the probable damage to the cord. High temperature and early bed-sores are 
 extremely ominous. Serious involvement of the bladder and bowel, implying 
 lumbar cord lesions, are distinctly unfavorable. The reappearance of sensa- 
 tion in the anaesthetic area is hopeful, and usually followed by some return of 
 voluntary motion. When improvement has distinctly commenced, it may be 
 expected to continue for a year, and progresses even two years or more in 
 some instances. Secondary degenerations mean an ataxic paraplegic condition. 
 Myelitis depending upon Pott' s disease or upon pressure may reasonably be 
 expected to make a fair recovery if the causal condition can be removed. 
 Indeed, it is marvellous to what an extent the cord may be slowly compressed, 
 and eventually regain functional activity with disappearance of all the para- 
 plegic symptoms. When the myelitis is due to active syphilis or to pressure 
 by a syphilitic neoplasm, some considerable improvement under treatment is 
 the rule, but an absolute recovery the extreme exception. This is especially 
 true when the luetic lesion is confined to the cord itself. 
 
 Treatment. — The patient should be put at once to bed, and kept on the 
 side, or, better, when possible, upon the face. This can usually be accom- 
 plished by building up a mound of pillows under the thorax and abdomen. In 
 this position the bowels and bladder can be readily evacuated and the patient 
 easily managed. A brisk cathartic should be administered and the bladder 
 carefully watched, the catheter being avoided as long as possible, and used 
 under the strictest rules of cleanliness when finally it is necessary. The 
 tendency to retention of urine, with cystitis, and its "unfavorable significance, 
 cannot be too much insisted upon. To the spine counter-irritation with mild 
 sinapisms is desirable. Here the dystrophic tendency must be borne in mind, 
 and blistering or severe irritation below the line of inflammation absolutely 
 avoided. A mustard plaster four inches wide and two feet long, made of one 
 part mustard to ten of flour and thoroughly mixed, can be applied for hours 
 and with benefit. The use of ergot and other drugs to control the circulation 
 is of doubtful value, but may be tried if the stomach is tolerant. The mechan- 
 ical causes of the disease must be met surgically. When present, except in 
 syphilitic cases and Pott's disease, nothing but operation promises any reason- 
 
INFLAMMATION OF SPINAL MENINGES AND CORD. 787 
 
 able relief, and operation under strict aseptic methods adds practically nothing 
 to the gravity of the situation. When bed-sores appear or the tendency to 
 their formation is marked, a water- or air-bed kept at a proper temperature is 
 useful, but, unfortunately, is rarely available. Great care to protect the skin 
 from discharges and uncleanliness of all sorts, with frequent applications of 
 alcohol and unirritating dusting powders, and repeated changes of position, will 
 do very much to obviate these dangerous complications. After ten days or 
 two weeks systematic passive movements, massage, and the use of faradic elec- 
 tricity should be adopted to prevent the wasting and tendency to contracture. 
 When, later, the contractures may be very prominent, splints should be em- 
 ployed. As sensation and slight voluntary motion return, a carefully guarded 
 system of mild exercises should be instituted. The intelligent use of the fara- 
 dic wire brush to the anaesthetic parts sometimes is of distinct benefit in hasten- 
 ing sensory improvement, which in turn is usually followed by more or less 
 volitional activity. 
 
 Some syphilitic cases yield promptly to large doses of iodide of potassium 
 and mercury, and nearly regain the condition of health. A certain residuum 
 of impairment is always left, however, when the cord has been actually invaded. 
 Other cases fail to respond to this line of treatment even when heroic doses are 
 employed. One should not be satisfied in an adult to stop short of an ounce 
 of iodide a day if smaller doses fail to make an impression, and by guarding 
 the stomach with Vichy and the bowels with bismuth this can usually be accom- 
 plished without much difficulty. In children the dose must be proportioned to 
 their age. 
 
 The bladder and bowel, except when the lumbar centres are destroyed, tend 
 to regain some power and control, which can be assisted by rendering their 
 contents unirritating and by encouraging regular habits regarding their evacu- 
 ation, with the use of faradization to strengthen the sphincters. Everything 
 conducing to the general healthy tone of the individual assists directly and 
 indirectly the local disability. 
 
 Chronic Myelitis. 
 
 Chronic myelitis is usually the terminal stage of an acute softening, and but 
 very rarely, if ever, is a primary condition. Its separate consideration is only 
 warranted by the fact that it is often mistaken for primary spastic paraplegia, 
 for ataxic paraplegia, rarely for locomotor ataxia, and that its treatment requires 
 description. Its diagnosis depends on its long duration and the history of an 
 acute, or at least tolerably rapid, onset, on the involvement of bladder and 
 bowels, on the paraplegic distribution of sensory and motor deficiency and 
 wasting, on the absence of pupillary symptoms, lightning pains and inco-ordi- 
 nation, on the presence of rigidity, increased reflexes and contractures, and on 
 the evidence of old bed-sores. 
 
 The treatment consists practically in the use of everything that will elevate 
 the general tone; in guarding against bed-sores, cystitis, contractures, and 
 wasting; in the use of massage, electricity, hot and cold spinal douches, and 
 counter-irritation in the form of flying blisters and the thermo-cautery ; in 
 operation for pressure conditions from tumor or bone ; in appropriate suspen- 
 sion and fixation in Pott's disease; in the persistent use of antisyphilitics in 
 luetic cases, and in operation when these do not succeed or a gummy tumor is 
 reasonably suspected. Exercises to develop the impaired muscular power, pas- 
 sive movements, and volitional efforts against resistance are valuable. The 
 sphincteric paresis can also be improved by the passive and active movements 
 
788 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 recommended by Brandt in prolapsus uteri, which serve to strengthen the 
 pelvic floor, and consist for the most part in having the patient adduct and 
 abduct the flexed thighs while lying on the back and raising the pelvis from 
 the bed, the motions being resisted by the attendant. Continued and often- 
 repeated voluntary attempts to contract the sphincters, as in restraining faeces, 
 should be encouraged. Late in the disease, when it has become stationary, 
 tenotomies and appropriate apparatus may enable an otherwise bed-ridden 
 patient to get about. The tendency toward some improvement during the first 
 two or three years should be kept in mind, and everything done at this time to 
 assist the reparative efforts of nature. 
 
ACUTE ANTERIOR POLIOMYELITIS. 
 
 By ARCHIBALD CHURCH, M. D., 
 
 Chicago. 
 
 Acute Anterior Poliomyelitis, also known as myelitis of the anterior 
 horns, atrophic spinal paralysis, infantile paralysis, or the essential paralysis 
 of children, is a febrile disease the activity of which falls upon the anterior 
 horns of the gray matter of the spinal cord ; it is marked by rapidly developed 
 and extensive paralysis, a portion of which remains permanently, and is usually 
 followed by atrophy of muscle and often by non-development of bone, and by 
 deformity. 
 
 Etiology. — It is a disease almost peculiar to childhood, and, though cases 
 occurring in adult life have been recorded, it is probable that many of these 
 late instances have been cases of peripheral neuritis, the diagnosis of which has 
 only of late years been generally made. The great majority of cases occur 
 before the tenth year of age, and three-fifths are encountered before the 
 fourth year, being equally divided for the first three years of life. As it 
 is comparatively rare during the first six months, the latter half of the first 
 year of life is therefore the most susceptible period. The coincidence of the 
 first dentition at this time has given an altogether undue importance to the 
 role played by the eruption of teeth as a probable cause. At one time ex- 
 posure to cold was considered an active etiological factor, but Sinkler of Phila- 
 delphia found that over four-fifths of all cases occurred during the hot months 
 from May to September inclusive, with a heightened frequency during the 
 hottest months, July and August. Heat may therefore be considered as a 
 predisposing or favorable condition for the evolution of the malady. It is to 
 be remembered, however, that slight colds among children are as frequent in 
 warm weather, from draughts when lightly clad, as in winter. In nearly every 
 case the history of a fall or blow of some sort is brought forward by the parents, 
 too frequently resulting in casting unmerited blame upon the nurse or others 
 in charge of the child. It must, of course, be admitted that a concussing force 
 applied to the spine might lower resistance to the disease, but there is no good 
 reason for attaching great weight to slight traumatism. In a numerous list of 
 instances the disease is said to have followed acute diseases, such as the exanthe- 
 mata, but in many such cases the initial fever of the poliomyelitis was probably 
 mistaken for some other complaint, and a careful study of these reports reveals 
 such a lack of detail that they must, as a rule, be accepted with caution. In 
 others the original ailment is stated to have been obscure or atypical, and as a 
 matter of fact the diagnosis of anterior poliomyelitis is very difficult during 
 the initial fever, and, until paralysis is apparent, diners but little from the febric- 
 ula of indigestion or other slight ailments. 
 
 Pathological Anatomy. — It is only since 1865 that the lesion in this 
 disease has been known. In that year Provost thoroughly described it, and 
 his findings have been invariably confirmed by workers in this field. Owing 
 
 789 
 
790 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 to the fact that only rarely does death occur in the very early stages of the 
 disease, or is then attributed to other causes, the initial appearances and con- 
 ditions are practically unknown, but can from later observations be fairly well 
 indicated. As a rule, the anatomical changes are limited to the anterior horns 
 of gray matter, only involving the neighboring white tracts of the anterior and 
 lateral columns by the extension of the inflammatory or hemorrhagic processes 
 which take place in the cornua, and which result in a softening and disintegra- 
 tion of their elements. The large motor and trophic cells either completely 
 disappear or only a few shrunken representatives are left ; in milder cases 
 slight alterations in the cells alone are found. Later, from the shrinkage of 
 the neuroglial tissue and from the deposition of other fibrous elements, a de- 
 pression is found in the implicated part of the cord, and granular disintegration 
 of the involved nerve-elements is present. When the pyramidal tract is in- 
 volved, descending degeneration may take place, though this is uncommon, and 
 when present is usually slight in transverse extent. The muscles depending 
 for innervation upon the affected cornual cells rapidly waste, and the sarcode ele- 
 ments in extensive cases entirely disappear, nothing but the fibrous tissue being 
 left. In less-pronounced cases individual fibres or groups of muscle-bundles 
 are destroyed, or sometimes merely a diminution in size is found ; and rarely 
 isolated muscular fibres are encountered which show a true hypertrophy, prob- 
 ably of a compensatory character. Where the bones are affected, they are 
 smaller, smoother, less well marked by muscle insertions, more compact, showing 
 less cancellated structure, and are consequently more fragile. 
 
 The peripheral nerves arising from the affected anterior horns show de- 
 generative changes of a corresponding degree. Sometimes in extensive cases 
 nothing but fibrous cords are left, but usually all the fibrils are not destroyed, 
 the cross-section of the nerve-trunk showing many normal elements. This, of 
 course, is to be expected, as the sensory fibres which enter the cord by the 
 posterior root are not implicated in the central lesion ; but the same is true of 
 sections of the anterior roots close to the cord, and the sympathetic fibres in the 
 anterior roots also escape. Examinations of the brain are usually negative. 
 In some extreme cases of extensive peripheral distribution of long standing the 
 corresponding cortical motor area has been found smaller or undeveloped. 
 
 A number of cases are on record in which an acute polyneuritis has ap- 
 parently coincided with the spinal attack, but these cases require more study, 
 and the presumption is that the tenderness in the nerve-trunks in such cases 
 is due to the degenerative process in the motor-fibres and the attending irri- 
 tation of the adjoining sensory bundles which furnish the nervi nervorum. 
 
 Pathology. — The acute onset, the short duration of the fever, its com- 
 paratively uniform range, and the immediate paralysis point to a systemic 
 infection, or, to adopt the expression of Gowers, "a blood-state," which finds 
 its local expression and its anatomical manifestation in the anterior spinal gray 
 matter. The elective action of certain drugs upon the spinal centres leads 
 naturally enough to the supposition that a ptomaine or leucomaine might have 
 a similar selective tendency, as, for instance, that of diphtheria is known to 
 have for the peripheral nerves, or of hydrophobia for the central apparatus. 
 This idea receives some support from instances in which more than one case 
 occurred at the same time in a given family ; and several practical endemics of 
 the disease are on record. The whole question is yet undecided, but the in* 
 fection theory would seem to be the best working hypothesis. 
 
 Symptoms. — Usually without apparent provocation the child is found to 
 be feverish and ill. A temperature of 100° to 102° F. has been frequently 
 noted, and this febrile invasion-stage lasts from a few hours to a few davs, when 
 
ACUTE ANTERIOR POLIOMYELITIS. 
 
 791 
 
 Fig. 1. 
 
 Leg Type, with Marked Cal- 
 caneus. 
 
 Fig. 2. 
 
 paralysis and flaccidity of one or more limbs are detected. It is not rare, how- 
 ever, for the child to go to bed apparently well and to awake paralyzed in the 
 morning. The febrile movement may be attended by 
 vomiting and diarrhoea, by convulsions of a generalized 
 character, or by delirium and diffuse cerebral manifes- 
 tations. As soon as the paralysis is noted the case is 
 usually recognized. Most writers state that rarely there 
 is a complaint of pain in the afflicted members, but the 
 rule is that sensation in all its phases is entirely normal. 
 It is probable, however, that early dysesthesia, owing 
 to the age of the patient and a lack of careful search for 
 such difficulty, has been many times overlooked. In 
 some considerable number of cases during the initial 
 fever handling of the affected limbs provoked outcries, 
 which were not elicited by similar manipulation of the 
 other members ; and it is likely that more attention in 
 this direction will show localized hyperesthesia or some 
 kindred state to be usually present and of diagnostic 
 importance. Indeed, complaints of pain and formica- 
 tion have been generally noted in cases of a comparatively advanced age, 
 
 lending perhaps undue weight to the supposi- 
 tion that such cases are not of a true spinal 
 type. The sphincters are almost never relaxed, 
 so that control of the bladder and bowel re- 
 mains unimpaired, but in the rare cases in which 
 these sphincters are relaxed there is more or 
 less apparent loss of sensation, the extent of the 
 lesion is greater, and the prognosis is extremely 
 unfavorable. 
 
 Even in fat children the implicated muscles 
 can be seen, after a few weeks, to have wasted, 
 and, if tested with the faradic current, either do 
 not respond at all or show a remarkable diminu- 
 tion in their excitability. At this time the 
 patient will have begun to show considerable 
 improvement, the motor paralysis remaining 
 complete only in the parts that are to per- 
 manently suffer, and a gradual improvement 
 may be reasonably expected to extend over 
 several months. In the muscles showing less- 
 ened faradic excitability galvanism produces 
 exaggerated responses as compared with the 
 sound limbs ; and the complete reaction of de- 
 generation or any modification of it may be 
 encountered. In a well-marked case faradism 
 fails by the tenth day, and the galvanic in- 
 creased response appears, lasting for about six months, when it gradually fails. 
 At this point faradic excitability returns, and the muscle regains something of 
 its size and strength; or, if too seriously impaired, faradic response does not 
 reappear, galvanic response disappears, and the muscle is irretrievably lost. 
 
 The reflexes are lessened or abolished in proportion as the muscles which 
 are anatomically associated with them are involved ; or perhaps it would be 
 better to say that their alteration depends upon the implication of the cornual 
 
 Anterior Leg Type, with Drop-foot. 
 
792 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cells making up a part of their arc. Bones which have not attained their full 
 growth are retarded or fail entirely to develop if their trophic centres are 
 
 mP The seriously atrophied muscles become unyielding fibrous bands ; and since 
 they offer to the synergic and antergic muscles neither assistance nor opposition, 
 
 Fig. 3. 
 
 Shoulder and Arm Type (Kindness of Drs. Ridlon and Jones). 
 
 distortions soon develop with joint-changes and sometimes subluxations. Joints 
 which depend upon muscular support, as the shoulder, may allow of so much 
 deformity by the relaxation of the muscles which have lost their tonicity that 
 the articular surfaces widely separate. The skin is inactive, often cold, and 
 sometimes dry and scaly, but the atrophic conditions so usual in neuritis are 
 practically absent, and bed-sores are almost unknown. 
 
 The distribution of the permanent paralysis and wasting is characterized by 
 non-conformity to any type, and the resulting deformities are therefore of all 
 grades and descriptions. The lower extremities are affected about three times 
 as frequently as the upper, and the left leg twice as often as the right. A 
 crossed form, in which the upper extremity on one side is involved with the 
 opposite lower limb, is not rare; but involvement of both limbs on the same 
 
ACUTE ANTERIOR POLIOMYELITIS, 793 
 
 side is extremely uncommon. In the lower extremity the extensors seem more 
 susceptible than the flexors ; hence drop-foot, with equine talipes, flexed knee, 
 and flexed thigh are common. "When the paralysis is below the knee the sural 
 muscles usually escape. In the upper extremity the most frequently encoun- 
 tered wasting is in the small muscles of the hands, the deltoid, and the exten- 
 sors of the wrist — the biceps and supinators generally escaping. For the most 
 part, the central lesion is confined to the cervical and lumbar enlargements; 
 consequently the body muscles usually are spared, and involvement of the cranial 
 nerves is so rare as to always raise a doubt regarding the diagnosis. 
 
 Course. — The course of the disease may be clinically divided into (1) 
 a stage of febrile invasion, lasting from a few hours to a few days, with local 
 tenderness and rapidly developing and increasing paralysis ; (2) a stationary 
 stage, lasting for several weeks ; (3) a period of improvement, lasting to the 
 end of the year; and (4) a stage of permanent disability for the remainder of 
 life. Relapses during the early weeks have been recorded in very rare 
 instances, and second attacks are still rarer. Among the sequelae the spastic 
 contractions, dislocations, and deformities have been already mentioned. The 
 fragility of the bones makes them liable to fracture, but union takes place with 
 ordinary promptness under proper fixation. 
 
 Diagnosis. — In the early stages of fever, before paralysis has appeared, 
 the diagnosis is usually missed except under rare epidemic conditions, and the 
 termination of an apparently trivial ailment in extensive paralysis is frequently 
 the cause of much chagrin on the part of the medical attendant, who may have 
 expressed, naturally enough, a favorable prognosis. As already indicated, the 
 initial fever may be readily mistaken for that of general disorders, and some- 
 times, though rarely, the pain in the limbs leads to the idea of rheumatism. 
 If, however, the possibility of anterior poliomyelitis be in mind, and examina- 
 tion discloses some slight local tenderness or diminished muscular activity, or 
 both, a guarded opinion will naturally follow. It is only when the paralysis is 
 developed or is developing that the nature of the disease becomes certain, and 
 even now, if there have been cerebral symptoms, such as delirium or con- 
 vulsions, difficulties are not at an end. The cerebral palsy of children is 
 almost invariably ushered in by convulsions, but these have a definite distribu- 
 tion involving one side or one limb, or only the face, while the convulsions of 
 the disease under consideration are generalized. Localized pain from traumat- 
 ism or inflammation may cause immobility of a limb, and when preceded by a 
 fever gives rise to doubt; but the usual, indeed, almost invariable, absence 
 of extreme sensory troubles in disease of the anterior horns is a distinguishing 
 feature, while the local conditions can be otherwise made out. After a few 
 days the electrical test gives absolute data. Faradic response is abolished 
 in no other disease so early ; even in severe neuritis it is longer maintained, 
 and is then attended by a very marked sensory disturbance, which also usually 
 precedes it for a long time. A few careful applications of the induced current 
 at this period .can do no harm. Diphtheritic palsy presents the history of the 
 throat affection, and the involvement of the palate and muscles of visual accom- 
 modation is distinctive. 
 
 Prognosis. — As far as life is concerned, this disease terminates fatally very 
 exceptionally, and if the patient survives but a short time the onset of the 
 paralysis, life may be considered out of danger. Further, one can say with a 
 reasonable degree of certainty that the paralysis at first developed will notably 
 recede, but, unfortunately, it is equally certain that a portion of it will per- 
 manently remain. At the end of a fortnight a carefully conducted faradic 
 examination of the muscles enables the physician to speak more specifically 
 
794 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 regarding the amount of permanent disability. At that time any muscle which 
 responds, however feebly, may be expected to regain a fair degree of its former 
 tone and strength, while those that do not respond even to strong currents are 
 not necessarily beyond hope of slight improvement. Even after several months 
 faradic stimulation, at repeated intervals, of a, at first, perfectly inactive muscle 
 may develop some contractility, and this is of favorable import for the given 
 muscle. The extent of permanent paralysis governs the amount of resulting 
 contracture and deformity; and likewise the retardation of development of the 
 limb and of the bones is in similar relation. The anticipated amount of these 
 deforming conditions will have a bearing on the probable general activity 
 of the individual, his prospective physical health, and liability to fractures. 
 Finally, the outlook is modified by any cachectic state, as tuberculosis, rickets, 
 or syphilis. 
 
 Treatment. — Owing to the irregularities of the course of this disease in 
 various cases, and its natural tendency to improve up to a certain point, it 
 becomes a matter of great difficulty to estimate the value of any therapeutic 
 agent or mode of treatment. In the early stage, as soon as the diagnosis is 
 made — and that is usually as soon as the palsy is recognized — if fever still 
 continues there is good reason to suppose that antipyretic antiseptics like the 
 salicylates, or even bichloride of mercury, would do good. To the spine hot 
 applications can be made if the circumstances of the patient will assure their 
 intelligent and faithful employment ; otherwise they are worse than useless, and 
 very mild sinapisms can be more properly used. The child should be kept on 
 the side or face, and the affected limbs should be thoroughly enveloped in cotton- 
 wool to maintain the circulation and the nourishment of the muscles in the 
 parts laboring under diminished trophic influence. The use of stimulants like 
 strychnia or electricity while the lesion is active is to be strictly avoided; but 
 when the active process has come to a standstill — that is, ordinarily at the end 
 of a fortnight — the systematic use of electricity is one of the most important 
 measures. Its object, however, should be thoroughly understood, and some occult 
 influence on the central lesion or the peripheral nerves should not be expected 
 of it. Its usefulness consists in maintaining the nourishment and normal con- 
 tractility of the muscles which are temporarily deprived of their natural trophic 
 and motor control, so that, as the inflammation subsides and the widespread 
 inhibitory effect of the local lesion recedes, the central apparatus may find the 
 muscular periphery in the most favorable state to respond to its enfeebled 
 influence. For this purpose, as faradism is early abolished, the interrupted 
 galvanic current must be used, the slightest intensity being employed that will 
 cause a contraction, and care must be exercised not to unduly fatigue the mus- 
 cles. A dozen contractions at most should be elicited at one seance, and often 
 only one or two can be provoked by a strength of current that is bearable. 
 Care not to alarm the child is imperative, as a daily struggle will probably do 
 more harm than the electricity will do good. It is well to commence with dry 
 or wet sponges alone until the young patient is accustomed to . the manipula- 
 tion. As the muscles often react better and with less pain to the positive pole 
 than to the negative, it is well to have for the negative electrode a broad sponge 
 which can be placed on the sacrum or breast, and with a smaller positive sponge 
 the muscles can be exercised. Applications of galvanism through the cord are 
 quite useless, and even if such currents reached the lesion, which is doubtful, 
 their effect for good is questionable. 
 
 Later on, as faradic response returns in the muscles only slightly affected or 
 temporarily inhibited, this form of electricity is efficacious for the purpose of 
 local stimulation, and the presence of this reaction in any muscle is always, as 
 
ACUTE ANTERIOR POLIOMYELITIS. 795 
 
 already indicated, a gratifying circumstance. To entrust electrical treatment 
 to the parents, however intelligent they may be, is a mistake. 
 
 In the same way, local frictions and salt baths, warm wrappings, and mas- 
 sage are valuable measures which can be more rationally entrusted to parents 
 or nurses who take an intelligent interest in the work. The moment a group 
 of muscles weaken, the limb tends to assume an abnormal position, and it is 
 verv highly important to meet this tendency from the very first moment, even 
 in cases where there is every probability that the paresis will recede. It can 
 be easily accomplished by means of the warm wrappings, or even by the appli- 
 cation of light apparatus. There can be no question that recovering muscles 
 will find their task much easier if their proper relations have been maintained, 
 and unbalanced muscles will be much less liable to contractures if an artificial 
 balance has been provided and joint surfaces have not been altered by vicious 
 positions long maintained. 
 
 As soon as the permanent paralysis can be fairly well foretold, massage 
 should be especially directed to obviate the contractures and deformities that 
 ordinarily result, as indicated by the anatomical knowledge of the physician. 
 Stretching of the unopposed muscles by passive movements of the joints will 
 accomplish much, and the moment a tendency to contracture is perceived the 
 case becomes one for permanent mechanical appliances. The tendency to 
 equine talipes, for instance, can be met by a slight elastic cord from the toe of 
 a shoe to a band at the knee ; and more elaborate orthopaedic apparatus should 
 be employed at the knee and hip if required. These cases are, therefore, prac- 
 tically orthopaedic troubles from the very first. 
 
 Nearly all the improvement that is to take place in the muscles will have 
 developed by the end of the first year, and what is slowly gained subsequently 
 in this direction is quite independent of any treatment whatsoever. 
 
 The treatment of a late or neglected case is practically surgical. Short- 
 ened tendons may be cut and joints straightened. A resection at the knee is 
 sometimes of advantage to secure a straight limb instead of a useless contor- 
 tion or a dangle leg ; by using a high shoe or other appliance crutches may 
 often be laid aside. In some of these cases electricity also does good. 
 Though the first few applications to the paralyzed muscles may show no 
 response, slight contractions not infrequently appear later, and voluntary con- 
 trol soon follows — weak, to be sure, but in proportion to the amount of muscular 
 tissue undestroyed, and better by far than no motion whatever. 
 
 The local hypodermatic use of strychnia has had many advocates, not only 
 in these late cases, but also in the early treatment. As any results to follow 
 its use depend upon its stimulating action on the spinal centres and upon its 
 general tonic value, the hypodermatic method is, in the case of timid children, 
 the cause of useless pain and often of harmful mental excitement. 
 
 The arrangement of exercises to increase the strength of the involved 
 muscles which retain some fraction of their muscular elements is of distinct 
 advantage, and must be devised to meet the requirements of each case, but no 
 elaborate apparatus is necessary. By passive and active movements and effort 
 against resistance everything of this sort can be accomplished. Underlying 
 systemic conditions like rickets, rheumatism, syphilis, tuberculosis, and bad 
 hygenic surroundings of course require early and suitable attention. A fatty 
 dietary, and particularly cod-liver oil, is often distinctly valuable. 
 
 Subacute and Chronic Anterior Poliomyelitis. 
 
 Analogy to other febrile and inflammatory conditions would lead one to the 
 expectation of encountering subacute and chronic forms of poliomyelitis, but 
 
796 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 4. 
 
 there are many who apparently doubt their entity or classify such instances under 
 other headings. Though Gowers devotes several pages to these forms in the 
 latest edition of his Diseases of the Nervous System, the impression conveyed 
 is one of uncertainty as to their existence and discredit as to the cases reported 
 under this caption. Other recent systematic treatises make no mention of the 
 subject, except the description of the classic form of progressive muscular 
 atrophy of the spinal variety. Cases, however, are encountered presenting 
 every gradation between the sudden acute form and the pre-eminently chronic 
 variety which produces our dime-museum "living skeletons." 
 
 In some instances there is a gradually developed weakness in one or more 
 limbs, without or with an initial fever, and the palsy increases slowly for 
 
 several weeks. After a stationary 
 period of considerable duration it 
 recedes, and only a trace is perma- 
 nently left. In others the paralysis, 
 insidious in its onset, goes progres- 
 sively forward, involving limb after 
 limb and producing conditions in- 
 distinguishable, as regards gross ap- 
 pearances, from those of progressive 
 muscular atrophy. 
 
 Of the milder forms the follow- 
 ing case is an example : A child 
 of three, of healthy parentage and 
 living in fairly good surroundings, 
 active, bright, and lively in disposi- 
 tion, was noticed to have difficulty 
 in getting up and down the stairs. 
 Two weeks later she was unable to 
 rise from the floor except by draw- 
 ing herself up with the aid of her 
 hands ; she could not walk, and the 
 lower extremities would quickly give 
 way under her. The hands and arms 
 then became slightly affected. A 
 month later the symptoms commenced to recede, and, a year after, nothing was 
 left but a little wasting of the anterior tibial muscles with slight quantitative 
 electrical changes. There has been no absolute loss of faradic excitability at 
 any time, no pain and no tenderness. 
 
 Of the chronic forms, the case figured in Fig. 4, from a photograph, is an 
 instance : A boy of fourteen years, with no family or personal history of sig- 
 nificance, at the age of six had an attack of "malarial fever" (?) lasting 
 several weeks, and then could not use his legs or even stand. He gradually 
 improved and after a year was quite active, when his muscular power again 
 became impaired in the legs. Atrophy and weakness have steadily progressed 
 to the trunk, neck, and upper extremities, with numerous contractures. He 
 is able, however, to use a bicycle and get about on crutches. Many muscles 
 fail to respond to all currents, some show only quantitative changes, and some 
 comparatively recently affected show the reaction of degeneration. 
 
 Perhaps some cases of pseudo-hypertrophic paralysis should be classed in 
 this place. 
 
 Diagnosis. — From neuritis the distinction is confessedly difficult, especially 
 from that variety of neuritis which involves mainly the motor filaments, and 
 
 Chronic Anterior Poliomyelitis. 
 
ACUTE ANTERIOR POLIOMYELITIS. 797 
 
 is not marked by the dysesthesia and sensory difficulties, usually of importance 
 and prominence in the history and differentiation of the peripheral disease. It 
 is not unlikely that many reported cases of subacute poliomyelitis have been 
 mistaken in this way. 
 
 Treatment is practically futile in the progressive form, but those measures 
 which commend themselves in chronic myelitis should be faithfully tried, and 
 local measures, such as vigorous massage and electricity, have produced tem- 
 porary improvement. In the subacute variety these measures seem to be 
 distinctly productive of good, and what has been said of the prevention of 
 contractures and deformity in the acute form of cornual disease may be 
 reiterated. 
 
LANDRY'S PARALYSIS 
 
 By ARCHIBALD CHURCH, M. D., 
 
 Chicago. 
 
 The obscure paralysis known, since Landry's description of it in 1859, by 
 his name, and designated "acute ascending paralysis" by English writers, 
 while presenting a striking clinical entity in typical cases, shades off materially 
 from early descriptions in many instances more lately observed. It may be 
 roughly described as an acute disease marked by paralysis commencing in the 
 lower extremities, usually in the feet, which progresses steadily upward, involv- 
 ing the trunk, upper extremities, the neck, until finally deglutition, respiration, 
 and the heart are implicated. There is slight or no modification of sensation ; 
 the muscles do not rapidly waste nor usually lose their electrical excitability and 
 myotatic response; the sphincters are exempt; bed-sores do not occur; and 
 the temperature is frequently normal throughout the attack. In cases that 
 recover the parts last and least affected soonest regain power, and improve- 
 ment, therefore, extends from above downward. Fatal cases terminate by 
 respiratory or cardiac failure in from one to two weeks. 
 
 Etiology. — The causation of Landry's paralysis is practically unknown. 
 It occurs in men more frequently than in women, and most frequently be- 
 tween the ages of twenty and forty. In children it has been recognized very 
 rarely. It is known to follow infectious diseases which are provocative of neur- 
 itis. Exposure to cold, and very rarely trauma, alcoholism, and syphilis, 
 have preceded it. 
 
 Pathology . — In some well-marked cases the most thorough examination 
 of the cerebro-spinal apparatus by competent pathologists has failed to discover 
 the slightest abnormality. Several cases have presented a diffuse myelitis; 
 one or two, a cross-myelitis ; a few, well-marked neuritis, and some have shown 
 changes both in the spinal cord and in the peripheral nerves. No constant 
 lesion is present. In some instances there has been pronounced swelling of the 
 spleen, pancreas, and mesenteric glands. 
 
 The frequent lack of anatomical findings, the onset and course of the dis- 
 ease, its relations to antecedent infectious maladies, such as typhoid, small-pox, 
 influenza, etc., and its close resemblance to multiple peripheral neuritis, with 
 which, indeed, a large number of observers consider it identical, lead to the 
 almost positive conviction that it is the result of some infection or toxine. 
 Bacteriological investigation has thus far been inconclusive, though highly 
 suggestive. 
 
 Symptoms. — Generally without malaise, fever, or premonitory symptoms, 
 usually without tingling, numbness, or other sensory disturbance, a feeling of 
 weakness begins in the feet and legs, and slowly creeps upward, becoming more 
 and more pronounced in the lower levels as the disease mounts. At the end of 
 two or three days or a week the lower extremities are completely paralyzed and 
 the weakness has involved the trunk and upper limbs. The breathing becomes 
 
 798 
 
LANDRY'S PARALYSIS. 799 
 
 superficial from involvement of the diaphragm, and difficulty of swallowing 
 soon appears. In severe cases every voluntary muscle below the face is com- 
 pletely paralyzed and relaxed. Cerebral and mental symptoms are absent 
 until the dyspnoea or cardiac failure is pronounced and induces them. The 
 sphincters are, as a rule, not relaxed ; there is no tendency to bed-sores or dys- 
 trophy ; the tendon and superficial reflexes are usually present ; the electrical 
 responses are normal ; and sensation, together with the special senses, is not 
 perverted. If a fatal issue do not occur, the symptoms of paralysis slowly 
 recede in the reverse order of their appearance, and when they have distinctly 
 subsided from the upper levels recovery may be anticipated. 
 
 In some cases the onset is reversed, the upper extremities first showing 
 weakness ; and, indeed, the ordinary type may be infinitely modified, as can be 
 readily understood from the varying anatomical distribution of the organic 
 lesions in well-authenticated observations. In one case falling under the 
 writer's attention, where the clinical history was typical, complete wasting of 
 isolated muscle-groups in all four extremities occurred, and was persisting four 
 years later, without any appearance of ultimate improvement. Paresthesia and 
 dysesthesia are not rare. Loss of reflexes has been noted. The progress of 
 the paralysis may stop at any point, and then recede. A temperature of 101° 
 to 103° F. has been rarely observed, but as a rule it does not rise above the 
 normal. 
 
 Course. — The course from inception to fatal termination may be very brief, 
 less than two days, and fatal cases usually end within ten days. Prolonged 
 cases may only reach their acme in a month. After a stationary period of vary- 
 ing length in the hopeful cases, improvement takes place usually in a retreat- 
 ing order, but convalescence is slow and may require months. On the other 
 hand, it may be rapid, or, as in the case mentioned above, permanent injury 
 may result. 
 
 Diagnosis. — The diagnosis in some cases must necessarily be extremely 
 difficult, but in the typical form is readily made, providing the existence of this 
 rare disease is kept in mind. It rests upon the method of invasion, the pure 
 motor paralysis, the negative conditions as to reflexes, sensation, and electrical 
 reactions, and the history of some possible toxemic state. Some cases are com- 
 plicated by hysteria, which is capable of greatly obscuring the diagnosis. When 
 slight electrical changes and paresthesia are present, it is impossible to exclude 
 neuritis, and the integral character of the peripheral disease in some instances 
 has already been pointed out. In general myelitis we have all spinal cord- 
 functions involved. In meningitis the pain and rigidity are distinctive. 
 
 Prognosis should always be grave, since even in the irregular and pro- 
 longed cases one cannot foretell at what moment bulbar symptoms may appear, 
 and the main danger to life depends on their presence. Rapidly-ascending 
 symptoms imply a speedy termination, but there is no invariable rule. Only 
 when the tide has turned and symptoms are receding can one entertain a rea- 
 sonably hopeful prognosis. The presence of neuritic conditions or of electrical 
 changes implies a prolonged convalescence and some doubt as to ultimate recov- 
 ery. Where cerebral symptoms appear, they are of bad import, signifying 
 either profound toxic conditions or the near approach of death from cardiac 
 and respiratory failure. 
 
 Treatment will be directed against any general toxic condition present or 
 reasonably suspected. The salicylates, tincture of the chloride of iron in full 
 doses, bichloride of mercury to the point of toleration, thorough cleansing and 
 disinfection of the alimentary tract, supportive diet, conservation of nervous 
 energy and strength, are valuable. To the spine a narrow sinapism the whole 
 
800 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 length of the back, frequently repeated, is of service ; even the thermo-cautery 
 is advised by some. Full and frequent doses of ergot or ergotine have strong 
 advocates. The paralyzed limbs should be gently massaged to improve circu- 
 lation and give comfort. When swallowing becomes difficult or impossible, feed- 
 ing by the stomach, nasal, or rectal tube must be adopted, and the preference 
 is for the nasal tube, providing care be exercised to avoid passing it into the 
 larynx. During convalescence massage, electricity, local douches, tonics, 
 generous diet, and general measures are the main reliance. 
 
TUMORS OF THE SPINAL CORD. 
 
 By JAMES HENDRIE LLOYD, A. M., M. D., 
 
 Philadelphia. 
 
 Under the head of Tumors of the Spinal Cord will be considered tumors 
 not only of the cord itself, but also of its enveloping membranes. The latter 
 are the most common. Tumors originating in the bones of the spine, if they 
 make pressure upon the cord, are very similar clinically to tumors of the mem- 
 branes, but they are exceedingly rare. 1 
 
 Tumors of the spinal cord and its membranes are comparatively rare at all 
 ages, but they are not unknown among children. Thus in a table of 50 cases 
 of cord-tumors analyzed by Dr. Mills and the author, 14 per cent, were in 
 patients under twenty years of age. Four were in the first decade of life, and 
 three in the second. 
 
 Etiology. — The causation of tumors of the spinal cord is usually very obscure, 
 just as it is for tumors of other parts of the body. The nature of these growths, 
 as will be seen, varies, and the causes that produce them vary as well. Syph- 
 ilitic and tuberculous tumors are of course caused by their respective infections 
 in the blood and tissues. Carcinomata and sarcomata have here, as elsewhere, 
 a totally unknown essential cause. Gliomata and myxomata are equally obscure 
 in origin. The gliomata originate always in the neuroglia, and are probably 
 the product of a proliferation of germinal tissue which has remained in an 
 embryonal state. They are most apt to occur in the central gray matter and 
 in the posterior gray commissure in the neighborhood of the central canal. In 
 this region they break down and form cavities to which the term "syringomye- 
 lia" is applied. As this process is now recognized as a distinct disease, it has 
 been described apart. Other cysts, simulating tumors, may be caused by small 
 haemorrhages, and possibly by emboli. Parasitic growths, such as echino- 
 coccus, have been found in the spinal cord. 
 
 As a direct exciting cause trauma has been regarded by many as not infre- 
 quent. Where there is predisposition to a cancerous growth or a syphilitic 
 deposit it is possible that trauma may so act. Exposure to cold, sexual excess, 
 and overwork have probably nothing to do with the origin of tumors of the 
 cord. 
 
 These growths are apparently about equally divided between the sexes. In 
 the table already referred to it is seen that 22 cases occurred in males, 21 in 
 females, and in the remaining 7 the sex is not recorded. 
 
 Symptoms. — The symptoms of tumors of the spinal cord may be con- 
 veniently classified according as they are sensory, motor, trophic, visceral, and 
 intracranial. They may then be grouped according to the level of the cord at 
 
 1 Mr. Wright of Manchester removed a fibro-sarcoma of the neck which had invaded the 
 spinal canal by way of one of the intervertebral foramina, causing pressure symptoms. ^Reported 
 by Thorburn, Surgery of Spinal Cord, p. 168.) 
 
 51 SOI 
 
802 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 which the tumor occurs. This twofold plan will be adopted here for the sake 
 of both clearness and brevity. Finally, a comparative study of symptoms will 
 be made under a separate head for the purposes of diagnosis. 
 
 It is doubtful if a distinction can always be made in diagnosis between 
 the meningeal and medullary growths. In some cases, however, this may be 
 possible. The tumors springing from the membranes are more likely to cause 
 pain as an initial and persistent symptom than are tumors within the substance 
 of the cord. They cause pressure symptoms later. It is probable, too. that 
 the early symptoms caused by them are more distinctly local, because they 
 press upon and irritate or destroy a comparatively small area of the cord at 
 first. 
 
 The sensory symptoms of all tumors of the cord and its membranes are 
 sooner or later conspicuous. Pain, as has just been said, is common. This 
 pain may be limited in the early stages to one or few nerve-trunks, in one of 
 the limbs or in the abdomen, for instance, simulating neuralgia, or it may 
 radiate from the spine in association with stiffness of the muscles of the neck 
 or back. It is often an urgent and distressing symptom. Hyperesthesia, 
 which is closely allied to pain, may appear in the course of the disease. In 
 cases in which the lesion is unilateral this hyperesthesia may exist in the 
 paralyzed side: in other cases its distribution is variable and its duration 
 uncertain. Hyperesthesia, and especially pain, may exist along the spinal 
 vertebrae, and localized pain may sometimes be elicited by tapping vigorously 
 on the spine at and near the seat of the tumor. Paresthesia, or perverted 
 sensibility — as, for instance, burning and pricking sensations and formication — 
 is closely allied to hyperesthesia, and may appear like it, especially in the early 
 and middle stages. 
 
 Anesthesia is a very common symptom of these tumors, yet the time of its 
 appearance, as well as its distribution, varies greatly according to the site and 
 progress of the neoplasm. As with pain, its early distribution may be quite 
 limited; for instance, it may be confined to the area of distribution of one 
 or few nerve-trunks or to one limb. This limitation of the early symp- 
 toms, whether motor or sensory, is a characteristic of these growths. The 
 anesthesia may be associated with pain in the affected area — the anoesthesia 
 dolorosa. In the later stages of the disease the anesthesia is more widely 
 extended, and may be profound. Thus it is often complete in the trunk and 
 limbs below the seat of the tumor. Thermo-anesthesia may be observed in some 
 forms of cord-tumors: perhaps it would have been oftener reported if it had 
 been oftener looked for. In the central gliomata, especially when they form 
 cavities, as in syringomyelia, anesthesia to heat and cold is a common symp- 
 tom ; it is then associated with analgesia, while tactile sensation is preserved, 
 thus forming a "dissociation" symptom which is quite characteristic. This 
 thermo-anesthesia is probably not a common symptom of meningeal growths ; 
 in fact, it is doubtful if it ever appears as a result of them, especially in this 
 dissociation. Analgesia, or loss of pain-sense, may be seen in some cases of 
 tumor of the cord. It may be associated, as above noted, with loss of tem- 
 perature-sense, or it may exist alone. It is always an accompaniment of pro- 
 found anesthesia. 
 
 A not uncommon symptom is the girdle-sense. This consists of a feeling 
 of constriction, as of a cord tied around the part. Its location varies with the 
 seat of the tumor. Thus it may be felt around the neck, chest, waist, or abdo- 
 men, and a rare case is reported in which it was felt even in the legs. 
 
 The motor, like the sensory, symptoms of tumors of the spinal cord vary 
 in kind and extent according to the seat and stage of growth of the lesion. 
 
TUMORS OF THE SPINAL CORD. 803 
 
 Like them, too, they are apt to be very limited when they first appear, and to 
 gradually extend. This mode of appearance and extension is very character- 
 istic of a neoplasm at some point in the spinal canal. The earliest motor 
 symptom may be a paresis or a cramp of the muscle, or these may alternate or 
 exist at the same time. Paresis may be limited at first to a muscle-group, 
 whence it may gradually extend to involve a limb or the limbs of one side or 
 both lower limbs. Before, however, it has spread thus far, it will most prob- 
 ably have deepened into a paralysis. When this paresis has well advanced, 
 contractures in the affected muscles appear. These contractures distort the 
 limbs, and often become so firmly set that they can be overcome only with great 
 difficulty, and perhaps only with great pain to the patient. The tone of the 
 muscle and the state of its reflex activity to a tap on its tendon vary accord- 
 ing to whether its centre in the cord is involved in, or is below the seat of, 
 the tumor. In the former case the muscle is flaccid and its reflex lost, while 
 in the latter case, the centre in the cord being cut off from the inhibitory 
 centre in the brain-cortex, the myotonus and the tendon reflex are much 
 exaggerated. 
 
 Muscular atrophy may be caused by tumors of the spinal cord, according 
 to the well-known pathological law that a muscle wastes when its trophic centre 
 in the cord is destroyed. Hence in cases of these tumors the atrophy usually 
 occurs in limited muscle-groups, or in one limb, or possibly in both arms if 
 the cervical enlargement is affected, or in both legs if the tumor is in the lum- 
 bar enlargement or cauda equina. Hence a not uncommon type of motor dis- 
 order is seen in cases of tumor of the cervical region ; in which cases, the 
 trophic centres in the anterior horns being destroyed, a muscular atrophy in the 
 arms results, while, the descending motor paths in the lateral columns being 
 injured, a spastic paresis, without atrophy, but with increased knee-jerks and 
 with ankle-clonus, is seen in the legs. When the process in the cord is rapidly 
 destructive, the atrophied muscles present very soon, as a rule, changes in 
 their electrical reactions. During the very early stage, or stage of irritation, 
 the electrotonus may be increased to both currents, but sooner or later this is 
 diminished, while modal changes occur ; and in very rapid or advanced cases, 
 in which the anterior horn has been quickly destroyed, the true reactions of 
 degeneration may occur. In slowly progressive cases, in which the horn is 
 destroyed very gradually, the qualitative changes may not appear in a typical 
 manner. 
 
 Spasms, twitching, and contractures of the affected muscles are frequently 
 seen. Cramps in the back and limbs are sometimes complained of. Con- 
 tractures, as already said, are usually secondary to advancing paresis. Fib- 
 rillary contractions, so common in progressive muscular atrophy, are rarely seen : 
 in the table of fifty cases referred to they are mentioned only once. Epileptic 
 convulsions do not occur. In the only case to which the author has a reference 
 the fit must have had some origin not recognized. Tetanoid cramps and 
 spasms, opisthotonos, torticollis, and scoliosis are all symptoms which may arise 
 in the course of tumors of the spinal cord. 
 
 .Ataxia is not a common symptom of these tumors. This may be because 
 tumors occupying the exact region of the lesion of locomotor ataxia — i. e. the 
 posterior columns, horns, and root-zones — must be exceedingly rare. 
 
 Various trophic lesions may occur. These lesions are identical with those 
 caused by other affections of the spinal cord producing transverse or exten- 
 sive destruction. The most important are bed-sores. These bed-sores may be 
 attended in time with septic infection of the blood, and thus cut short the 
 patient's life. Other trophic lesions are oedema, glossy skin, maculae, and 
 
804 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bronzing of the skin, and perhaps in some cases more destructive lesions. 
 Vaso-motor involvement has been noted by some observers. Flushing of the 
 skin and excessive sweating are among these phenomena. Alterations in tem- 
 perature in the paralyzed parts occur. The most common permanent alteration, 
 especially when paraplegia is complete, is a slightly subnormal temperature. 
 Early in the case the more paralyzed parts may present an increase in tem- 
 perature. 
 
 The visceral symptoms of tumors of the spinal cord depend to some extent 
 upon the location of the growth. The most common is paralysis of the blad- 
 der. It is the most common because the centre for the bladder is low in the 
 cord, and consequently is cut off from volitional control by tumors at almost 
 all levels. When the tumor is in the lumbar enlargement the centre for the 
 bladder may be destroyed, causing complete paralysis, both direct and reflex, 
 of the viscus. When the tumor is above this level, however, the reflex irrita- 
 bility of the bladder may be retained for a while. In the former case retention 
 is much the more common ; in the latter, incontinence. Later, in all cases, 
 retention, with overflow, is apt to be the rule. Paralysis of the sphincter ani 
 is caused in exactly the same way as that of the bladder. 
 
 In lesions in the cervical region embarrassed breathing and rapidity of the 
 heart's action may occur. Choking sensations are sometimes experienced. 
 Vomiting is not a common symptom. 
 
 Intracranial symptoms are, from the very nature and seat of the growth, 
 not common in tumors of the spinal cord, but they are not unobserved. Vertigo 
 has been recorded in one case in which the tumor was high in the cervical 
 cord. Changes in the optic disk have also been seen in similar cases. Head- 
 ache is noted in only three instances in the table of fifty cases already referred 
 to. Alteration in the pupil might be caused by paralysis or irritation of the 
 sympathetic centre in the cervical cord. Mental symptoms are not caused by 
 tumors in the spinal canal except as secondary phenomena due to pain, weak- 
 ness, and abandonment of hope. 
 
 Among other secondary symptoms are cystitis and pyelo-nephritis. Priapism 
 has been reported in a few cases. 
 
 Tumors of the spinal cord present several clinical types according to the 
 area and the level occupied by the new growth. In some cases in the early 
 stages one lateral half of the cord is first and most involved. Such a case 
 presents the type first described by Brown-Sequard. 1 There are paralysis and 
 loss of muscular sense, with hyperesthesia, on the side of the lesion, and 
 anaesthesia, and possibly analgesia, on the opposite side. This distribution 
 depends on the fact that some of the sensory fibres decussate at or about the 
 level of their entrance into the cord. A notable absence of sensory symptoms 
 occurred in a patient of the author's. A carious spot in one of the* cervical 
 vertebrae caused hemiplegia without any sensory involvement whatever. The 
 case exactly resembled hemiplegia of cerebral origin. An operation was per- 
 formed by Dr. Deaver. 
 
 Other types depend upon the level of the cord at which the tumor occurs. 
 The favorite sites for these tumors are the cervical and lower dorsal regions. 
 Of the 50 cases in Mills and Lloyd's table, 22, or almost one-half, were included 
 entirely or in part in the cervical cord ; 4 were in the upper dorsal region ; 12 
 
 1 The author gives a place in the text to a description of this tvpe, although he knows that 
 recent experiment throws much doubt upon the accuracv of the claim to anv such clinical find- 
 ings. Thus Gotch ("Recent Research on the Spinal Cord," Liverpool Med.-Chir. Journ., Jan., 
 1893) says: "Recent physiological research shows that, in opposition to the views formerly 
 advocated by many neurologists ; the path for sensory conduction is almost entirely on the same 
 side as that of the entering sensory nerves." 
 
TUMORS OF THE SPINAL CORD. 805 
 
 in the lower dorsal ; and of the remainder, 4 were in the lumbo-sacral region, 
 3 in the filuni terminale and cauda equina, and the rest were of doubtful 
 location or nature. 
 
 The type presented by a cervical tumor is often quite characteristic. Pain 
 is located in the neck, arms, and upper part of the back. Torticollis or retrac- 
 tion of the head may occur. Anaesthesia is variously distributed according 
 to the region most involved. The anterior cornua, entire or in part, on one 
 or both sides, may be destroyed, and consequent atrophy of muscles in the 
 arm or arms, with altered electrotonus, may be observed. Paraplegia, begin- 
 ning perhaps as crural monoplegia, is sure sooner or later to appear ; and 
 this is of the spastic type, with increased knee-jerks and ankle-clonus, but 
 without muscular atrophy in the leg muscles. Complete anaesthesia in the 
 trunk and legs supervenes ; paralysis of the bladder and bed-sores complete 
 the picture. 
 
 Tumors in the dorsal region present the type of a simple transverse lesion 
 slowly advancing to paraplegia and anaesthesia, with bed-sores, incontinence, 
 and cystitis, but without involvement of the neck and arms. The signs of 
 irritation, such as neuralgic pains, girdle-sense, and zone of hyperaesthesia at 
 the level of the growth, are sometimes very characteristic. Dyspnoea, due to 
 partial paralysis of respiration, may be caused by tumors in the cervical and 
 upper dorsal region. 
 
 Tumors in the lumbar region and in the cauda equina give a still dif- 
 ferent type, depending upon the fact that the trophic cells in the anterior 
 horns, the anterior nerve-roots, and the nerve-trunks are implicated. Hence, 
 in addition to paraplegic symptoms and neuralgic pains about the lower part of 
 the trunk and in the legs, there may be muscular atrophy, reactions of degen- 
 eration, and abolished tendon-reflexes in the legs, and possibly an irregular dis- 
 tribution of anaesthesia in areas supplied by nerve-trunks in the cauda equina 
 most involved. Moreover, the reflex centre for the bladder in the lumbar 
 cord being destroyed, obstinate retention, with overflow, may occur. In tumors 
 limited entirely to the cauda equina the symptoms are simply those of neu- 
 ritis — i. e. neuralgic pain, often intense, anaesthesia, muscular atrophy with 
 reactions of degeneration, abolished reflexes, and paralysis. The distribution 
 of these symptoms will depend entirely upon the distribution of the nerves 
 implicated. This distribution may be very irregular, and by this irregularity 
 constitute a distinct type. Paralysis of the bladder may occur in these cases. 
 
 Morbid Anatomy. — According to the table already referred to, the most 
 common forms of tumor of the spinal cord are the sarcomata and the structures 
 allied to them. Thus, of 50 cases, 12 are described as sarcomata and gliomata ; 
 9 are distributed in the list among myxomata, psammomata, and fibromata, of 
 which number it is fair to assume that some at least were structurally similar 
 to the sarcomatous type ; while of the 2 described vaguely as " cancer," and of 
 the 6 unclassified, a proportion would probably have been found to be sarcoma 
 or glioma on more exact observation. Carcinoma occurred but once, parasitic 
 growths three times. Syphilitic growths were found in 5 cases, massive tubercle 
 in 4. 
 
 Dr. Herter, in a contribution to the pathology of solitary tubercle of the 
 spinal cord, has analyzed 26 cases. His study shows that the affection is a 
 disease of adolescent and early adult life, 20 of these cases occurring before 
 the age of thirty-five. In all but one the massive tubercle was solitary. In 
 most of the cases tubercular disease existed in other parts of the body and 
 antedated the cord lesion. Hayem, however, quoted by Herter, reported a 
 case which he regarded as primary. 
 
806 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 Secondary lesions are usually found in cases of tumors of the spinal cord. 
 Meningitis and oedema of the membranes, also inflammatory exudate, are occa- 
 sionally noted. The cord is usually compressed, its substance softened both 
 above and below the tumor. Secondary degeneration occurs in the system- 
 fibres of the cord. Haemorrhages have been observed. Cysts may be formed, 
 or the central canal may be dilated (hydromyelia). Gummata and carcinomata 
 have caused erosion of the vertebrae. 
 
 Diagnosis. — Tumors of the spinal cord may be confused with haemor- 
 rhage, pachymeningitis, transverse myelitis, spinal caries, fractures of the 
 vertebrae, neuritis, and hysteria. 
 
 Haemorrhage into the spinal canal or spinal cord, unless the result of 
 violence, is extremely rare. When it happens from diseased blood-vessels it is 
 very sudden, and the symptoms attain almost at once their maximum of inten- 
 sity. Compression and destruction of tissue may be sufficient to cause para- 
 plegia in a few hours. It is possible that some of the early symptoms, due to 
 compression, might abate in time, and that the permanent results would be 
 focal with secondary degenerations. The usual result, however, is death. 
 
 Pachymeningitis, especially in the cervical region, is very difficult to distin- 
 guish from a tumor. It causes, perhaps, on an average, more acute pain and 
 stiffness in the neck than does tumor, and it is more widely distributed in 
 vertical extent. 
 
 Transverse myelitis also closely simulates tumor. In some of these cases 
 the lesion is very limited in vertical extent. The onset of myelitis, however, 
 is not usually so gradual as that of tumor, and this is probably the best dis- 
 tinguishing point. Another distinction is the degree of pain. In myelitis 
 pain is sometimes not very severe. Cases are seen in which the girdle-sense 
 and a zone of hyperaesthesia are the nearest approach to it. The writer has 
 seen also white softening of the cord, very limited and entirely transverse, 
 cause symptoms very similar to transverse myelitis, the absence of pain being 
 very conspicuous. 
 
 Spinal caries in its early stages may resemble a tumor, but the cases must 
 be very rare in which a deformity of bone cannot be detected comparatively 
 soon. As a rule, pressure-symptoms do not appear until long after the defor- 
 mity is apparent. 
 
 Fractures of the spinal vertebrae are indicated by the history, even though 
 deformity is not very apparent, as is sometimes the case. It is not probable 
 that confusion could often arise between this, or any other form of trauma in 
 which the history were known, and tumor. 
 
 Neuritis might simulate a neoplasm in some cases ; in fact, neuritis is one 
 of the symptoms of tumor of the spinal cord. When it is caused, however, by 
 a tumor within the spinal canal, it is not likely to be the only symptom ; thus 
 evidence of compression is soon made manifest. Multiple neuritis is not apt to 
 be confined to the arms : in a case in which it were, compression symptoms in 
 the legs would be wanting. If confined to the legs, it would not cause para- 
 plegia with involvement of the bladder, etc. But such a distribution of mul- 
 tiple neuritis is rare. It is usually apparent in both arms and legs, in which 
 case confusion with tumor is hardly possible. 
 
 It is customary to say that hysteria simulates all diseases, but this state- 
 ment is based upon superficial observation. Blocq is nearer the truth when he 
 says that hysteria does not simulate any disease perfectly — that there is always 
 something wanting. To detect this missing element is often the rather easy 
 forte of the expert. No rule can be given in brief space. It may be said, 
 however, that the symptoms most dependent upon organic change are most apt 
 
TUMOBS OF THE SPINAL CORD. 807 
 
 to be wanting in cases simulating tumor or other organic disease of the cord ; 
 excessive knee-jerks, very free ankle-clonus, muscular atrophy, and the reac- 
 tions of degeneration are not usually seen. In fact, the latter two symptoms are 
 never seen. But more important even than to detect the negative evidence is 
 to observe the positive symptoms of hysteria itself. These are the so-called 
 stigmata, which in probably all cases simulating grave organic disease can be 
 detected. Among these stigmata are hemianesthesia, including the special 
 senses, concentric narrowing of the visual fields with alteration of the color 
 fields, segmental anaesthesia in paralyzed limbs, tremor, and convulsive phenom- 
 ena. Transfer and suspension of symptoms by suggestion (hypnotism) may be 
 obtained. The mental stigmata, emotional, lethargic, etc., are often charac- 
 teristic. 
 
 Prognosis. — The prognosis of tumors of the spinal cord is not quite so bad 
 as formerly, because, in some cases at least, surgery may come to their relief. 
 The success of surgery will depend primarily, of course, upon the successful 
 localization of the growth and upon its situation at an accessible part of the 
 spinal canal. Even then some permanent damage may have been done by the 
 neoplasm before its removal. The prognosis, if dependent upon treatment by 
 drugs, is uniformly bad. No exception to this rule can be made in favor of a 
 syphilitic tumor, because syphilitic lesions large enough to be called tumors are 
 not, in the author's experience, removable by such means. 
 
 The duration of these cases varies. Some cases are rapidly fatal, last- 
 ing only a few months ; others are reported as lasting for more than three 
 years. 
 
 Treatment. — As has just been said, treatment by drugs offers no hope in 
 any case of tumor of the spinal cord. While we believe that the syphilomata are 
 no exception to this rule, we should, nevertheless, give the patient very active 
 antisyphilitic treatment if he had a clear history of syphilis. We should do 
 this in the hope that the lesion were not truly a tumor, but rather a more dif- 
 fused process, such as pachymeningitis, and that it had not yet irreparably 
 damaged essential portions of the cord. When the syphilitic neoplasm has 
 become sufficiently massive to be worthy of the name of tumor, it has usually 
 produced, and will continue to produce, such destruction of the nerve-elements 
 that repair on the one hand, and arrest on the other, cannot be obtained by 
 drugs. The writer says this from personal experience, not exactly with syphi- 
 litic tumors of the- cord, but with their congeners, meningeal gummata within 
 the skull. In several cases, in which progressive erosion of the bone occurred, 
 no perceptible influence was exerted by the so-called specifics. 
 
 Surgery offers the only rational treatment of these cases, but this remedy 
 must be used with rare caution after the most painstaking diagnosis, and with 
 the clear understanding that success may not be obtained. The following points, 
 according to Thorburn, must be considered in all spinal lesions : First, the cura- 
 bility without operation ; second, the dangers of the operation ; third, disas- 
 trous results, such as weakening of the vertebral column ; fourth, the selection 
 of appropriate cases. In the case of a spinal tumor it may be said, in reference 
 to these four points, that, first, the case is not curable without operation ; 
 second, that the dangers of the operation are not so great as the risk of going 
 without it ; third, that the spine would not be weakened seriously, except in 
 the very rare event of extensive erosion ; and, finally, that the selection of 
 appropriate cases depends entirely upon the successful diagnosis and localiza- 
 tion of the tumor at as early a stage of its growth as possible. Hence, the 
 operation is not only advisable, but, it would seem, in properly selected cases, 
 imperative. Tumors of the spinal cord have been successfully localized and 
 
808 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 removed. Such an operation was performed by Mr. Horsley on a man with 
 myxofibroma in the upper dorsal cord. The symptoms were complete para- 
 plegia, motor and sensory, of slow development, accompanied with attacks of 
 agonizing pain. Although degeneration of the lateral pyramidal tracts had 
 existed, as shown by intense spastic paraplegia, every indication of this is 
 reported by Dr. Gowers to have since passed away. 
 
 In cases in which, for any reason, surgery is declined or ignored, and 
 exclusive reliance is placed upon other treatment, the most important, and, in 
 fact, only useful, means to give comfort to the patient are the water-bed and 
 opium. Antiseptic treatment of bed-sores is important. 
 
SYRINGOMYELIA. 
 
 By JAMES HENDRIE LLOYD, A. M., M. D., 
 
 Philadelphia. 
 
 Syringomyelia is a disease of the spinal cord, characterized by the growth 
 of a gliornatous tissue, which breaks down and forms a cavity, usually in the 
 mid-region of the gray matter. 
 
 Syringomyelia has been recognized within only a comparatively recent 
 period. The word was coined by Ollivier in 1837, and applied by him to all 
 canals or cavities in the cord. Every such canal or cavity was considered 
 pathological until Stilling demonstrated the normal central canal. Virchow 
 and Leyden used the word " hydromyelia " to designate cavities in the cord, 
 which they claimed were always dilatations of the normal central canal. 
 Simon, in 1875, pointed out the pathological process which interests us here. 
 He demonstrated that cavities, quite apart from the central canal, may occur 
 in the cord in the midst of a newly-formed gliornatous tissue by the breaking 
 down of which they are caused. He proposed to reserve the term " syringo- 
 myelia" for this special form of cavity; and this specialization is now accepted 
 by most writers. Syringomyelia therefore has come to be regarded as the pro- 
 duct of a gliomatosis. The word "hydromyelia," on the other hand, may be 
 restricted to the dilatation of the central canal, which happens occasionally as a 
 secondary phenomenon in various cord lesions, and which is different, both 
 anatomically and clinically, from true syringomyelia. 
 
 Of late years a quite voluminous literature of syringomyelia has grown up. 
 Among monographs we may note especially that of Bruhl, which brings the 
 subject quite up to 1890. Since that time some reports of cases, proving 
 the accuracy of the symptomatology of the disease, as verified by the post-mor- 
 tem findings, have appeared. 1 Doubt lingered in the minds of many for a 
 long time whether syringomyelia could justly be regarded as a disease-entity, 
 but these accumulating observations in very recent years must effectually 
 silence all criticism. 
 
 Etiology. — Syringomyelia is much more common in males than in females. 
 Bruhl found the proportion as 28 to 8. Roth is reported as saying that 
 the disease is three times more common in males than in females. 
 
 The disease appears usually at a comparatively early age. Charcot, quoted 
 by Bruhl, says that the first manifestations appear between the fifteenth and 
 twenty-fifth years. In some cases the time of the d£but of the disease is uncer- 
 tain. The author's case was in a male, and appeared first about the twenty- 
 seventh year. 
 
 From the above facts it is seen that syringomyelia, while not exactly a dis- 
 ease of childhood, is usually a disease of adolescence or early adult life. It 
 
 1 See report of a case by the author, with photographs of sections of the spinal cord, Univ. 
 Med. Mag., Philada., March, 1893. 
 
 309 
 
810 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 probably has close affiliations with at least one well-recognized disease of child- 
 hood — viz. hereditary ataxia or Friedreich's disease. 
 
 Traumatism and exposure to cold seem to have been exciting causes in some 
 cases. The infectious diseases also have appeared to be the starting-point. 
 
 Syphilis and alcohol do not seem to be causes of this disease. 
 
 According to Bruhl, syringomyelia is a disease probably of evolution, a 
 congenital affection having its origin in an anomaly of development of the epen- 
 dyma. We shall refer to this subject again. 
 
 Pathology. — Cavities in the cord, as already said, are the results probably 
 of several pathological processes. Thus they may be formed by the dilatation 
 of the central canal, this dilatation being an accompaniment of some other 
 morbid state, such as inflammation, haemorrhage, or neoplasm. They result 
 sometimes perhaps from small haemorrhages into the substance of the cord. 
 Some recent authors, notably Hoffmann, still classify all these varieties, and 
 make, as it were, one general group of them. We believe this is wrong. Most 
 of such cavities are merely accidents or terminal products left by various patho- 
 logical processes. The true syringomyelia is, in our opinion, a process sui generis, 
 and is in no way identical with the other members of the rare and heterogene- 
 ous groups alluded to. We accept the theory, adopted now by Schultze, Bern- 
 hardt, Simon, Westphal, Charcot, Dejerine, and others, that syringomyelia is the 
 product of a true gliomatosis, which occurs usually in that region of the cord 
 that is developmentally the weakest — i. e. the region of the posterior gray com- 
 missure and posterior median septum. This proliferation of neurogliar tissue 
 leads to the formation of a cavity by the gradual softening and absorption of the 
 new growth. Its usual site in the gray commissure and posterior septum sug- 
 gests that it may result from an anomaly in the development of that region of the 
 cord last formed by the folding over of the medullary folds in the embryo. 
 According to this theory, the central canal is not necessarily the starting-point 
 of the process, although it may be involved ultimately in it. In the author's 
 case this profuse overgrowth of neurogliar tissue was a conspicuous feature, 
 while the central canal, as marked by a mass of epithelial cells, was entirely 
 distinct from the cavity. In another case, however, published recently by Dr. 
 James Taylor, the cavity was lined in some places with epithelial cells, proving 
 conclusively that the central canal had become included in the syringomyelia. 
 
 Morbid Anatomy. — The cavity is usually largest in the cervical region, 
 whence it extends downward to various levels in different cases. In some 
 cases it trends to one side. It may extend as far as, or even into, the lumbar 
 enlargement, but this is not the rule. In many cases the lumbar enlargement, 
 with exceptions yet to be noted, is normal. At its seat of greatest extent the 
 cord may be literally a hollow tube. In the fresh state the cord is flat or 
 ribbon-like, and gives to the finger a sense of fluctuation. 1 There is usually not 
 much, if any, evidence of inflammation. The integral parts of the cord are 
 much distorted and even injured by the syringomyelia. The cavity (see Fig. 1) 
 occupies the central gray matter or commissure, the anterior, or white com- 
 missure, usually escaping. The normal central canal may exist apart, in which 
 case it is apt to be disfigured, and perhaps only recognizable by its epithelial 
 cells, or it may be included in the cavity, in which case the latter is lined at 
 places with columnar epithelial cells. The cavity is often widely extended 
 laterally, and may run down the posterior horns or even the posterior median 
 septum. It pushes before it the gray matter, which is seen in the author's case 
 to be stretched around the ends of it. The anterior horns are distorted, and 
 
 1 In two cases observed post-mortem by the writer, this macroscopic appearance was very 
 
S YBING OMYELIA . 
 
 811 
 
 the multipolar cells in them are in many instances atrophied. The posterior 
 horns, the posterior root-zones, and the posterior columns are especially liable 
 to injury. The horns and root-zones may be distinguished only with difficulty, 
 and the posterior columns present various stages of degeneration. The lateral 
 
 
 Cervical Region of the Spinal Cord from the author's case of Syringomyelia. (Univ. Med. Mag.) 
 
 pyramidal tracts are often very much degenerated, as are, also, the direct 
 pyramidal tracts. The cavity itself is usually surrounded by a newly-formed 
 tissue. This is seen, under the microscope, to be a densely felted tissue, with 
 fibrils making innumerable meshes. It is rich in neurogliar nuclei. Some 
 writers point out a lining membrane to the cavity, composed apparently of a 
 comparatively more densely felted layer of gliomatous material. Blood-vessels 
 are scattered but sparsely through this tissue. Above and below the region of 
 
 Fig. 2. 
 
 Upper Dorsal Region of the Spinal Cord from the author's case of Syringomyelia. ( Univ. Med. Mag.) 
 
 greatest extent of cavity the morbid anatomy varies. System-lesions may 
 extend in either direction according to their nature. The medulla oblongata 
 is variously aifected. It may be the seat of nuclear degenerations identical 
 with those of bulbar palsy. In the author's case one pyramidal tract was 
 degenerated through the decussation, and the ascending cerebellar tract on one 
 side, as well as the funiculi gracilis and cuniati on each side, was deeply 
 sclerosed. Below the cavity the lateral pyramidal tracts are often degenerated 
 to their extreme limits in the lumbar enlargement. The lumbar enlargement, 
 even when it apparently escapes invasion, may exhibit, on close microscopical 
 search, the presence of gliomatosis in a small area in the gray commissure. The 
 anterior horns in the lumbar cord, unless the cavity extends thus far, are 
 not affected. 
 
812 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Symptoms. — The symptoms of syringomyelia may be divided into two 
 classes, according as they are dependent upon lesions, first, of the gray matter 
 of the cord, and second, of the white matter. The first class includes the essen- 
 tial symptoms ; the second, those that are secondary to them. These essen- 
 tial symptoms may be subdivided into three groups, according to the region of 
 the gray matter affected. 
 
 The first probably of these essential symptoms to appear is a characteristic 
 disorder of sensation. This presents a type. It is an analgesia, or loss of 
 pain-sense, combined with thermo-anaesthesia, or loss of power of distinguish- 
 ing heat and cold, without true tactile anaesthesia and loss of muscular sense. 
 This peculiar type has been called by Charcot the dissociation symptom of 
 syringomyelia. It is more typical of the disease than any other one symptom- 
 group, and is truly typical of no other affection, although occasionally seen in 
 hysteria. 
 
 These sensory changes usually show a segmental distribution. They are 
 sometimes hemiplegic in type, sometimes monoplegic, but usually distributed 
 only to segments of the limbs or trunk. Exceptions and variations occur. 
 Thus in the author's case zones of anaesthesia were found on the shoulders and 
 about the waist. Occasionally areas of hyperaesthesia exist ; thus, in this same 
 case, while one side presented quite typically the "dissociation" symptom, the 
 other was the seat of hyperaesthesia. The zone of anaesthesia to heat and that 
 to cold do not always exactly correspond. The analgesia of syringomyelia is 
 often very profound, so that the patients may be quite insensible to most destruc- 
 tive trophic or traumatic lesions, to which reference will be made later. The 
 exact affected region of the cord that gives rise to the sensory symptoms is 
 probably the posterior gray commissure and parts of the posterior horns. 
 
 The essential motor-symptoms of syringomyelia depend upon a progressive 
 atrophy of the cells of the anterior horns of the gray matter. As the cervical 
 enlargement is invaded much more commonly than the lumbar, it follows that 
 the arms rather than the legs are the parts involved in the consequent mus- 
 cular atrophy. This progressive muscular atrophy is usually of the atonic 
 variety — i. e. the muscles are not spastic and do not show exaggerated myo- 
 tonic and tendon reflexes. This is the type called Aran-Duchenne. There 
 are exceptions to this rule, however, as in the author's case, in which the tonic 
 or spastic type, with exaggerated reflexes, was present. The affected muscles 
 exhibit fibrillary movements. Reactions of degeneration are not seen in these 
 muscles, although in advanced cases quantitative changes occur, and in extreme 
 cases very little if any response can be elicited by either current. This wasting 
 often begins in the hand — for instance, in the thenar and hypothenar eminences. 
 It may be the first symptom to attract the patient's attention. Loss of power 
 is proportionate to the atrophy. One hand may be affected before the other. 
 The wasting in the muscles of the shoulders and arms may become extreme. 
 The biceps, deltoid, infra- and supra-spinati and lower part of the trapezius 
 may be almost entirely lost. The forearm and deeper neck-muscles also may 
 be much affected. The weakness of the neck-muscles may become so extreme 
 that the head falls forward on the chest, and even requires an assistant to sup- 
 port it when the patient sits upright. Tremor has been observed not unfre- 
 quently, especially in the hands and fingers. 
 
 The third group of essential symptoms is a somewhat arbitrary one. It is 
 composed of those symptoms that are claimed by some writers to depend upon 
 the invasion of the mid-region of the central gray matter. Bruhl includes in 
 this group trophic lesions, scoliosis, vaso-motor disturbances, weakness of the 
 sphincters, oculo-motor disorders, and involvement of the bulb. Without 
 
SYRINGOMYELIA. 813 
 
 criticising this grouping we may accept it for convenience in clinical descrip- 
 tion. Whatever their exact origin, it is certain that some at least of these 
 svmptoms are common in this disease. 
 
 The trophic lesions occur in the skin and in the bones and joints. The 
 skin may show hypertrophies, callosities, ulcerations, various eruptions and 
 maculae, or may be glossy in places. The nails of the fingers and toes are 
 sometimes involved. They become thickened, have transverse ridges, and may 
 even fall off. Panaris, or whitlow, is an obstinate and destructive lesion in 
 that form of the disease first described by Morvan and named for him. These 
 whitlows are painless and chronic, and they often destroy the ends of the affected 
 fingers. Abscesses may occur in various places. Arthropathies are not unusual 
 in syringomyelia. They are very similar to those occurring in locomotor 
 ataxia. They cause great deformity of the joints affected, with exudation 
 within the capsule, increase in the articular surfaces, denudation of bone, 
 stalactites, etc. Any one of the large joints, either the knees, shoulders, 
 elbows, hips, or ankles, may be involved : occasionally more than one joint 
 suffers. Fragility of the long bones, leading to easily-produced fractures, 
 occurs. 
 
 Deviation of the spine is a very common affection in syringomyelia. Bruhl 
 says it is present in 50 per cent, of cases. The most common form of deviation 
 is scoliosis. In the author's case this scoliosis was so marked in the neck that 
 it presented the appearance of torticollis. It is most marked usually in the 
 dorsal region. Kyphosis is the next form in frequency, and lordosis the last. 
 Scoliosis may be an early symptom of the disease. Many theories have been 
 advanced to account for this symptom, but that of Roth, who attributes it to an 
 atrophy of some of the transverse muscles of the spine, appears to us the most 
 reasonable. 
 
 Vaso-motor disturbance may be shown by oedema or coldness of the extrem- 
 ities, or by burning sensations in them, by excessive sweating and by persis- 
 tence of lines, marks, or maculae left after contact of objects with the skin. 
 Pilocarpine by injection, according to Dejerine, is delayed in its action, and 
 causes much more abundant sweating in the analgesic regions than in other 
 parts. 
 
 Affections of the sphincters are certainly rare in syringomyelia. They 
 might occur in extreme cases in which the cavity in the cervical region was so 
 expanded as to act as a total transverse lesion. Yet in the author's case, in 
 which the expansion was extreme, there was no interference with the inner- 
 vation of either the bladder or bowel. 
 
 Pupillary and oculo-motor symptoms have been reported. The sympathetic 
 centre in the cervical cord may be either paralyzed or irritated, causing con- 
 traction or dilatation of the pupil as the case may be. When the bulb is 
 involved, the symptoms of bulbar palsy may appear. In Taylor's recent case 
 the aqueduct of Sylvius was dilated, probably causing, by involvement of the 
 underlying nuclei of the third nerve, the nystagmus which his patient had. 
 
 The second class of symptoms observed by us includes those caused by 
 involvement of the white matter of the cord. These are, briefly, the symp- 
 toms, first, of lateral sclerosis ; and, second, those of posterior sclerosis. 
 It can easily be understood that a widely-extended destructive process, like 
 syringomyelia, in the cervical region, must involve inevitably some of the fibres 
 in the white matter. The extent of this involvement of course varies. The 
 most common is lateral sclerosis. This produces, as is well known, spastic 
 paresis in the legs. The knee-jerks are exaggerated, ankle-clonus is present, 
 the gait is feeble, the muscles are spastic, but not wasted, and the innervation 
 
814 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 
 of the bladder and rectum is not affected. The symptoms of posterior scle- 
 rosis, or locomotor ataxia, are not so common. Ataxia, however, and sway- 
 ing with closed eyes, may be present, possibly dependent upon involvement of 
 Clark's column and the ascending cerebellar tract. Fulgurant pains are rare. 
 
 The brain is not involved in typical cases of syringomyelia. The author 
 once saw, however, a diffuse gliomatous lesion in the mid-brain and cerebellum 
 which strongly suggested an identity, in all but position, with the gliomatosis 
 of the cord. 
 
 Diagnosis. — The diagnosis of syringomyelia rests upon the recognition of 
 certain groupings of the various symptoms already described. The most com- 
 mon grouping is that of muscular atrophy, especially in the shoulders and arms, 
 spastic paresis of the legs, the " dissociation " sensory symptom, and a variety 
 of trophic disorders. The most characteristic of these symptoms is the pecu- 
 liar disorder of sensation. Hysteria may simulate this sensory change, but it 
 does not present true muscular atrophy. Anterior poliomyelitis does not cause 
 sensory changes. Amyotrophic lateral sclerosis is undoubtedly identical in some 
 reported cases with syringomyelia. Tumors of the cord and localized myelitis 
 may closely simulate the disease, and can best be distinguished by the history 
 of the case and a careful study of the sensory and trophic disorders. Trophic 
 changes may be conspicuous, and direct the attention from other symptoms. 
 Thus, destructive whitlow, described as Morvan's disease, is a type of syringo- 
 myelia. Friedreich's ataxia has some analogies with syringomyelia : Griffith's 
 statistics prove that 25 per cent, of autopsies in the former present cavities in 
 the cord. Cases of precocious locomotor ataxia ought to be most carefully 
 studied for the symptoms of central gliomatosis. Finally, hemiplegia and 
 monoplegia have been caused by syringomyelia ; they could probably be distin- 
 guished by sensory and trophic symptoms. 
 
 Prognosis. — The course of syringomyelia is slow, but its termination is 
 never favorable. Many patients die from some intercurrent affection. 
 
 Treatment. — There is no specific, or even palliative, treatment for such an 
 inveterate degenerative process as that which produces syringomyelia. It is 
 possible only to treat some of the isolated symptoms, to preserve the strength, 
 to guard against accidents, and to avert the tendency to death by intercurrent 
 disease. 
 
HEREDITARY ATAXIA. 
 
 By ARCHIBALD CHURCH, M. D., 
 
 Chicago. 
 
 Hereditary Ataxia, or hereditary ataxic paraplegia, also known as Fried- 
 reich's disease, is a form of spinal sclerosis appearing usually before twenty 
 years of age, with marked hereditary features. It is usually characterized by 
 generalized ataxia beginning in the legs, by nystagmus, and by impairment 
 of speech, and pursues a chronic progressive course. 
 
 As compared with Friedreich's description of this interesting disease pub- 
 lished in 1863, this scant definition is too brief; but succeeding groups of cases 
 observed in various parts of the world, practically of a similar nature, have 
 shown that features of the malady at first insisted upon as essential are not 
 invariably present or even usual. Cramped by the rigid lines of the early 
 description, many observers have either slavishly followed, seeing only what 
 had been before pointed out, or, if finding marked variations, regarding them 
 as unusual and anomalous. Even Ladame so late as 1890 erected a clinical 
 criterion which does not include a very fair proportion of these cases, although 
 at that time some two hundred had been published, and probably very many 
 more overlooked because of the false standard of measurement that was, and 
 still is, followed. Gray, for instance, in his recent work, states as a "cardinal 
 symptom " that " the knee-jerk is always absent," and Gowers looks upon the 
 report of a case beginning at sixty-six years of age as a coincidence to be rele- 
 gated to a foot-note. As a matter of fact, aside from the ataxia and perhaps 
 the family history, no single item can be insisted upon in every case, yet 
 the symptom-group is a very striking one, and the numerous variations are 
 merely the expressions of an unsystematized and widely-distributed lesion. 
 
 Etiology. — The most striking fact in this disease is its transmission from 
 generation to generation, either in the same form or by related sclero-neurotic 
 disease, and the increasing susceptibility that is encountered in the later gene- 
 rations, where it numbers many members of the same immediate family and 
 shows a distinct tendency to appear at a constantly earlier period of life. In 
 this way may be explained the fact that many of the progenitorial cases have 
 been misunderstood, overlooked, or misclassed. In this connection I wish to 
 refer to the instructive family tree published by Sanger Brown, 1 and here 
 reproduced by his permission. (Fig. 1). Nonne describes a somewhat similar 
 group, and the one post-mortem obtained showed only an abnormal smallness 
 of all the parts of the spinal cord, a deficient development which had not taken 
 on sclerotic degeneration. Occasionally a generation escapes this disease, but 
 atavism is likely to occur. The developmental defect is therefore strongly pro- 
 nounced, and constitutes the background of the picture. It is as if portions of 
 the nervous system, especially of the spinal cord, were incapable of maintain- 
 ing their functions in accordance with the demands of growth and active life, 
 
 l Chicago Medical Recorder, Feb., 1892. 
 
 815 
 
816 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and underwent regression, producing the sclerotic changes to be described 
 
 lflitPF 
 
 The developmental periods of life are those at which it is most likely to 
 
 rw 
 
 b 
 
 J — L 
 
 u r 
 
 O 
 
 iO 
 
 kj 
 
 % 
 
 4n 
 
 tO 
 
 t] 
 
 Family Tree of Hereditary Ataxy, reported by Dr. Sanger Brown. 
 Explanation of Diagram.— Shaded enclosures indicate Hereditary Ataxy. Squares indicate males, circles females. 
 The numbers to the left refer to the cases in Brown's paper; the first number to the right the age at death 
 or the present age. t indicates deceased. The last number indicates the age at onset. 
 
 appear — the seventh and eighth years of age, the age of puberty, and at about 
 twenty, the age of full physical and sexual strength. But it sometimes is con- 
 genital, and may appear at any period of life. This is clearly shown in the 
 
PLATE XVI. 
 
 r^ 
 
 / 
 
 \ * ( 
 
 1, 2, 3, 4. The F. Family.— Showing Apathetic Facies Increasing with Duration of Disease 
 
 1. Tina F., Five years old, unaffected. 
 
 2. Oscar F., Eight years old, affected one year. 
 
 3. Frederick F., Seventeen years old, affected three years. 
 
 4. Rose F., Twenty years old, affected five years, helpless. 
 
PLATE XVII. 
 
 (Th 
 
 M 
 
 |P 
 
 
 6, 7. The S. Family.— Showing Facies: 
 
 5. Ella S., Nineteen years old, affected two years, slightly. 
 
 6. Miles S., Twenty-five years old, affected four years, cannot walk. 
 
 7. Hugh S., Twenty-nine years old, affected fourteen years, helpless. 
 Lucy R., Sixteen years old, affected one year, shows mask-like face. 
 
 Alfred W., Nineteen years old, affected four years. A sister similarly affected at sixteen years of aire 
 met an accidental death at twenty-one. 
 8 and 9 have increased reflexes and double ankle-clonus. 
 
 2, 3, 4, 5, 6, and 7 have knee-jerks abolished. 
 
 3, 4, 6, and 8 show nystagmus in the photographs. 
 
 In 2, 3, 4, 6, 7, 8, the head was so much affected that it required to be supported by pillows to make a 
 four-second photographic exposure. 
 
HEREDITARY ATAXIA. 817 
 
 remarkable series of Brown and of Nonne, in the cases reported by Wells, 
 and in the instances of Everet Smith. The sexes are about evenly affected, 
 though in some family groups males or females greatly predominate, and it is 
 somewhat more liable to be transmitted through the females than by the male 
 branches, probably because the males affected early do not marry, and in later 
 cases are impotent. 
 
 Pathological Anatomy. — With the exception of a few cases, notably one 
 reported by Menzel, post-mortem changes in the nervous matter have been con- 
 fined to the spinal apparatus, including the posterior nerve-roots and an occa- 
 sional peripheral nerve, and to the cranial nerves, especially the hypoglossal, 
 optic, and motor-oculi, and their centres in the medulla. In Menzel's case 
 gross changes were traced into the cerebrum and cerebellum, and the latter was 
 markedly atrophied. Very few autopsies are on record, however, 
 
 The change in the spinal cord is histologically practically identical with 
 that in ataxic paraplegia and locomotor ataxia, for a full description of which 
 the reader is referred to articles on those diseases. Dejerine and Letulle, 
 however, basing their observations on a single case, claim that the sclerosis in 
 this disease is peculiar in being confined to neuroglial hyperplasia without vascu- 
 lar changes. The distribution of lesions is the matter of most interest, for upon 
 it depends the preponderance of symptoms in any given case. In every 
 instance subjected to a post-mortem examination, except Nonne's, the postero- 
 internal and postero-external columns have been found involved throughout 
 the entire length of the cord. In the large majority of cases the pyramidal 
 motor-tracts in the lateral columns have been sclerosed, and this process has, 
 at different levels in different cases, invaded the anterior horns, the anterior 
 columns, the direct cerebellar tract, and the posterior roots. The tract of 
 Lissauer and Clark's columns usually escape. It is this multilocular distribu- 
 tion of the sclerosis which gives rise to such a variety of clinical manifestations 
 and accounts for the confusion in literature. It is apparent that as the poste- 
 rior columns or the pyramidal tracts are principally involved, the locomotor and 
 spastic symptoms will vary, just as occurs in ataxic paraplegia. It is not 
 incredible that even knee-jerks lost early in a case may later reappear, or 
 myotatic irritability of a highly exaggerated type subsequently diminish or 
 entirely fail. 1 The lesion has been traced through the medulla and pons 
 involving the post-pyramidal nucleus. In the posterior columns it is that of 
 an extremely intense tabes, and the involvement of the posterior roots is also 
 analogous, but less marked. In the lateral columns it is that of spastic para- 
 plegia plus the involvement of the cerebellar tract, the anterior direct motor- 
 tract, and the frequent implication of the anterior horn. 
 
 Symptoms. — Unsteadiness upon the feet, a tendency to tumble, and 
 clumsiness are the first noted indications. Ordinarily the symptoms advance 
 slowly. As a rule, and in the type of Friedreich, the knee-jerk is lost very 
 early, but the writer now has two cases under observation in which it is 
 greatly exaggerated, and in both of them there is ankle-clonus. A number 
 of Brown's cases also show increase of myotatic excitability, and the same 
 thing has been not infrequently recorded. The superficial reflexes may be 
 present or absent. Sexual power is frequently undeveloped or disappears, 
 though in one of the cases under the writer's care, where the deep reflexes are 
 prominently increased, sexual inclination is pronounced. As the case advances 
 the ataxia increases, though standing with the eyes closed is often possible 
 when the gait is sprawling and extremely bad. The trunk may be involved, 
 so that, in sitting on a chair without arm or back support, marked swaying is 
 
 1 In one of the writer's cases an ankle-clonus is rapidly diminishing. 
 62 
 
818 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 present. The gait is simply staggering. The stamping of tabes is rarely 
 seen, and even in the cases marked by clonus and exaggerated knee-jerks the 
 stiff-legged gait of spastic cases is absent or only slightly present. Eventually, 
 the upper extremities and the neck are involved, so that the patient becomes 
 practically helpless, and the head, under very little control, rolls around on 
 the shoulders. From the implication of the musculature of vocalization 
 speech is characteristically modified. It is drawling, with the accent and 
 modulation misplaced, hesitating, sometimes slightly explosive; in a word, 
 ataxic. Usually early, and almost invariably late, in these cases nystagmus 
 is present. It is readily overlooked if the patient be not examined carefully. 
 It is not constant, subsiding when the line of vision is directly forward, and 
 only occurring when the eyes are moved. Early in the disease it is necessary 
 to have the eyes turned sharply outward, upward, or outward and upward to 
 demonstrate it. The nystagmic movements are of comparatively short range, 
 unequal in length, and tend to subside as the eyes settle down to the new posi- 
 tion, seeming to the writer to be part and parcel of the general lack of balance 
 in the entire voluntary muscular apparatus. A few instances of temporary 
 strabismus and diplopia are on record. Pupillary symptoms and optic atrophy 
 are absent in the Friedreich type, but frequent in Brown's cases. 
 
 There is not much pain, even in the markedly ataxic types ; the lightning 
 pain of locomotor ataxia, the girdle sensations, and the visceral crises are 
 absent, but dull rheumatoid aching, pain on starting micturition, and painful 
 cramps at night are not infrequent. Until late in the course of the disease 
 errors of sensation are slight or absent. Slight anaesthesia, retardation in the 
 transmission of sensations, variations in sensitiveness relative to temperatures, 
 pressure, and electricity, have all been occasionally noted. 
 
 Muscular power is ordinarily greatly reduced, but paralysis only appears 
 very late, and is comparatively of moderate extent. Sometimes there is dis- 
 tinct atrophy, owing either to the involvement of the anterior horns or to an 
 occasional peripheral neuritis, and it is only in these cases that any notable 
 changes in electrical responses are found. After the patient is bedridden gen- 
 eral emaciation ensues. A coarse tremor is sometimes present, and choreoid 
 movements of head and limbs of an ataxic character, ceasing when the part is 
 supported, are common. 
 
 The facial appearance of these cases, when the disease is moderately well 
 developed, has not received sufficient attention. The lines of expression are 
 lost, the jaw drops, the mouth is partly open, the eyelids droop and look heavy, 
 the whole expression or lack of expression is of apathy, and even of imbecility. 
 In some families the change in the face has been the first intimation to their 
 relatives, familiar with the type, of the invasion of the malady, though an intel- 
 ligent examination would probably have sooner discovered it. This facies is 
 imperfectly shown in the series of photographs published herewith. When 
 pleased or disappointed, emotions are tardily and clumsily or grotesquely shown 
 in their faces, which shortly return to an appearance of blankness. The mind 
 is not necessarily impaired, but mental enfeeblement has resulted in some cases, 
 and the enforced inactivity leads, perhaps naturally, to some hebetude. The 
 drooping head, the scoliotic spine, and clubbed foot, which are common, are 
 other evidences of muscular weakness and lost synergism. Sexual attributes 
 are greatly delayed in the younger cases or fail entirely to develop, giving the 
 patient a childish appearance and bodily formation. 
 
 Course. — The disease is essentially chronic, and very rarely the immediate 
 cause of death, which results from intercurrent maladies, to which the inac- 
 tivity of the patient in some instances no doubt conduces. Some cases have 
 
HEREDITARY ATAXIA. 819 
 
 lasted over forty years, and some have terminated in two or three. As in other 
 respects, there is in this regard a striking similarity among the members of any 
 family group, but it is not unusual to see the younger members of such a family 
 attacked at an earlier age and in a more active manner. Some cases present 
 long-stationary periods or even temporary slight improvement under treatment 
 and bettered conditions of life. The progressive tendency, however, toward 
 physical helplessness is apparently invariable ; and even after the patient is 
 bedridden life may last many years with ordinary care, as there seems to be no 
 especial liability to bed-sores or other dystrophic condition. Occasionally acute 
 myelitis has terminated the case. 
 
 Diagnosis. — The diagnosis hangs upon the youth of the patient, the slow 
 onset, the history or presence in the family of other similar cases or of in- 
 stances of spinal or cerebral sclerosis (among which paretic dementia should be 
 included), upon the ataxia, the nystagmus, the halting peculiar speech, and 
 possibly upon the facial appearance. Absence of locomotor pains, of pupillary 
 symptoms, of acquired syphilitic infection, and of pronounced sensory disturb- 
 ances are negative conditions of corroboratory value. 
 
 Treatment. — The prognosis is always grave, as has already been implied, 
 and treatment seems to be of exceedingly little value. A course of arsenic, 
 of massage, of stretching the spinal column, especially by Benedickt's method, 
 have all apparently caused slight amelioration in progressing cases. Those 
 measures recommended in tabes should be tried, and cauterization with the 
 thermo-cautery over the spine repeated at intervals of two weeks may be em- 
 ployed for a prolonged period. A light touch of the smallest point opposite 
 each vertebra is quite sufficient and not particularly painful. General measures 
 to maintain the physical state are of course always in order. With young 
 patients it is well to allow a reasonable amount of instruction, as they are often 
 dependent upon themselves for entertainment during long years of helplessness. 
 
RAYNAUD'S DISEASE 
 
 By THOMPSON S. WESTCOTT, M. D., 
 
 Philadelphia. 
 
 In a thesis published at Paris in 1862, Maurice Raynaud first called atten- 
 tion to a complex of symptoms to which, for want of a more satisfactory title, 
 he gave the descriptive name "Local Asphyxia and Symmetrical Gangrene of 
 the Extremities." This essay was founded upon the clinical histories of 25 cases 
 collected from various sources, only five of which came under his personal obser- 
 vation. Some of the cases drawn from other sources dated back many years 
 and were very inadequately reported, but Raynaud succeeded in presenting a 
 clinical picture that was at once recognized by his contemporaries, and which 
 soon took a place in medical literature as a new disease worthy to be named for 
 the author who first described it. In this and later studies Raynaud defined 
 the disease as "a neurosis characterized by enormous exaggeration of the 
 the'excito-motor energy of the gray parts of the spinal cord which control the 
 vaso-motor innervation." The stage of cyanosis he considered as due to a spas- 
 modic closure of the arterioles of the parts affected, with a regurgitation of 
 venous blood into the capillaries ; and if this condition was continued sufficiently 
 long, gangrene of more or less gravity supervened. This gangrene, which is 
 often strikingly symmetrical in its distribution, he distinguished from all other 
 varieties of local death as not being due to embolism, thrombosis, or changes 
 of an inflammatory character in the intima of the blood-vessels. There can 
 be no doubt that many of the cases subsequently described under this name, 
 and indeed some of those collected in Raynaud's original thesis, do not properly 
 come within the definition laid down by this author. So recent a writer as 
 Sturmdorf, of New York {Medical Record, Aug. 1, 1891), goes so far as to 
 question the existence of such a disease, which, he states, cannot be diagnos- 
 ticated during life ; for, " admitting the possibility of excluding all other con- 
 ditions capable of producing gangrene, we must exclude" that form of "endar- 
 teritis [Meigs] whose presence could be demonstrated only on the post-mortem 
 table, and whose absence is a sine qua non to the acceptance of Raynaud's 
 disease in the sense of its author's conception." It is quite probable that modern 
 pathology may succeed in disproving the existence of Raynaud's disease as a 
 morbid entity, but it is certain that there are a sufficient number of cases on 
 record — and, curiously enough, many of them are in children — which bear out 
 in all essential respects the original clinical picture. 
 
 The leading characteristic of the disease consists of paroxysms of more 
 or less continuous and complete sj>asm of the arterioles of the extremities, 
 usually occurring, with a fair degree of symmetry, upon like parts of the two 
 hands or two feet, or upon both hands and feet, or — and this less frequently — 
 upon other symmetrical regions, such as the ears, sides of the nose, or but- 
 tocks. This spasm, if sufficiently long continued, gives rise to more or less 
 extensive trophic changes, or even death of the parts involved. 
 
 820 
 
RAYJVAUD'S DISEASE. 821 
 
 Symptoms. — As originally described by Raynaud, this affection may be 
 conveniently divided into three principal stages : 1, Local Syncope ; 2, Local 
 Asphyxia ; 3, Gangrene. The first stage, local syncope, may be transitory, or 
 even wanting altogether, but when the disease assumes its severest form the 
 second and third stages always occur in the order named. 
 
 Local Syncope. — This term was employed by Raynaud to designate a 
 condition, usually of one or more fingers or toes, which in its slightest manifesta- 
 tion is not incompatible with health. The patient, usually a female of neurotic 
 temperament, after exposure to slight cold, or even under the influence of 
 moral emotion, observes one or more of the fingers become pale and cold. The 
 skin assumes a dead-white or parchment-yellow color, cutaneous sensibility is 
 quickly abolished, and the digit feels icy-cold and dead. While tactile sensi- 
 bility may be for the time abolished, the heat-sense may still, in a measure, be 
 maintained. At times a cold perspiration may cover the affected part, while 
 at others it is dry and shrivelled as if frozen. This spasm of the arterioles, 
 with the consequent temporary abolition of local circulation, which is popularly 
 known as " the dead finger," is insignificant from its transitory duration, 
 being succeeded by a variable period of usually very painful reaction, in which 
 the blood gradually returns to the part. It is simply an exaggerated form of 
 what so commonly occurs after the hands have been exposed to a low tempera- 
 ture when confined in tight kid gloves. This, the slightest and in some cases 
 the only stage of the disease, has been but rarely observed in children. 
 
 Local asphyxia, or cyanosis, may be preceded for a time by more or less 
 frequent occurrences of local syncope, or may be the first manifestation of the 
 disease. In the latter case the onset is generally sudden, but sometimes is pre- 
 ceded by paresthesia or pain, usually limited to the fingers or toes about to be 
 affected. After exposure to a more or less marked depression of temperature, 
 or even without appreciable cause, one or more fingers or toes become cold and 
 usually somewhat swollen. The particular phalanx or phalanges will be found to 
 have assumed a dusky or cyanotic tint and to feel icy-cold to the touch, while 
 the whole limb is colder than the rest of the body. Tingling or shooting pains 
 of varying severity are felt, and hyperesthesia or anaesthesia of the parts may 
 be observed. The cyanosis affects most intensely the distal portion of the 
 phalanx, but it may extend in decreasing degree as far upward as the wrist- 
 joint or ankle, or may even pass beyond, while venous marblings may be traced 
 far up the limb. This condition may affect one phalanx or several in vary- 
 ing degree, either upon a single limb or upon both hands or feet, or even 
 upon all four extremities. When both hands or both feet are affected, the 
 degree of cyanosis is generally more marked upon one side ; and in some 
 paroxysms in the same patient the asphyxia may be confined to one member 
 alone, while in others both feet or both hands or a hand and foot are affected. 
 In any particular case, however, in the successive paroxysms local asphyxia 
 generally involves the same phalanx or manifests the same order and inten- 
 sity of involvement of several phalanges. After a variable duration the 
 cyanosis gradually passes away and the parts regain their color ; this reaction 
 may even be excessive, and redness and burning pain be noted. Such parox- 
 ysms vary greatly in severity and duration. In some instances the attack 
 passes off in a few seconds, to be frequently repeated at the slightest exposure 
 to a change of temperature ; while in other cases it is prolonged for several 
 hours or even several days. Pain is also a very variable symptom, some 
 patients experiencing little discomfort during the asphyxial attack, while 
 others complain bitterly of intense burning sensations in the part. As with 
 the preceding stage, local asphyxia may be the most serious manifestation of the 
 
822 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 disease, and in this case we find it occurring at irregular intervals, but often as 
 frequently as several times daily, usually during the winter months, being pro- 
 voked by the slightest exposure to cold. 
 
 A symptom frequently noted during this stage is haemoglobinuria, to which 
 attention has been lately directed principally by the observations of Barlow 
 and Southey in England" Shortly after the beginning of a paroxysm of local 
 asphyxia the child may pass very dark urine, which is found to contain albumin, 
 and responds to the guiacum test for haemoglobin. Both Southey and Barlow 
 report cases of this kind in which, during some of the paroxysms, the urine 
 was found to contain no blood-corpuscles, but showed fine granular brown 
 debris and a profusion of oxalate-of-lime crystals. This phenomenon does not 
 occur after every attack ; but it has been observed that a copious deposit of 
 urates may at times replace the loss of haemoglobin. It is most likely to occur 
 when the attack is preceded by yawning, drowsiness, nausea, or pain in the 
 belly referred to the ensiform cartilage, which are the symptoms preceding 
 haemoglobinuria due to other causes. 
 
 When an attack of local asphyxia has lasted several days, the nail ceases 
 to groAv, and the occurrence is marked upon the nail by a transverse striation 
 of variable distinctness. When paroxysms have frequently occurred, the 
 affected digits may become rather soft and flabby from an increase in the sub- 
 cutaneous fat. 
 
 General symptoms are very slight, and fever, if present, does not usually 
 exceed 100° F: if higher, it is attributable to other causes. A stage of local 
 erythema has been said sometimes to replace the asphyxial stage, being ascribed 
 to an irritation of the vaso-dilator nerves ; but it has rarely been followed by 
 gangrene, and would seem more properly to be classed as the erythromelalgia 
 of Weir Mitchell. In rare cases the tip of the nose or the ears, and occasion- 
 ally other symmetrical regions of the body, may be affected with local asphyxia, 
 but the symptoms are the same as in the more common variety. 
 
 Gangrexe. — When local asphyxia persists sufficiently long, the vitality of 
 the part suffers. Small blebs form upon the tips of the affected digits, partly 
 at the expense of the outer layer of corium ; these rupture, discharging a serous 
 or sero-purulent, often blood-stained, fluid, and leave an excoriation which 
 heals with some little loss of substance. When this process has attended 
 repeated attacks, the fingers or toes exhibit numerous little white cicatrices, 
 and become somewhat conical in shape, with distorted nails and shrunken parch- 
 ment-like skin. In the severer cases the destructive process may involve a 
 more extensive portion of one or more digits. In this event there are no 
 phlyctenulae, but the part at once assumes a dark violet or blackish color, and 
 passes through a condition similar to senile gangrene, with subsequent elimina- 
 tion of the sphacelus — a process requiring usually two or three weeks. And 
 thus the patient may pass through an attack with the loss of one or more 
 distal phalanges, or even more extensive portions of the member. Loss of a 
 portion of the margin of the external ear may thus occur, but similar loss of 
 substance of the tip of the nose has rarely, perhaps never, been observed. 
 
 Many cases of symmetrical gangrene of greater severity than here described 
 have been reported as Raynaud's disease without seemingly good grounds. Some 
 of these have shown concomitant constitutional symptoms which throw grave 
 doubt upon their accepted pathology ; and in others, again, ergotism or vas- 
 cular disease has not been satisfactorily excluded. As seen in children, where 
 the ground is considerably clearer, the most carefully studied cases have rarely 
 shown lesions more serious than those above described. 
 
 Etiology. — As far as its occurrence in children is concerned, sex or age 
 
BAYNAUD'S DISEASE. 823 
 
 seems to have little influence. It occurs most commonly during the winter 
 months, often being excited by exposure to the slightest depressions of tempera- 
 ture. Heredity seems to play some part. Raynaud observed a female infant 
 who exhibited a marked disposition to local asphyxia during the first five 
 months of life, at a time when her mother was passing through attacks of dry 
 gangrene of all the extremities. A neurotic family history must be accepted 
 as a powerful predisposing cause, since many victims of this disease show a 
 distinct nervous inheritance. Making saw symmetrical gangrene in a brother 
 and two sisters whose mother had died of progressive muscular atrophy ; and 
 Colman and Taylor report local syncope in a girl of ten years, whose mother 
 was extremely neurotic, and whose maternal grandfather and grand-uncle had 
 suffered from similar local syncopal attacks. As regards previous conditions 
 of health, in some cases the disease has followed upon acute and depressing ill- 
 nesses ; but in others no such exciting cause could be assigned. 
 
 Pathology. — Raynaud ascribed this affection to an exaggerated vasocon- 
 strictor irritation dependent upon an increased excitability of the vaso-motor 
 centres of the cord, since, according to his observation, galvanization of the 
 cord modified the arterial spasm, and in one case, carefully studied by himself 
 and Galezowski, there was a remarkable coincidence between the peripheral 
 circulatory disturbances and like phenomena observed in the retinal vessels. 
 Weiss, however, inclined to the theory of peripheral irritation arising in the skin, 
 viscera, or the brain, and thus ascribed many of the cases observed in neurotic 
 women to uterine or ovarian irritation. As the disease is rarely in itself fatal, 
 no satisfactory pathological study has as yet been possible. The most import- 
 ant addition to our recent knowledge of the disease is the occurrence of inter- 
 mittent hemoglobinuria. Of ten children suffering from local asphyxia and 
 symmetrical gangrene, as reported principally by English observers, at least 
 eight at some time during the course of the disease exhibited undoubted evidence 
 of blood coloring-matter in the urine. Dickinson, the chief English authority 
 on renal diseases, states that the two conditions, Raynaud's disease and inter- 
 mittent hemoglobinuria, seem so to approach each other and mingle as to 
 render it impossible to make a distinct demarcation between them. Abercrombie 
 holds that we are warranted in believing that both paroxysmal hemoglo- 
 binuria and Raynaud's disease are symptoms of a more general affection, and 
 he suggests that the jaundice sometimes found after attacks of hemoglo- 
 binuria (and also after attacks of local asphyxia) is the result of arterial spasm 
 of the hepatic vessels. But it seems more probable, as Barlow believes, that 
 this jaundice is due rather to breaking up of blood coloring-matter elsewhere 
 in the circulation. Several observers have noted that during a paroxysm of 
 intermittent hemoglobinuria blood drawn from a cold extremity showed changes 
 in the red corpuscles, which exhibited a decided tendency not to form rouleaux 
 and appeared markedly crenated, with granular masses in the surrounding 
 serum. In a very interesting case of a boy of twelve years, who manifested 
 both intermittent hemoglobinuria and local asphyxia of the extremities, with 
 gangrene of the tips of the ears, Myers found that blood taken from ears and 
 hands during an attack of hemoglobinuria showed changes similar to those 
 just described. It is thus seen that in this case blood-changes, local asphyxia 
 and gangrene, and hemoglobinuria occurred in the same patient. 
 
 This association with paroxysmal hemoglobinuria at once suggests a rela- 
 tion to malarial infection — a relation which, in not a few cases at least, is borne 
 out by the existence of previous malarial attacks in such patients. Hereditary 
 syphilis also has obscured the earlier history of several children suffering from 
 well-marked Raynaud's disease ; and it is doubtful how much of the symptoms 
 
824 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 in these cases could be attributed to specific endarteritis capable of causing 
 vascular obstruction. It is noteworthy, perhaps, that both Boas and Murri, as 
 well as Flensburg more recently, mention syphilis together with ague as prob- 
 able etiological factors in the production of hemoglobinuria. 
 
 Course, Duration, and Results. — As observed in children, symmetrical 
 o-angrene pursues a more benign course than in adults. Local asphyxia may 
 be the only stage, and the disease may be a regular accompaniment of cold 
 weather, disappearing as summer approaches, to recur the next winter. Parox- 
 ysms may occur frequently during the day on the slightest exposure to cold, 
 or they may be seen at irregular and longer intervals. Other cases may termi- 
 nate speedily in gangrene, and leave the child with deformed fingers or toes 
 and only a tendency to blueness of these extremities after exposure to severe 
 cold ; while, again, the repeated occurrences of superficial sloughs may result 
 in painful conical fingers with blunted tactile sensibility. 
 
 Diagnosis is comparatively easy, provided satisfactory exclusion can be 
 made of cardiac or vascular disease, diabetes, frost-bite and ergotism. From 
 chilblains it may be distinguished by the history, by the absence of itching, 
 and by the presence of pain during spasm which passes off after relaxation. 
 Its localized character at once serves to exclude congenital cyanosis. 
 
 Prognosis. — As regards life prognosis is almost always good. Only in 
 one or two reported cases in very debilitated children has a fatal result been 
 traceable to exhaustion from the disease. The prospect of its duration as a 
 chronic or subacute condition or as a periodical visitation is not to be disposed 
 of so easily, and there seems to be no means of judging upon this point at any- 
 time during the earlier paroxysms of the disease. The occurrence of hemo- 
 globinuria, so far as yet observed, has not proven more than a curious episode 
 without much serious import. It is possible, however, that aggravated forms 
 may occur in which a more profuse loss of blood may seriously affect the out- 
 come of the case. 
 
 Treatment. — When the milder stages of this disease are first manifested 
 much may be done to prevent the more serious results of repeated paroxysms. 
 If the general health and constitution of the child be satisfactory, and the 
 symptoms seem to depend entirely upon exposure to cold, great care must be 
 exercised to guard against all chances of chilling of the surface or the extrem- 
 ities. He should not be sent out into the open air until he has partaken of 
 food; woollen underclothing and stockings must be constantly worn. If the 
 child is ill-nourished or cachectic, a plentiful supply of nourishing food and 
 appropriate constitutional treatment must be secured. Imperfect circulation 
 of blood and coldness of the extremities certainly predispose to attacks of local 
 asphyxia, and therefore douches may be ordered, the effect of which must, 
 however, be carefully watched. A rapid sponging in a bath of water at a 
 temperature of about 100° F. may be followed by a douche of colder water of 
 about 70°, emptied upon the back and shoulders as the child sits in the warm 
 water. This bath, which is best given in the morning, together with a few 
 minutes' exercise with a skipping-rope or football after breakfast, will do much 
 to keep the extremities warm during the day. By this means attacks of local 
 asphyxia may be prevented : but if they should occur care must be taken not 
 to employ the bath while any blueness of the extremities is noticeable, nor for 
 some hours after the subsidence of a paroxysm. 
 
 Raynaud was the first to call attention to the beneficial influence of gal- 
 vanism applied in the form of descending currents either to the spine or down 
 the affected extremity. In the former case the positive pole is applied over the 
 fifth cervical vertebra, the negative near the commencement of the cauda 
 
RAYNAUD'S DISEASE. 825 
 
 equina ; while in the latter the negative pole is applied to the closed fingers or 
 the toes. Barlow has obtained most satisfactory results by placing one elec- 
 trode on the upper part of the limb and the other in a basin of warm salt water 
 in which the affected extremity is immersed. As many elements as the patient 
 can bear should be used, and the current should be made and broken at fre- 
 quent intervals. The stance should be given daily for about ten minutes. 
 Shampooing is often valuable in conjunction with galvanism, especially in the 
 chronic forms in which the extremity of the limb undergoes atrophy. 
 
 Beyond an appropriate tonic treatment little is to be expected from internal 
 medication. Quinine is the only drug whose use in some cases has apparently 
 produced beneficial results, as might be expected from the frequent association 
 with symptoms which suggest the probable etiological importance of malarial 
 infection. This drug should certainly be given a fair trial in every case. 
 Nitrite of amyl has been tried during the asphyxic stage upon theoretical 
 grounds, but without any observed effect. 
 
 If pain is severe, much relief will be experienced from the local use of 
 chloroform liniments. In some cases, curiously enough, cold applications, like 
 the ice-bag, give greater relief than warmth. 
 
 When gangrene has begun the limb should be maintained in an elevated 
 position, well wrapped in cotton, and kept clean with an antiseptic wash. 
 Stimulants may be required in this stage, and occasionally hypnotics and seda- 
 tives to secure sleep, allay restlessness, and alleviate pain. When the line of 
 demarcation has formed, dry hot applications should be kept to the part to 
 favor the process of elimination and repair. In rare cases the destruction of 
 tissue may be so great as to demand a more or less formal amputation. 
 
PART VIII. 
 DISEASES OF THE RESPIRATORY SYSTEM. 
 
 DISEASES OF THE NOSE. 
 
 By W. E. CASSELBERRY, M. D., 
 
 Chicago. 
 
 I. Acute Rhinitis. 
 
 Acute Rhinitis, colloquially termed " cold in the head," is an acute 
 inflammation of the mucous membrane lining the nasal cavities from the ante- 
 rior nares to the naso-pharynx. It is prone to extend to adjoining mucous 
 surfaces, and usually embraces the naso-pharynx, at least to some degree, and 
 thence invades, not infrequently, the middle ear. 
 
 Etiology. — Reasoning from analogy and from its pathology and clinical 
 history, we must regard acute suppurative rhinitis as an infection by pathogenic 
 micro-organisms, although germs specific to this particular form of suppuration 
 have not, as yet, been identified. This statement, however, will bear indefinite 
 qualification, which we must limit to two phases : 1. Some special predisposing 
 condition of the part is essential to infection. 2. It follows certain exposures 
 with such regularity and precision that we must infer a causal relationship 
 between chilling of the body and rhinitis. A draught between the shoulders, 
 permitting the feet or other parts of the body to become cold and damp, or too 
 rapid checking of the perspiration, causes, through the intervention of the vaso- 
 motor nervous system, a sudden turgescence of the nasal vessels, especially of 
 of the turbinated bodies. In the majority of instances this congestion is but 
 transitory, passing off in a few minutes or a few hours, and followed merely by 
 increased mucous secretion ; but in other instances it does not subside, but 
 augments in violence, and is followed in from twelve to twenty-four hours by 
 a muco-purulent, and then almost a purulent, discharge. The congestion of 
 the nasal vessels occasioned by thus "taking cold" evidently favors a microbic 
 invasion of the mucous membrane by impairing, in some manner, its powers of 
 resistance. 
 
 Instances are not wanting of direct infection of one person by the discharges 
 of another — an accident which is apt to happen among children by the use of 
 handkerchiefs in common. Suppurative rhinitis in infants is also attributable 
 to direct infection from the vaginal discharges during birth. 
 
 Symptoms. — A sense of stuffiness in the nostrils, with burning and dry- 
 ness, together with slight febrile reaction, is succeeded in a few hours by- an 
 acrid watery discharge, which later leads to a free muco-purulent secretion. A 
 simultaneous congestion of the frontal sinuses, which occasions headache, is 
 frequent, but this does not argue pressure by accumulated muco-purulent secre- 
 
 826 
 
DISEASES OF THE NOSE. 
 
 827 
 
 tion within these cavities, for actual empyema of the frontal sinuses is very 
 rare. Mere swelling of the orifice of the Eustachian tube will occasion tinni- 
 tus aurium and impairment of hearing, and a direct extension of the inflamma- 
 tory process to the middle ear is, seemingly, the cause of nearly all cases of 
 abscess of the cavity of the tympanum. Certain individuals, and even certain 
 families, manifest a decided predisposition to this complication. Associated 
 conjunctivitis is common, and, at times, the external nasal appendage appears 
 swollen, florid, and excoriated by the irritating discharges. 
 
 Treatment. — It is much too customary to permit this acute inflammatory 
 disease of a delicate part of the body to progress without efforts to mitigate and 
 abbreviate it. Such a course is fraught with immense possibilities of ultimate 
 damage, chronic catarrh of the nose and accessory organs being thereby estab- 
 lished. Many remedies are of real service, but a multiplicity of recommenda- 
 tions is confusing and tends to lessen confidence in any one line of treatment. 
 We will therefore describe simply our own methods of dealing with these cases. 
 
 If it is sought to abort the attack of rhinitis, a single average-sized dose of 
 Dover's powder, proportionate to the age of the child, is given at bed-time, also 
 a laxative if needed. The patient is especially well covered in bed, outside night 
 air is excluded, and the temperature of the apartment maintained during the 
 night at 60° to 69° F., but no effort is made to produce profuse perspiration. 
 
 The following day, or even the first day if called upon to prescribe before 
 evening, this formula will meet the indications : 
 
 ^. Tr. aconiti Hlxij. 
 
 Tr. belladonna Tttxxiv. 
 
 Morphinae sulphatis gr. \. 
 
 Potassii bromidi . . . 3j . 
 
 Spts. menthse piperita ITLxx. 
 
 Aquae q. s. ad f^iij. — M. 
 
 Sig. Adult dose, one teaspoonful every hour, to be lessened for children 
 according to age. 
 
 The same ingredients could readily be prepared in the form of a capsule, 
 pill, or compressed tablet. 
 
 Local treatment is of the utmost importance, and the following mixtures 
 render satisfactory service by atomization: 
 
 fy 
 
 Bit 
 
 Sprat/ No. 1. 
 Cocainse hydrochloratis.gr. ij. 
 
 xx. 
 
 XX. 
 
 Sodii boratis . 
 
 Sodii bicarbonatis 
 
 01. eucalypti . . , 
 
 01. gaultherise . . 
 
 Thymol 
 
 Menthol 
 
 Glycerini f^ss. 
 
 Aquae . . . . q. s. ad f^j. — M. 
 Dilute, adding one or two tea- 
 spoonfuls to one ounce of warm 
 water for use as a spray. 
 
 gr. 
 gr. 
 
 mj. 
 mj. 
 
 gr. ss. 
 
 Spray No. 2. 
 
 1^. Cocainse hydrochloratis . gr. ij. 
 01. pini Canadensis. . . Tltv. 
 
 01. gaultherise TTtij. 
 
 01. eucalypti TTtij. 
 
 Thymol gr. ss. 
 
 Menthol gr. j . 
 
 "Vaselinoil" .... fgj.— M. 
 
 Sig. Use with double bulb (Davidson) 
 atomizer, either alone or follow- 
 ing the use of Spray No. 1. 
 
 For young children, who are often terrified by spraying, may be substituted 
 a small syringe or an ordinary medicine-dropper used as a syringe, with which 
 
828 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 to project, gently, either of these solutions through the nostrils. Spraying or 
 gentle syringing in this manner may be performed twice or three times daily, 
 or even every three hours in severe cases. The cocaine can be omitted from 
 either spray formula, if there be any objection to its use, without seriously 
 impairing the effectiveness of the remedy. All solutions for nasal use should 
 be somewhat warm. 
 
 Of the many inhalations, we will mention only camphorated steam as a 
 domestic remedy of power. It is conveniently used by placing a pint of steam- 
 ing hot water in a glass fruit-jar and adding two fluidrachms of spirit of cam- 
 phor. A funnel, preferably of glass, is then inverted to cover the mouth of 
 the jar, and the rising steam is inhaled through the nostrils as it escapes from 
 the small end of the funnel. So used, especially during the evening, for a half 
 hour, it conduces to a comfortable night's rest and facilitates recovery. 
 
 IE. Simple Chronic Rhinitis and Purulent Rhinitis. 
 
 Recurrent attacks of acute rhinitis establish, in children and young people 
 especially, a chronic inflammation of the mucous membrane, which is charac- 
 terized by variable degrees of proliferation of the epithelium, and by muco- 
 purulent secretion, which is often profuse. The disease is not accompanied by 
 material enlargement of the turbinated bodies or distention of the erectile tis- 
 sues, and stenosis is not a prominent symptom ; which differentiates it from 
 hypertrophic rhinitis. 
 
 Etiology. — Bosworth plausibly contends that children are particularly 
 prone to inflammation of the epithelial lining of mucous membranes, and that 
 the epithelial proliferation of muco-lymphoid glands becoming organized with- 
 out desquamation accounts for enlargement of the tonsils, etc., while an allied 
 inflammation in the nose, with rapid desquamation of the epithelium, con- 
 stitutes the most important element in purulent rhinitis. The disease bears no 
 constant relationship to scrofula, tuberculosis, or syphilis, since it affects chil- 
 dren who are otherwise robust quite as frequently as it does the subjects of 
 these dyscrasise. Inattention to hygienic matters, leading to frequent attacks 
 of acute rhinitis, and failure to treat the same effectively, are potential factors 
 in the establishment of this form of catarrh. 
 
 Symptoms. — A profuse muco-purulent discharge from both nostrils, swell- 
 ing and redness of the external nasal appendage, and excoriation, with incrus- 
 tation of the anterior nares, are the chief manifestations, a too profuse dis- 
 charge being the sole complaint in the milder cases. 
 
 In the course of years, if the purulent type of rhinitis be not arrested, the 
 mucous glands atrophy, the secretion grows less but thicker, and tends to accu- 
 mulate in crusts. In other words, the disease passes gradually into the atrophic 
 form of rhinitis, which is the successor to purulent rhinitis perhaps more fre- 
 quently than to hypertrophic rhinitis, although commonly credited to the latter 
 disease. 
 
 On the other hand, if simple chronic rhinitis does not assume the purulent 
 type, it is prone to pass gradually into hypertrophic rhinitis. 
 
 Diagnosis. — Hypertrophic rhinitis is accompanied by more nasal obstruc- 
 tion and less secretion, although it is sometimes difficult to draw the line 
 between these two affections, however distinct one type may be from the other ; 
 indeed, in rare instances the two pathological processes are seemingly associ- 
 ated. Hereditary syphilitic rhinitis can be excluded by rhinoscopic exami- 
 nation, and the purulent discharge occasioned by a foreign body in the nose is 
 commonly unilateral, and the object can be discovered by the probe. 
 
DISEASES OF THE NOSE. 
 
 829 
 
 Treatment. — The first indication and most important point in the treat- 
 ment of purulent rhinitis is to maintain absolute cleanliness of the nostrils. 
 Muco-pus must not be permitted to accumulate and decompose in the sinuosities 
 around the turbinated bodies, thus perpetuating the disease. In not too invet- 
 erate cases thorough cleansing by means of an antiseptic alkaline and mildly 
 astringent spray, used three or four times daily with a hand-ball atomizer, is all 
 that is necessary to effect a cure. The following modification of Dobell's 
 solution answers this purpose admirably 
 
 ly. Sodii boratis . . 
 Sodii bicarbonatis 
 01. eucalypti . . 
 01. gaultheriae . 
 Thymol .... 
 Menthol .... 
 Glycerini . . . 
 Aquae . 
 
 xv. 
 
 XV. 
 
 gr. 
 
 gr. 
 
 mj- 
 mj. 
 
 gr. ss. 
 f§ss. 
 . adfgj.— M. 
 
 Sig. Dilute, adding two teaspoonfuls to one ounce of warm water for use 
 as a spray. 
 
 The patient should be directed to use the spray several times at intervals 
 of five minutes, especially during the morning and evening toilet, and to 
 cleanse the nose by "blowing" in each interval. 
 
 If a more active astringent is necessary to check the hypersecretion, sul- 
 pho-carbolate of zinc, two to five grains to the ounce, may be used as a spray 
 following the cleansing solution. In young children, who are terrified by spray- 
 ing, these solutions, well warmed, can be used by means of a small syringe. 
 
 Where the purulent type of the disease is complicated by the presence of 
 hypertrophies of the turbinated bodies, deformity of the septum, adenoid 
 vegetations, etc., any of which obstructions will impair the drainage and cause 
 a muco-purulent discharge, surgical treatment appropriate to this special cause 
 or complication is usually indicated. However, the case should not then be 
 regarded, strictly speaking, as one of simple rhinitis. 
 
 HI. Hypertrophic Rhinitis. 
 
 This is a chronic inflammation of the mucous and submucous tissues of the 
 nose, characterized by enlargement, especially of the turbinated bodies, which 
 encroach upon the normal lumen of the nostrils and cause impairment of nasal 
 respiration and drainage. The disease is stated to be rare with children, espe- 
 cially under ten or twelve years of age, but we are convinced that a mild form, 
 or early stage, of the affection is very common at all ages. 
 
 Pathology. — Advanced hypertrophic rhinitis is characterized by enlarge- 
 ment and proliferation of all the elements which compose the turbinated bodies : 
 the epithelial surface is thickened ; the adenoid layer, which lies between the 
 epithelial and submucous layers, is wider, and the lymph-corpuscles and fibrous 
 connective-tissue bundles are more numerous ; the acinous mucous glands are 
 increased in number and size. The submucosa, which is composed largely of 
 blood-vessels of a venous character — sometimes called a venous plexus — is par- 
 ticularly affected, the vessels being enlarged, more numerous, their walls thick- 
 ened, and the intervascular connective tissue proliferated. The blood-vessels 
 are more or less continually congested, causing "erection" of its structures, 
 and they are no longer capable of complete "retraction" under favorable 
 
830 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 influences or under the action of cocaine, but shrink only moderately or but 
 little. 
 
 As Bos worth truly remarks : " These are changes which can only ensue 
 during the lapse of years ;" and to this extent we would not, therefore, expect 
 to encounter them in children. However, in children and adolescents persistent 
 enlargements of the turbinated bodies can and do present themselves in conse- 
 quence of mere dilatation and engorgement of the vessels of the submucosa, 
 without any considerable degree of cell-proliferation. Complete retraction in 
 this form is possible, either spontaneously on one or both sides at intervals, or 
 by means of cocaine, the mucous membrane shrinking close to the bony base. 
 
 This condition is occasionally referred to as a vaso-motor paresis, permitting 
 over-distention of the vessels of the turbinated bodies and other parts affected ; 
 or, again, it is designated by Ingals as a distinct affection under the name of 
 " intumescent rhinitis." But I am disposed to view it simply as an early stage, 
 or, at most, a variety of hypertrophic rhinitis, for cases which present each 
 degree of gradation between this and the advanced stage of the disease above 
 described are continually encountered. 
 
 In addition to the intumescent type, even somewmat advanced grades of 
 hypertrophic rhinitis are certainly met with in children. 
 
 Etiology. — The most prolific source of hypertrophic rhinitis in young chil- 
 dren is adenoid vegetations, which by partial occlusion of the posterior choanae 
 interfere with the proper drainage and evaporation of nasal secretions, the irri- 
 tation of retained and decomposing secretions serving to excite proliferative 
 changes in the nose. It would seem, also, that the same dyscrasia— lympha- 
 tism, which predisposes certain children to hypertrophy of the tonsils and to 
 naso-pharyngeal adenoid hypertrophy — favors the development of hypertrophic 
 rhinitis. Clinically, these conditions are frequently conjoined, and it is cer- 
 tain that they sustain some dependence upon each other, for removal of the 
 "adenoids" is often followed by subsidence of the nasal hypertrophies. 
 
 Recurrent acute rhinitis is another potent factor in the development of 
 hypertrophic rhinitis, and, therefore, whatever serves to excite acute rhinitis 
 must be accorded etiological consideration in reference to hypertrophic rhinitis. 
 
 Symptoms. — Nasal stenosis, or obstruction on one or both sides, is the 
 most prominent symptom, together with many indirect effects due to the stenosis. 
 As a rule, one side of the nose is stopped at a time, the two sides alternating 
 in this respect, sometimes changing with great rapidity and without apparent 
 cause. Again, absolute stoppage of one or both nostrils may manifest itself 
 only under certain conditions, as during railroad travel or otherwise from inha- 
 lation of dust, from superheated apartments, and from exposure to a cold, damp 
 atmosphere — conditions which necessarily arise so commonly as to cause much 
 annoyance to the patient. 
 
 The secondary results of nasal stenosis are a nervous restlessness, which is 
 excited in many by the sense of obstruction and pressure in the nose, inability 
 to sleep soundly at night or intellectually to apply themselves persistently by 
 day, together with headache and reflex pressure symptoms, such as hemicrania, 
 or nervous sick headache, asthma, spasm of the glottis, and even epileptoid 
 seizures. The most frequent of the reflex nasal symptoms in childhood are 
 asthma in association with bronchitis, and spasm of the glottis in association 
 with laryngitis; in fact, so common, in childhood, is dependence, at least in 
 part, of chronic bronchitis with asthmatic symptoms upon nasal stenosis and 
 adenoid vegetations that the closest scrutiny and attention should be given to 
 the upper respiratory tract in all such cases. 
 
 Plethora of the blood-vessels of the nasal mucous membrane tends to develop 
 
DISEASES OF THE JVOSE. 831 
 
 a like plethora in the bronchial mucous membrane, and anaemia induced in the 
 turbinated tissues tends to effect an anaemic state of the bronchial tubes. The 
 physiological relationship between the two regions — the nasal erectile tissues 
 being designed to warm and moisten the inspired air — demands, through the 
 vaso-motor system, an intimate correspondence between their blood-supplies. 
 As might therefore be expected, a pathological correspondence also obtains, 
 and, without entering into a discussion of the hypothetical details of nervous 
 mechanisms, we simply state the oft-observed fact, that turgescence and vaso- 
 motor paresis of the nasal erectile tissues may occasion vaso-dilation, congestion, 
 and inflammation of the bronchial mucous membrane. 
 
 The term "reflex" is doubtless often misappropriated, yet it has a definite 
 significance, and the pathological reflexes which originate in nasal or naso- 
 pharyngeal irritation, and terminate in cough, laryngeal spasm, or asthma, fol- 
 low much the same pathway as the physiological reflex known as sneezing. 
 The nasal branches of the ophthalmic division of the fifth nerve and the nasal 
 branches of the anterior palatine, descending from Meckel's ganglion, which 
 is in connection with the superior maxillary division of the fifth nerve, conduct 
 the sensory impression to the medulla. It is there reflected to the respiratory, 
 pneumogastric, and other centres, whence the deep inspiration, forced expira- 
 tion, and the coincident spasm of the pharyngeal and laryngeal muscles, termed 
 a sneeze. This mechanism, of course, varies somewhat with the different 
 pathological reflex acts. 
 
 But nasal irritation does not in every case result in reflex phenomena. 
 Evidently, still other conditions are essential, which must be sought in func- 
 tional derangement tending toward special susceptibility of certain nerve-cen- 
 tres, including those wrought upon by peripheral nasal irritation ; and in chronic 
 inflammation or a predisposition to acute congestive states of particular organs, 
 which unquestionably favors the development in that organ of the ultimate 
 link in the reflex chain. Thus, one affected with bronchitis would suffer the 
 more readily from asthma, excited reflexly by nasal irritation ; laryngitis predis- 
 poses under like conditions to spasm of the glottis, and digestive derangements 
 to migraine. So, in the completed cycle, three factors obtain — nasal-irritation, 
 superexcitable nerve-centres, and a susceptive peripheral organ. But the nasal 
 irritation is the initial link without which the peculiar reflex is not excited, 
 and to which the other factors are subservient. 
 
 Another symptom of hypertrophic rhinitis, secondary to this stenosis, is 
 compulsory mouth-breathing with its many deplorable consequences — e. g. dry- 
 ing out of the mouth and pharynx, facial deformity, and mental obtundity — a 
 symptomatic sequence which has been sufficiently elaborated in the article on 
 " Naso-pharyngeal Adenoid Hypertrophy." 
 
 Also, concerning secondary impairment of hearing, what is said in that 
 article pertains equally to this disease. 
 
 A very annoying symptom, and one which may first attract attention, is 
 dysphonia ; in fact, such children are constantly declared to be tongue-tied and 
 the lingual fraenum cut without benefit, when the real defect in speech lies in 
 occlusion of the nares or naso-pharynx. 
 
 Diagnosis. — This is established by direct rhinoscopic examination ante- 
 riorly and posteriorly ; the latter, however, is not always possible with young 
 children. The turbinated bodies appear red, turgid, and swollen, but they 
 occupy their natural positions and maintain their normal relations to each other 
 and to surrounding parts ; by which fact this disease can readily be distin- 
 guished from nasal polypus. A polypus occupies one of the spaces beneath, 
 
832 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 between, or beside the turbinated bodies ; it is, moreover, movable, and is of 
 paler color than the inflamed mucous membrane. 
 
 Treatment. — When dependent upon adenoid vegetations, the surgical re- 
 moval of these growths in children usually results in subsidence of the hyper- 
 trophic rhinitis. Resolution will be favored in these cases, however, as well as 
 in the milder forms of the disease not secondary to naso-pharyngeal adenoid 
 hypertrophy, by the use twice daily of an antiseptic, alkaline, and mildly 
 astringent spray or lotion, formulated as prescribed in the section on " Simple 
 Chronic Rhinitis." This is especially important as a cleansing measure in 
 cases in which some degree of hypertrophy is conjoined with the suppurative 
 type of rhinitis. Refined petroleum products, variously known as " albolene," 
 lavolene, benzoinol, etc., are just now extensively employed in many combina- 
 tions in all forms of rhinitis, but antiseptic, alkaline, aqueous solutions are 
 certainly more eifective when the parts are to be cleansed of muco-purulent 
 accumulations. Petroleum sprays are, however, often soothing and protective 
 to the parts, especially at times of acute and subacute exacerbations, and may 
 be used in such cases following the aqueous spray twice daily, or used alone 
 with patients who have no retained muco-purulent secretions. " Vaselin oil," 
 being more viscid than the whiter products, and yet sufficiently fluid to be con- 
 verted into spray by a good double-bulb hand-atomizer, is best adapted to this 
 use, and may be prescribed in the following combination : 
 
 Jfy. 01. pini Canadensis Tltv. 
 
 01. gaultherise • .... fflij. 
 
 01. eucalypti TlXij. 
 
 Thymol gr. ss. 
 
 Menthol gr. j . 
 
 "Vaselin oil" q. s. ad fgj. — M. 
 
 Sig. Use with a double-bulb atomizer. 
 
 A more astringent spray is occasionally beneficial, although strong astrin- 
 gents are not well borne by the nasal mucous membrane 
 
 3^. Zinci sulphocarbolat 
 Iodi .... 
 Potassii iodidi 
 Menthol . . 
 01. gaultherise 
 Glycerini 
 Aquae . . . 
 Sig. Use with atomizer. 
 
 • gr- v. 
 
 • g r -j- 
 
 • g r - y- 
 
 ■ g r -j- 
 
 • miij. 
 
 • fsj. 
 
 adf$j.— M. 
 
 Persistent use of these remedies, together with the surgical removal- of ade- 
 noid vegetations and enlarged faucial tonsils, and hygienic guards to prevent 
 frequent "colds," will effect a recovery in the majority of cases of hypertrophic 
 rhinitis of children. A minority, however — which "includes, especially, the 
 older children— will not yield to this treatment, and will require reduction of 
 the hypertrophy by means of the electro-cautery in order to overcome the nasal 
 stenosis. One should not hesitate to adopt this method in suitable subjects, 
 for the results are very satisfactory and the disadvantages trivial ; but consider- 
 able technical skill is necessary to ensure entire safety ; consequently it should 
 not be attempted by one who is unfamiliar with intranasal operating. 
 
 " Vaselin oil " or albolene can be substituted for the glycerin and water in this formula. 
 
DISEASES OF THE' NOSE. 833 
 
 Five per cent, cocaine solution on cotton is first placed in contact with the 
 whole length of the inferior turbinated body for ten minutes. The knife elec- 
 trode is commonly used, but we prefer, as better adapted to the purpose, the 
 ordinary point electrode, which we curve slightly upon the flat, using the sur- 
 face of "the platinum end, and not the very point, with which to burn. This 
 makes a broader eschar than the knife electrode, it is less apt to occasion 
 haemorrhage, it requires less space in transit through the nostrils, and it adapts 
 itself better to the curved contour of the turbinated body, permitting appli- 
 cation farther toward the posterior end of that body. 
 
 The cocaine retracts the erectile structures and temporarily provides space 
 through which the unheated electrode is passed ; the length of the platinum tip 
 is pressed against the turbinated body, commencing as far posteriorly as one 
 can see, and then, when at white heat from the battery, it is drawn slowly for- 
 ward, marking its passage by the production of a white linear eschar. Through 
 this same linear eschar, in order to deepen it, one now draws the instrument a 
 second and a third time. Many will direct that the electrode be employed at a 
 cherry-red heat, but during use the point is sunk in a moist tissue, and what is 
 a white heat in the atmosphere is no more than a cherry heat when in contact 
 with the moisture of the turbinated body. 
 
 The two nostrils should never be treated at the same sitting, and more than 
 one linear cauterization should not be made at one time, although it may be well 
 to draw the electrode two or three times along the same track in order to obtain 
 sufficient depth, as the subsequent cicatrix, in addition to breaking up the free 
 continuity of blood-vessels and substituting a certain overplus of tissue, should 
 serve also to bind down the neighboring portions by attachment to the bony base. 
 Bad cases require six to eight applications of the cautery at intervals of one to 
 two weeks, two or three on each lower turbinated body, and others of less 
 extent on the middle bodies. Antiseptic cleansing sprays should be used dur- 
 ing the intervals. Moderate sepsis has followed this operative treatment in a 
 few instances ; consequently it is best to see the patient on the second and 
 fourth day after operating for the purpose of effecting absolute cleanliness. 
 
 The best substitute for the galvano-cautery when this is not available is 
 chromic acid, which may be used by fusing a bead on the end of a probe and 
 applying it much as one would the electrode. It is apt to produce excessive 
 breadth and insufficient depth of eschar. 
 
 IV. Atrophic Rhinitis. 
 
 This disease, termed also dry catarrh, ozaena, and fetid rhinitis, is charac- 
 terized by atrophy of the mucous membrane, of the underlying cavernous struc- 
 tures, and of the bony projections within the nose, which leads to increased 
 spaciousness of the nostrils ; also by atrophy with impairment of function of 
 the mucous glands, by reason of which the muco-purulent secretion becomes 
 inspissated and accumulates in the form of crusts, which, in turn, undergo 
 decomposition and occasion fetor. 
 
 Etiology. — Frankel first promulgated the theory that atrophic rhinitis was 
 a sequel to hypertrophic rhinitis, a late stage of that disease ; and his views 
 have seemingly been adopted by most other writers, a few guarding this dictum 
 by stating that this disease can also arise independently. 
 
 In a discussion before the American Laryngological Association in 1891, I 
 made this statement : " With regard to the transition of hypertrophic rhinitis 
 into atrophic rhinitis, .... I have never seen a case in which distinct hyper- 
 trophy had passed, definitely, into the atrophic condition." 
 
834 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The life-histories of the two affections are dissimilar. Atrophic rhinitis is 
 common in childhood and early adult life, becomes rare after thirty-five years 
 of age, and is very infrequently observed in patients exceeding forty years of 
 age. 
 
 Hypertrophic rhinitis of the early intumescent variety is not uncommon in 
 childhood and early adult life, but the disease does not become firmly estab- 
 lished, with permanently organized infiltration of the turbinated bodies, at least 
 until maturity; and in the vast majority of cases the quantity and density of 
 infiltrated tissue continues to increase until advanced age. 
 
 Since it is conceded that about ten years' duration of the hypertrophic type 
 is usual before transition into the atrophic type, it is apparent that this theory 
 leaves us without an adequate explanation of the many cases of atrophic rhin- 
 itis which occur in early life. 
 
 The few cases which are explicitly reported by competent observers as 
 having undergone this transition were doubtless illustrations of coincidence, in 
 which, notwithstanding the previous existence of hypertrophy, some other 
 unnoticed or obscure intercurrent cause had served to effect the atrophic change. 
 Bosworth has advanced thfe most rational explanation of the etiology of atrophic 
 rhinitis in designating " suppurative rhinitis of children " as the real cause — 
 a view which harmonizes with the life-history of the disease, and which is con- 
 sistent with the undoubted occurrence of the coincidence above mentioned ; for 
 it is possible for one already the subject of hypertrophic rhinitis to acquire, in 
 addition, the suppurative type of rhinitis, which latter may terminate in the 
 atrophic state in spite of the previously existing hypertrophy. 
 
 Bosworth's theory, moreover, is of special value from a prophylactic stand- 
 point, since it teaches us the importance of promptly suppressing chronic sup- 
 purative rhinitis, viewed as a cause the ultimate effect of which, atrophic 
 rhinitis, is, itself, difficult of suppression. 
 
 Bosworth says, in brief, that the predominating morbid condition of puru- 
 lent rhinitis is desquamation of epithelium ; that as long as this desquamation 
 is confined to the superficial epithelial cells the disease is attended with a thin 
 and fluid muco-purulent discharge, but that, sooner or later, the desquamative 
 process extends to the epithelial lining of the muciparous and follicular glands ; 
 the glandular function is then impaired, and the muco-purulent discharge 
 becomes thick and firmly adherent, in the form of crusts and scales, to the 
 sinuosities of the nose. Further, that this film of desiccated muco-pus, in 
 drying, contracts, and embraces the underlying turbinated tissues in a grasp 
 which necessarily must interfere with the circulation of blood — a condition 
 which limits glandular action still more and conduces to general atrophy. 
 
 Hereditary predisposition to atrophic rhinitis is often pronounced. For 
 instance, a patient, aged twenty-two, has developed the disease during the last 
 two years ; her mother, for some years deceased, suffered from the disease in a 
 typical form ; the patient's child, aged three years, is likewise affected. 
 
 Pathology. — The prominent features of the atrophic process are thus 
 summarized by Bosworth: "First. — Decrease of covering epithelium, with 
 profuse desquamation. Second. — Decrease of the adenoid layer, with lack 
 of blood-vessels, together with destruction of the acinous glands. Third. — 
 A total disappearance of the venous sinuses of the submucous layer of the 
 membrane." 
 
 Symptoms. — Crust-formation and fetor are the most prominent symp- 
 toms of the disease, although other secondary manifestations are numerous. 
 
 The crusts may accumulate only in thin scales or in large masses of 
 horny consistency, which may even occlude the nostrils at times, being firmly 
 
DISEASES OF THE NOSE. 835 
 
 adherent and impacted in the sinuosities of the nares, until by decomposition 
 and softening of the layer adjoining the mucosa they are finally cast loose and 
 expelled in large pieces by blowing, often leaving abraded surfaces behind. 
 
 The fetor varies in intensity in different cases, but is rarely entirely 
 absent, and in its severe forms is so horribly nauseating and penetrating as 
 to contaminate the atmosphere of an entire room in a few minutes, and to 
 necessitate comparative isolation of the patient. The fetid odor is apparently 
 due solely to decomposition of the incrusting secretion in situ, but there is 
 reason to believe that this decomposition may extend to the secretion which is 
 still in process of elaboration in the substance of the glands themselves, 
 although this is difficult of absolute demonstration ; for, however thoroughly 
 one may cleanse the parts, fetor, persisting, might still be caused by small 
 invisible particles of crust in the accessory cavities, ethmoid cells, or sphenoid 
 sinuses. 
 
 In advanced cases, commonly, the sense of hearing is impaired, the patient's 
 own sense of smell obtunded, the external nose broadened, its alse thickened, 
 and the physiognomy lacking in acuteness of expression. 
 
 The disease extends after a time to adjoining surfaces, constituting atrophic 
 naso-pharyngitis and atrophic pharyngitis. The naso-pharynx becomes so 
 incrusted that the fetid masses must be literally pried out with probes and for- 
 ceps. The pharynx presents a capacious, glazed, and dry aspect characteristic 
 of the disease. Much more rarely even the larynx and trachea become in- 
 volved, crusts accumulating in these passages to the point of occasioning 
 dyspnoea. 
 
 Diagnosis. — On rhinoscopic examination, both anteriorly and posteriorly, 
 one is impressed by the spaciousness of the nasal cavities and the presence of 
 scales or crusts. After thorough cleansing the mucous membrane appears 
 smooth and thin, although oftentimes congested and abraded in spots from the 
 irritation of long-retained incrustation. In advanced cases the turbinated 
 bodies appear merely as rudiments. 
 
 The disease is likely to be confounded, especially in childhood, with heredi- 
 tary syphilitic rhinitis, which is also accompanied by fetor and incrustation. 
 Unfortunately, by reason of the fetor the term " ozsena " has been applied to 
 both diseases ; consequently it is a bad name for either affection, especially 
 since it refers only to the symptom fetor. 
 
 In atrophic rhinitis there is uniform atrophy and incrustation without deep 
 destructive ulceration. In syphilitic rhinitis the atrophic process, if present at 
 all, is not uniformly distributed, the nostrils being contorted by deep ulceration 
 and destruction, with subsequent cicatrization, of various parts. Reference 
 may be made to the section on hereditary syphilis of the nose for additional 
 details. 
 
 Prognosis. — Atrophic rhinitis requires persistent thorough treatment over 
 a period of from four months to two years, in order to effect recovery even in 
 young subjects and in recent cases. Both patient and physician are prone to 
 become discouraged and to abandon treatment, much to the disadvantage of the 
 former. Old, inveterate cases must continue cleansing measures for years, as 
 part of the toilet, with the same regularity that is given to the teeth. In the 
 worst cases the difference between persistent treatment and total inattention is 
 the difference between the lot of an acceptable member of society and that of a 
 social outcast. 
 
 The fact that the disease is rarely observed at an age of over thirty-five to 
 forty years argues a natural predisposition to recovery as life progresses, and 
 should operate as a further incentive to persistent treatment. 
 
836 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 1. 
 
 Treatment. — The first essential to successful treatment is absolute and 
 continuous cleanliness of the parts. The crusts must not be allowed to form, 
 much less to undergo decomposition. One of the most efficient means to this 
 end, especially for young children, is the nasal douche. I believe it to be 
 justifiable, for the sake of efficient treatment of this particular disease, to 
 assume the slight risk of inflammation of the ear possible by this instrument. 
 This risk, with proper use of the instrument, is remote in comparison with the 
 danger to the same organ from atrophic rhinitis inefficiently cleansed. The 
 original instrument of Thudicum was of glass, but the ordinary soft-rubber 
 
 bag gravity douche, fitted with a nasal noz- 
 zle (Fig. 1), answers the purpose still bet- 
 ter. It should be suspended from a nail 
 over a convenient basin at such a moderate 
 height that the bottom of the bag is only 
 about three inches above the level of the 
 nose as the head is held over the basin. 
 The patient must maintain breathing by the 
 mouth, well opened : when on applying the 
 nozzle to one nostril the liquid will gravi- 
 tate gently and slowly into one nasal pas- 
 sage and out through the other, the oral 
 respiration sufficing to close the naso-phar- 
 ynx from the oro-pharynx by the velum 
 palati. Not force, but thorough maceration, 
 is requisite to detach the crusts ; therefore 
 one to two pints of fluid should be gently 
 and slowly used twice daily as a part of 
 the morning and evening toilet. The 
 liquid employed should be alkaline, to 
 facilitate solution of the crusts ; antiseptic, 
 to counteract the fetor ; and stimulating, to encourage regeneration of the 
 atrophied glands. These qualities are provided in the following formula : 
 
 ]^. Sodii bicarbonatis giij. 
 
 Sodii boratis 3iij. 
 
 Extracti pini Canadensis fluidi . . . f,^j. 
 
 Glycerini f^iv. 
 
 Aquae q. s. ad f^viij. — M. 
 
 Sig. To be diluted according to tolerance, adding one ounce to the pint 
 or quart of warm water for use with the nasal douche. 
 
 With older children, who can be taught the necessary manipulation, War- 
 ner's post-nasal douche (Fig. 2) should be substituted for the anterior douche 
 of Thudicum, on account of greater safety relative to the ear. The same 
 solution in the same proportion can be used with it. One must first draw 
 up a part of the liquid through the instrument into the rubber ball; then 
 insert the curved nozzle through the mouth, behind the velum palati, into 
 the naso-pharynx, and squeeze the ball, thus expelling its contents forward 
 through the nasal passages. This procedure should be repeated until half a 
 pint of liquid is thus used morning and evening. Children who will not 
 tolerate either of these means can conveniently have the nostrils syringed by 
 an ordinary soft-rubber- tipped ear-syringe. 
 
 Peroxide of hydrogen has the property, by rapid oxidation, of disin- 
 
 Anterior Nasal Douche and Method of Using 
 it. 
 
DISEASES OF THE NOSE. 
 
 837 
 
 Fig. 2. 
 
 tegrating muco-purulent matter, and, when sprayed into the nostrils, it will 
 thus assist materially in loosening the desiccated secretion. 
 It should be used a few minutes before the employ- 
 ment of either form of douche, of a strength just insuffi- 
 cient to cause smarting, sprayed by a powerful double- 
 bulb hand-atomizer. On account of variability and 
 instability of the drug, an exact strength cannot be 
 named, but a 20 to 40 per cent, solution of a 10- to 15- 
 volume peroxide of hydrogen is suitable. 
 
 The patient should receive treatment, preferably, 
 from one to three times weekly in the office, at which 
 time any resisting crusts should be detached by a cotton 
 probang, and more actively stimulating and antiseptic 
 medicaments applied. Of these, the powder insufflation 
 of dithymol iodide (aristol) is one of the most satis- 
 factory. 
 
 For the excoriation and incrustation around the ante- 
 rior nares and over the cartilaginous septum, which is 
 often one of the most annoying features with children, 
 the following ointment, thoroughly used each night, being 
 inserted into the nostrils as far as the finger will reach, 
 gives the most satisfactory results: 
 
 Post-nasal Douche. 
 
 Sig. 
 
 1^. Hydrargyri oxidi flavi . 
 
 " Vaselin" 
 
 For local application. 
 
 g r - J- 
 3J.-M. 
 
 Sprays of " liquid vaselin," with which antiseptic and stimulating medica- 
 ments, such as thymol and menthol, may be incorporated, are also serviceable 
 at times, tending to retard crust-formation. 
 
 Of extraordinary measures, electricity is advocated by Delavan of New 
 York, and "vibratory massage" by Braun of Trieste. 
 
 Cod-liver oil and syrup of iodide of iron are seemingly the most useful 
 internal remedies, although neither can be relied upon to the exclusion of local 
 treatment. 
 
 V. Nasal Myxomata. 
 
 Nasal myxomata, or mucous polypi, are connective-tissue neoplasms which 
 originate from the mucous and submucous tissues of the nose. The disease does 
 not exist as a primary affection — a dictum which is more emphatically, albeit 
 less elegantly, expressed by stating that polyps will not grow in healthy noses. 
 They are always associated with, and caused by, some other nasal malady. 
 Indeed, the removal of such associated maladies together with the polypi is the 
 "keynote" to the proper and effective handling of the patient. 
 
 Polyps are stated to be rare with children, but are probably only relatively 
 so, since the diseases which influence their development are somewhat less 
 usual in young children than in adults. We have observed them in children 
 from the age of eight years upward. 
 
 Recognition of the exact points of origin of the neoplasms is essential to a 
 clear understanding of their etiology and treatment. 
 
 In the outer wall of the middle meatus of the nose is the ethmoidal fissure, 
 or hiatus semilunaris, the anteroinferior boundary of which is a sharp-edged 
 ridge of hook-like curve, and hence termed the unciform process of the ethmoid 
 
838 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bone (Fig. 3). The fissure itself communicates through its upper end with the 
 frontal sinus, and through its lower extremity, the ostium maxillare, with the 
 antrum of Highmore. All of these parts lie high up beneath the middle 
 
 Fig. 3. 
 
 Representing the Outer Wall of the Left Nasal Fossa, with the middle turbinated body turned upward to 
 show beneath the hiatus semilunaris (printed in deep black), to the edges of which polyps are fre- 
 quently attached. 
 
 turbinated bone, which, in the natural state, hangs down over them like a 
 curtain. 
 
 To summarize Zuckerkandl's post-mortem observations of forty-two distinct 
 growths, he found that two-thirds originated from the middle meatus, and that, 
 approximately, two-thirds of this number were attached to the edges of the 
 hiatus semilunaris. With this knowledge, and judging from the superficial 
 position of the neoplasm and the direction of its pedicle toward its attachment, 
 we can be reasonably certain of the deep point of origin even when such 
 is not visible, and can often destroy the very root of the growth by insin- 
 uating a properly-curved cautery point-electrode to the spot. 
 
 Etiology. — The most common complication, acting also in a causal relation 
 to nasal polypus, is hypertrophic rhinitis. Of course, additional factors are 
 necessary to influence the perversion of a simple hyperplasia of the mucosa into 
 one of myxomatous type. 
 
 Stenosis, whether induced by hypertrophy of the inferior turbinated bodies, 
 
DISEASES OF THE NOSE. 
 
 839 
 
 septal deflections, or excrescences, results in defective drainage. Muco-purulent 
 secretion, imprisoned and decomposing in the middle meatus and around the 
 middle turbinated body, excites irritation and furnishes the most favorable soil 
 for polyp growth. 
 
 Very narrow nostrils, because more readily stenosed, are predisposed, in this 
 manner, to myxomata, and peculiar curvatures or deformities of the septum and 
 middle turbinated bodies, by obstructing drainage, have a like effect. 
 
 A tendency to vaso-motor paresis of a diathetic or hereditary nature, which, 
 in certain subjects constitutes the basic lesion of bronchial asthma, will in the 
 same individual underlie the development of nasal myxomata. 
 
 The influence of hypertrophic rhinitis on the etiology and treatment is well 
 illustrated in the following history : 
 
 Miss T , set. ten years. Total obstruction of the left nostril of one 
 
 year's duration. Enormous hypertrophy of the inferior turbinated bodies. 
 Numerous polypi were closely impacted between the turbinated bodies and the 
 septum ; they proceeded from the middle meatus, and were continuously im- 
 bedded in a mass of thick, viscid muco-purulent secretion (Figs. 4 and 5). The 
 
 Fig. 4. 
 
 Fig. 5. 
 
 Polypi in the Middle Meatus, 
 caused by hypertrophy of 
 the inferior turbinated body 
 (child aged ten years). 
 
 Lateral View of the Same (Fig. 4). 
 
 polypi seemed secondary to the hypertropic rhinitis and defective drainage. 
 On the right side hypertrophy was present, but was insufficient to obstruct the 
 drainage, and no polypi were visible. 
 
 Operations first by the cold wire snare resulted in the removal of numerous 
 growths during repeated sittings, but without improvement. The polypi 
 developed as rapidly as removed, springing up like mushrooms in the soggy 
 soil maintained by the imprisoned secretions. The inferior turbinated body 
 was next cauterized along its entire extent, being reduced in front almost to 
 a rudiment, where it previously interfered with vision, instrumental passage, and 
 drainage. One was enabled then to trace the tumors to their exact seat 
 of attachment in the immediate vicinity of the hiatus semilunaris, and to 
 thoroughly eradicate them by reaching that position with a cautery point. No 
 recurrence. Cure complete. 
 
 Again, Miss R , aet. twelve years. Has had catarrhal symptoms for 
 
 some years, with adenoid vegetations and obstruction to the left nostril. Exami- 
 nation Feb., 1893. A single polypus proceeds from the left middle meatus, 
 and is traceable in the direction of the hiatus semilunaris, to which it is evi- 
 
840 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dently attached (Fig. 6). The inferior and middle turbinated bodies are hyper- 
 trophied, and obstruct drainage from the middle meatus. 
 
 In Fig. 7, taken from an older subject, is depicted the manner in which a 
 septal excrescence, by serving as an obstruction to respiration and drainage, 
 
 Fig. 6. 
 
 Fig. 7. 
 
 Single Polypus in the Middle 
 Meatus, caused by hyper- 
 trophic rhinitis (child aet. 
 12). 
 
 Polypus in the Middle Meatus, 
 associated with hypertrophy 
 of the inferior turbinated 
 body and excrescence of the 
 septum. 
 
 especially when conjoined with hypertrophy of the opposite turbinated body, as 
 illustrated, may dam up the secretions in the middle meatus and encourage the 
 growth of polyps. 
 
 Septal excrescence often originates during the developing period of child- 
 
 Fig. 
 
 hood, and is a deformity of the septum narium characterized by an exuberant 
 and projecting growth of bone and cartilage along the sutural lines of the com- 
 ponent bones and cartilages of the septum narium. The most frequent location 
 
DISEASES OF THE NOSE. 
 
 841 
 
 Fig. 9. 
 
 is the sutural line of the vomer and the superior maxilla and cartilaginous 
 septum just within the anterior nares and close to the floor of the nose (Fig. 8). 
 
 Necrosing ethmoiditis of Woakes also figures as a persistent cause and com- 
 plication of nasal polypus. It involves the nasal tributaries of the ethmoid bone, 
 especially its process, the middle turbinated body, which usually appears cleft 
 asunder, leaving a fissure down its centre, from which will protrude the polypi. 
 This is illustrated in Fig. 9, which was taken from a patient, aged twenty years, 
 who had suffered since childhood. 
 
 Empyema of the antrum of Highmore, although 
 rare with children, is also a prolific source of nasal 
 polypus in adults, apparently caused by the constant 
 presence of fetid pus in the middle meatus as it escapes 
 from the antrum through the hiatus semilunaris. 
 
 The form, aspect, and consistence of a myxoma has 
 been compared to a grape-pulp. The natural shape is 
 pyriform, but this is often varied by pressure. When 
 small, it is sessile, but it becomes pedunculated by 
 gravity as development proceeds, and the point where 
 the pedicle is confounded with the tissues of attach- 
 ment is known as the "root." The color varies accord- 
 ing to vascularization from gray to yellow and from 
 yellow to pink and red. 
 
 Pathological Histology. — A typical myxoma, or 
 "myxoma hyalinum," resembles in structure the vitre- 
 ous body of the eye and the gelatin of Wharton of the umbilical cord. Micro- 
 scopically, there are observed either a few roundish cells, as in the vitreous 
 body, or scattered fusiform and stellate cells which send off anastomosing 
 trabecule, as in Wharton's gelatin, or both together, and these are imbedded 
 in a large quantity of a homogeneous gelatinous mucin containing intercellular 
 substance. 
 
 But myxomata rarely appear in this purely typical form, the " myxoma 
 hyalinum " being prone to transformation into allied histological structures or 
 to be represented from the beginning by one of its modified forms. Of these, 
 the most common is the myxo-fibroma, which contains a greater but variable 
 quantity of fibrous tissue. Those which are ordinarily called myxomata usu- 
 ally contain enough of the fibrous element to include them, strictly speaking, 
 within the class of myxo-fibromata. 
 
 Symptoms. — The chief symptom is nasal stenosis, which increases with 
 the development in size and number of the polypi until complete obstruction 
 of one or both nostrils results. Mucous or muco-purulent discharge, cephal- 
 algia, aural complications, and other symptoms of a catarrhal nature, together 
 with those incident to mouth-breathing, are observed. To quote the words of 
 a sufferer : " It affects the sight, the hearing, the taste, and the smell, of course." 
 Spasmodic asthma, paroxysmal cough, and sneezing attacks are among the reflex 
 phenomena which are occasionally excited. 
 
 Diagnosis. — For diagnostic purposes it is usually only necessary to look 
 with a good light and to feel with a probe in order to establish correspondence 
 with the physical characters just described, but more rarely an accurate know- 
 ledge of all pathological states is essential to a precise diagnosis. 
 
 Treatment. — The treatment consists first in the establishment of free nasal 
 passage for respiration, drainage, vision, and instrumental manipulation, and, to 
 this end, in the reduction of hypertrophied turbinated bodies, and removal when 
 
842 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 necessary of septal excrescences by means of the nasal saw. Adenoid vegeta- 
 tions, if present, should be removed. 
 
 While this work is progressing such polypi as can be reached should be 
 removed, and others as rapidly as access is gained. This is done preferably by 
 the cold wire snare. 
 
 But the real success of the treatment, after having gained access to the 
 polypi, consists in tracing them to their points of attachment, and in thoroughly 
 cauterizing these so-called roots ; if not at the same sitting, then at the next, 
 remembering meanwhile the exact spot. Knowing the hiatus semilunaris to 
 be a favorite point of origin, those polypi which proceed from beneath the 
 middle turbinated body should be followed up by insinuating to this point a 
 fine electrode slightly curved on the flat. 
 
 The permanent success of the treatment will depend upon the possibility, 
 in individual cases, of thus reaching the deep points of origin, and upon the 
 establishment of good drainage in the nose. 
 
 VI. Hereditary Syphilis op the Nose and Throat. 
 
 Hereditary syphilis manifests itself in children at any time from birth to 
 four months of age. It has, of course, originated during intra-uterine life, 
 and simply progresses to the point of becoming particularly apparent in the 
 upper respiratory tract during the period stated. In rarer cases it seemingly 
 thus manifests itself first at the age of puberty, or, indeed, at any time pre- 
 vious to this age, but in these cases it is doubtful whether the slighter symp- 
 toms at the earliest period of life have not simply been overlooked. 
 
 From birth onward the disease passes through stages which in their symp- 
 tomatology and pathology are identical with the secondary and tertiary stages 
 of acquired syphilis. Thus, soon after birth syphilitic rhinitis is manifested 
 by coryza, which, as the disease progresses, gradually develops into a muco- 
 purulent discharge, the acrid secretion causing excoriation and incrustation at 
 the margins of the nostrils. It is probable that infiltration of the superficial 
 layers of the mucosa by embryonic cells, and subsequent degeneration of the 
 same into "mucous patches," also occur; but a satisfactory examination of the 
 interior of the nose is impossible at this early age, and a definite diagnosis of 
 this stage may be dependent upon the concomitant symptoms of syphilis. The 
 disease, however, usually runs a rapid course, and the later manifestations, 
 which correspond to the tertiary symptoms of the acquired form, are sufficiently 
 characteristic. A gummatous infiltration, either diffused or circumscribed, 
 occurs in the depths of the tissues, the entire thickness of the mucosa, the car- 
 tilages, and bones being alike subject to an infiltrating deposit of small round 
 cells of embryonic type. These deposits readily undergo degeneration, and 
 result in deep destructive ulceration of the tissues and cartilages and in necrosis 
 of bones. 
 
 The disintegration may commence either in the centre or depths of the tis- 
 sue or upon its surface, and is seemingly occasioned by the cutting off of the 
 blood-supply to this lowly-vitalized material by pressure exerted in all direc- 
 tions by the cells themselves. The cartilaginous septum narium soon disap- 
 pears, the vomer is attacked, the nasal bones affected, and the external nasal 
 appendage sinks backward and downward, acquiring the "saddle-back " deform- 
 ity or "flat nose." One or both alae are not uncommonly destroyed, and sub- 
 sequent cicatrization may obliterate the nasal orifices. In fact, there is no 
 limit to the horrors of this disease when left unchecked, necrosis continuing 
 until death is caused by haemorrhage or meningitis. 
 
DISEASES OF THE NOSE. 843 
 
 In the throat favorite points of attack are the velum palati and the junc- 
 tion of the velum with the hard palate, as well as the palatal processes of the 
 palate bone and of the superior maxillary bone. Thus, the cavities of the nose 
 and mouth are caused to communicate by perforations of greater or less extent. 
 The pillars of the fauces and the posterior pharyngeal wall are by no means 
 exempt. The ulceration being deep, the following cicatrices must be exten- 
 sive, and are found to be thick, dense, and prone to extreme degrees of con- 
 traction, so that they appear, oftentimes, stellated or twisted and contorted 
 into various shapes. They are comparable to, but worse than, the cicatrices 
 which follow deep burns. In this way the pharynx and velum become adhe- 
 rent, the throat being contorted and twisted apparently into one cicatricial mass, 
 which may leave but a minute opening between the pharynx and naso-pharynx. 
 Crusts accumulate in the nasal cavities, and the fetor is intense, occasioned 
 both by the decomposing incrustations and necrosis of bone. 
 
 Treatment; — The patient should be placed as rapidly as possible under the 
 influence of mercury, which is best done by inunction with mercurial ointment. 
 In many cases mercury alone seems superior to the potassium iodide or the 
 mixed treatment. Attention to the bowels and care of the general health are 
 not to be omitted, nutritious diet, fresh air, and tonics being indicated. 
 
 The local treatment is of the utmost importance. The ulcers must be kept 
 absolutely clean and free from decomposing discharges. The means to this end 
 are the same as those detailed in connection with atrophic rhinitis. As a 
 topical application to the ulcers we value most highly the following solution : 
 
 1^. Iodi, 
 
 Acidi tannici, . . 
 
 Potassii iodidi ddsj. 
 
 Glycerini fgss. 
 
 Aquae . . . q. s. ad f§j. — M. 
 
 Sig. Apply by a cotton swab. 
 
 Under this treatment it is a veritable pleasure to watch the absorption of 
 infiltrated masses and the cicatrization of the ulcers. 
 
CATARRHAL LARYNGITIS (SPASMODIC CROUP) 
 
 By H. ILLOWAY, M. D., 
 
 Cincinnati. 
 
 Catarrhal Laryngitis, termed also spasmodic laryngitis, pseudo-croup 
 (false croup), and acute laryngitis, is an acute inflammation of the mucous mem- 
 brane lining the larynx, and not infrequently involves that of the trachea. The 
 disease may present itself with varying intensity ; clinically, three distinct forms 
 have been recognized — the mild, the severe, and the very grave. 
 
 In addition to the usual symptoms we may have — and this is more especially 
 true of the severe form — paroxysms of dyspnoea manifesting themselves, which 
 by some are regarded as true laryngeal spasms. The catarrhal laryngitis 
 with the paroxysms of dyspnoea superadded, which is frequently treated as a 
 distinct disease, has been designated laryngitis stridulosa, angina stridulosa, 
 and spasmodic laryngitis; it is also called pseudo-croup or false croup, to dis- 
 tinguish it from true croup or pseudo-membranous laryngitis. 
 
 Catarrhal laryngitis is a disease that occurs at all periods of child-life from 
 birth up to the fifteenth year. Pseudo-croup is seen with greatest frequency 
 between the second and fourth years. It is rarely seen before the second year, 
 and still more rarely after the fifth year. It attacks children both strong and 
 weak, and does not make much distinction between the children of the rich 
 and those of the poor. It is said that boys are more prone to the disease than 
 girls ; there are, however, no sufficiently reliable statistics upon this point, as 
 this disease has been confounded by many writers with laryngismus stridulus 
 (spasm of the glottis), for which this statement holds good. 
 
 Catarrhal laryngitis presents itself either as an idiopathic affection or as a 
 secondary and symptomatic one, and then usually in the course of some general 
 disease. It occurs with greatest frequency in the colder months, about the 
 beginning and end of winter. In certain latitudes, where the winters are rather 
 mild and the snow melts very quickly and the streets are thus wet and slushy, 
 it prevails throughout the whole winter. The sudden setting in of cold, wet 
 days in summer may cause an outbreak of catarrhal laryngitis. 
 
 Etiology. — The principal etiological factor is taking cold. A very young 
 child may contract a cold by sitting on a cold floor, by throwing off the 
 coverlet at night after the temperature of the room has cooled considerably, 
 by a sudden transference from a very warm to a cold room, more particu- 
 larly a cold draughty hall, or by being taken out on a cold, windy, blustery 
 day ; older children take cold by going out insufficiently clothed, by taking off 
 top-coats in the street after having become heated at play, by wading in water 
 or in snow. Cold air inspired directly, and especially whilst the vocal organs are 
 violently exercised, as in screaming or yelling, is not an infrequent cause of 
 laryngeal catarrh. In some instances I have attributed attacks of pseudo- 
 croup to the cold, moist atmosphere created in the bed-room by a floor scrubbed 
 late in the evening and not thoroughly dried before the child was put to bed. 
 
 844 
 
CATARRHAL LARYNGITIS. 845 
 
 In some children a predisposition to catarrhs of the upper air-passages un- 
 doubtedly exists as the result of a faulty physical training, faulty domiciliary 
 hygiene, and perhaps improper diet in combination with some of the other 
 factors. Scrofulous, weak, anaemic children, with proneness to coryza and to 
 inflammatory affections of the tonsils, are more especially liable to attacks of 
 pseudo-croup. A characteristic of this latter form of catarrhal laryngitis is 
 the tendency to recurrence : children who have once had an attack of spasmodic 
 laryngitis are liable to have a like attack after every, even very slight, expo- 
 sure. After the fifth year, especially if placed under more favorable hygienic 
 conditions, they soon outgrow this tendency; I have, however, observed in- 
 stances where children have remained croupy as late as their ninth year. It is 
 this affection which people really mean when they speak of their children having 
 had three, four, or more attacks of croup. 
 
 Whilst catarrhal laryngitis may be of the mild or severe type from the onset, 
 the grave form is always an acute progression, chiefly due to neglect, of one or 
 the other milder form. The child is allowed to play around at its will despite 
 hoarseness and cough, to expose itself to draughts, to get wetted by rain, till 
 all at once the symptoms of the grave type manifest themselves. The majority 
 of the cases of this character observed by me were due to premature exposure 
 after an attack of measles, before the catarrhal laryngitis that usually accom- 
 panies that disease had fully subsided. 
 
 Laryngo-trachitis is frequently but part of a general inflammatory con- 
 dition extending downward from the nose to the bronchi ; more rarely it is due 
 to the upward extension of a tracheo-bronchitis. 
 
 Occasionally it is due to the exciting influence of local irritants. The in- 
 halation of hot steam, a very dusty atmosphere, and irritating vapors are not 
 infrequent causes of catarrhal laryngitis. Baginsky reports a case where the 
 prolonged inhalation of coal-gas produced a violent laryngo-trachitis. 
 
 As a symptomatic expression of a general affection catarrhal laryngitis 
 occurs in measles, scarlet fever, variola, and erysipelas. It may appear as a 
 complication in typhoid fever, in broncho-pneumonia, and in pulmonary phthisis. 
 
 Pathology. — The most reliable data concerning the coarser anatomical 
 changes occurring in this disease have been obtained by laryngoscopic exami- 
 nation. The principal features of a catarrhal laryngitis are hyperemia, swelling 
 of the mucous membrane, and rather abundant muco-purulent secretion, some- 
 what viscid in character and found adhering to various sections of the laryngo- 
 tracheal mucous membrane. Diffusion and intensity of the hyperemia may 
 vary greatly. The inflammation may be confined to the entrance of the larynx 
 or to the epiglottis (angina epiglottidea) ; it may be more marked in the mid- 
 dle portion of the laryngeal cavity ; it may attack only the vocal cords and the 
 posterior commissure, or it may be diffused over the whole of the larynx. The 
 color of the mucous membrane may range from that of a slight vascular in- 
 jection to a deep dusky red. The vocal cords may present an almost normal ap- 
 pearance, their lustre perhaps somewhat dimmed ; they may be more or less 
 hypersemic, or they may appear as two large rolls of deep red color by reason 
 of marked swelling of their under surface. The tumefaction also varies in 
 extent — sometimes so slight as just to prevent free movement of the vocal 
 cords, at other times so great as to cause marked stenosis. The epithelium is 
 exfoliated in patches, and shallow erosions there appear ; in other parts it will 
 be seen swollen up and forming grayish circumscribed elevations. Small ulcers 
 are sometimes seen, the result of destruction of the epithelial covering and of 
 bursting of distended muciparous follicles. The secretion is at first scant, and 
 if the catarrh be of the mild form and remain limited to the vocal cords, may 
 
846 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 continue so throughout the whole course of the disease. Usually it is at first 
 viscid and transparent like glass ; later on, by the addition of cell-detritus, it 
 becomes turbid and yellowish gray. 
 
 In the severe forms of catarrhal inflammation of the larynx the epiglottis 
 presents a characteristic change of form ; the incurvation of its lateral borders, 
 which to a certain extent is normal in childhood, becomes greater, and fre- 
 quently gives it the appearance of a deep-red swollen stump, which can be 
 seen even without a mirror by simply depressing the tongue. 
 
 In the trachea the vascular injection is rarely a diffused one; only in the 
 more intense forms do we find the whole mucous membrane deep red and 
 velvetv. Ordinarily the redness is here found in patches ; the tracheal rings 
 can be readily recognized, and the mucous membrane covering them is less 
 injected, paler than that of the interspaces. 
 
 In the grave form the inflammation frequently involves the submucous 
 tissue. 
 
 For greater lucidity and better comprehension the various types will now 
 be considered separately. 
 
 I. The Mild Form (Laryngitis Catarrhalis Simplex; Supraglot- 
 
 tic Laryngitis). 
 
 Symptoms. — The main features of the disease are the change in the voice 
 or crv and the cough. In young infants it is only the cry that is altered, 
 whilst in older children the speaking voice is also changed ; they are hoarse. 
 This hoarseness may be very slight, only noticeable to those familiar with the 
 child, or marked and apparent at once to every one. There is almost never 
 aphonia ; however, in infants who cry and scream a great deal aphonia may 
 result from this. Older and more intelligent children may complain of a tick- 
 ling or burning in the larynx or about the sternal region. Pressure over the 
 cricoid cartilage or over the trachea usually produces manifestations of pain. 
 There is not much cough ; it is chiefly due to voluntary efforts at expulsion of 
 mucus. The cough is dry at the outset, but very soon becomes looser and 
 softer, an indication of the resolution of the catarrhal process. It never has 
 the barking tone of the severe type. Respiration remains unchanged. There 
 are no paroxysms of dyspnoea. Generally there is greater hoarseness and 
 more cough in the morning just upon awakening and in the evening. Fever 
 is most frequently wanting ; when it does present itself, it is usually of slight 
 degree. There is but little disturbance of the economy as a rule ; the child 
 eats, plays and sleeps about as usual. Acute rhinitis is almost always present ; 
 at times some redness and swelling of the pharyngeal mucous membrane may 
 be noted. In some instances the child may complain of earache, which, how- 
 ever, very soon disappears, or he may complain of a "cracking" in the ear, 
 heard in the act of swallowing. Occasionally some bronchial catarrh may be 
 present, as indicated by rales heard over the thorax. 
 
 Laryngoscopy examination discloses a moderate hyperemia of the larynx 
 or a more intense hyperemia of the larynx and trachea. In the majority of 
 cases it is limited to the supraglottic portion of the larynx. The posterior por- 
 tion of the vocal cords, the posterior commissure, and the mucous membrane of 
 the ventricular bands are the principal seat of the catarrh. There is but very 
 little or no swelling of the mucous membrane. 
 
 Course and Duration. — Under fair conditions the disease runs a very 
 rapid and favorable course, ending in recovery. Its duration, dependent some- 
 what upon the degree of intensity, is from three to eight days. Either from 
 
CATARRHAL LARYNGITIS. 847 
 
 neglect of the primary affection or from some inherent idiosyncrasy the disease 
 may become chronic ; this, however, is rather a rare occurrence in young 
 children. An acute progression into the severer forms is not very frequent. 
 
 Complications. — Bronchitis or catarrhal pneumonia may develop in the 
 course of a catarrhal laryngitis as a result of the downward extension of the 
 inflammatory process. 
 
 Diagnosis. — The diagnosis is not difficult. The hoarseness of the cry or 
 of the voice, the cough, and the tenderness over the larynx will clearly indicate 
 the seat of the affection. The mildness of the special symptoms, the absence 
 of fever or its low degree, the undisturbed condition of the general economy, 
 and the coincident rhinitis will indicate the type. 
 
 Prognosis. — The prognosis is always favorable ; recovery is the rule. 
 
 Treatment. — The treatment is simple. The child must be kept in the 
 house and if possible in one well-ventilated room, the atmosphere of which is 
 maintained at an equable temperature. If the room be heated by a stove, a 
 pot of water should be kept constantly thereon to moisten the air. Attention 
 must be paid to the child's clothing that it shall be sufficiently warm, lest 
 he should be chilled every time the door is opened or if he should happen to 
 run out into an adjoining room or hall. If the bowels are costive, a laxative 
 — e. g. a dose of castor oil — must be administered. When children object to 
 taking oil or do not retain it upon the stomach, I have found the following 
 formula answers the purpose very well : 
 
 1^. Mass. hydrargyri grs. ij. 
 
 Syr. mannse f 3v. 
 
 Syr. rhei aromat f ^iij. — M. 
 
 Sig. One teaspoonful every two hours till bowels are moved (for a child 
 from two to four years old). 
 
 Or this, 
 
 I^j. Aquae laxativae Viennensis (Ph. G.) 1 . . . . f ^j. 
 
 Syr. rhei aromat f* 3iij . — M. 
 
 Sig. One teaspoonful every two hours till bowels are moved. 
 
 For the local process in the larynx mild demulcent drinks are given, as 
 warm milk sweetened, or milk and seltzer water, or oatmeal- or barley-water 
 sweetened. Of medicines, some preparation of ammonia (I prefer the carbon- 
 ate on account of its more agreeable taste), of ipecacuanha, or of both com- 
 bined, or a combination of syrup of ipecacuanha and syrup of senega, will be 
 of great benefit. For example: 
 
 1^. Ammonii carbonatis grs. ij— v. 
 
 Syr. ipecacuanhse fjij-^iij. 
 
 Syr. senegae f 3ij-3iij. 
 
 Syr. tolutan q. s. ad f^j. — M. 
 
 Sig. One teaspoonful every two hours (for children from two to five years 
 old). 
 
 1 Very much like the infusum sennse compositum of the U. S. P. ; instead of Epsom, 
 Rochelle salts are used. 
 
848 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 For children under two years I use the following formula : 
 
 fy. Ammonii carbonatis g r s- ij- 
 
 Mucilag. acaciae *3iJ- 
 
 Vin. ipecacuanha gtt; xxxv. 
 
 Syr. senegse *3J- 
 
 Syr. tolutan q. s. ad f Bi.— M. 
 
 Sig. One teaspoonful every two hours. 
 
 Externally a stimulating embrocation, as camphorated oil, with or without 
 the addition of a little turpentine or of tincture of ginger, or amber oil, may 
 be applied. . . 
 
 If the child be of sufficient age and of sufficient intelligence, an inhalation 
 from a steam atomizer of a mild solution of sodium bicarbonate in glycerin 
 and water (a few drops of carbolic acid can be added to the solution for its 
 antiseptic properties) may be given twice a day. In very young children 
 inhalations cannot be satisfactorily administered, and are therefore useless. 
 
 The rhinitis that is usually present should receive prompt attention. The 
 nose should be sprayed every four hours ; for this purpose either a 1 or 2 per 
 cent, solution of menthol in albolene or some astringent solution, like the 
 following, should be used: 
 
 fy. Cocaine hydrochlorat grs. ij-iij. 
 
 Acid, tannic • grs. v. 
 
 Aq. destillat f^iv. 
 
 Hydrogen peroxide f3J- 
 
 Giycerini f^iii- — M. 
 
 Sig. Use as a spray. 
 
 If fever be present, a few small doses of quinine will allay it. The choco- 
 late quinines (for very young children I have them powdered and administered 
 in milk) are, by reason of their tastelessness, excellent for this purpose ; two to 
 four tablets may be given every four hours. If the cough is very troublesome 
 at night, one-half to two grains of Dover's powder or five to fifteen drops of the 
 syrup of Dover's powder, according to the age of the child, or a few doses of the 
 bromide of ammonium, will procure a good night's rest. 
 
 Throughout, the diet should be a bland but nutritious one. 
 
 II. The Severe Form ; Spasmodic Laryngitis (Laryngitis Stridu- 
 lus a ; Pseudo-Croup; Catarrhal Croup). 
 
 Symptoms. — The characteristic feature of the disease usually sets in sud- 
 denly. The child has been asleep for three or four hours, sleeping quietly, when, 
 either with preceding manifestations of restlessness or suddenly, it wakes up 
 with a suffocative attack. It coughs ; the cough is short, barking, deep-toned ; 
 between the coughs the deep inspirations have a stridulous, crowing sound. 
 Great anxiety is manifested by these little patients ; very young children will 
 want to be taken up and held upon the arm ; older children will sit up in bed 
 and clutch at the throat, as if to remove the obstacle they imagine there. 
 The face is somewhat congested ; the skin is bathed in perspiration, and the 
 pulse is accelerated. Generally the accessory respiratory muscles are not called 
 upon ; at most there may be noticed a slight distention or increased movement 
 of the alse nasi. In very severe paroxysms, which are of exceptional occur- 
 rence, the accessory respiratory muscles are called into activity, the epigas- 
 
CATARRHAL LARYNGITIS. 849 
 
 trium and false ribs are drawn in on inspiration, and the face is somewhat 
 cyanotic. The dyspnoea lasts for about a minute, a little longer in the very 
 severe cases, when it begins to diminish in intensity, and in half an hour has 
 entirely or almost entirely disappeared. In about an hour the child has quieted 
 down, and soon goes to sleep again. It may cough several times during the 
 night : that short, barking cough, without, however, being disturbed thereby. 
 The next morning the child is apparently well ; older children will want to 
 get out of bed or even out of the room, and nothing but an occasional 
 raw. barking cough remains to tell of what has occurred the preceding night. 
 Occasionally towards the afternoon the cough may become dryer and tighter, 
 and the child have another suffocative paroxysm the succeeding night. This 
 usually ends the matter, and nothing but a loose cough remains. 
 
 There may be some variation in this picture. The dyspnoea may last for a 
 longer period than above described, although the child may fall asleep after 
 a while ; but even during sleep the inspiration will be attended by a stridulous 
 or sawing noise. Or there may be no dyspnoea at all, nothing but the croupy, 
 barking cough (and that is the phenomenon that fills the family with terror). 
 This is more frequently the case when this form of catarrhal laryngitis occurs 
 in older children, those beyond the fifth year. 
 
 It is stated that there may be a recurrence of the paroxysms for from three 
 to five nights. In a large experience I have never seen such recurrence; in 
 fact, never noted a recurrence on the second night. Steiner and Monti observed 
 the recurrence of the suffocative attacks for ten or twelve nights; this was, 
 however, more particularly noted in rachitic children. The special tendency 
 of such children to laryngismus stridulus is perhaps no unimportant factor in 
 the protraction of an attack of pseudo-croup. 
 
 The occurrence of an attack of spasmodic laryngitis during the morning or 
 day sleep is exceedingly rare. Barthez and Rilliet state that they have occa- 
 sionally observed the second paroxysm to set in during the early morning 
 hours. 
 
 Frequently the paroxysms are preceded a day or a few hours by a mild 
 catarrh of the upper respiratory tract — a coryza; there may have been some 
 hoarseness of voice and some cough, but of so mild a character that no 
 attention was paid to them by the parents, and no measures for their cure 
 instituted. Or there may have been marked hoarseness and sonorous cough. 
 Occasionally, and not infrequently, no such preliminary manifestations have 
 occurred, the suffocative attack setting in suddenly after some prolonged 
 exposure on the part of the child some hours previously. 
 
 As to the mechanism of the paroxysm of dyspnoea opinions differ. It is 
 possible that true spasm of the laryngeal muscles may, in a certain category 
 of cases, as in rachitic children or children who have at one time been afflicted 
 with laryngismus stridulus, be a prominent factor in its production; in the 
 majority of instances, however, it is undoubtedly primarily due to the increase 
 of the tumefaction during sleep, when the child is lying down — to the dryness 
 of the laryngeal and pharyngeal mucous membrane at this time, and the incrus- 
 tation of mucus upon the vocal cords, still further narrowing the already some- 
 what contracted glottis, and producing an impediment to respiration sufficient 
 to wake the child. That these are the main and necessary conditions for its 
 production is proven by the rapidity with which the symptoms abate after the 
 child has been taken up and some warm drink given it. It is also more than 
 probable that the hoarse, barking cough with which the child usually awakes 
 is the result of reflex irritation proceeding from the inspissated mucus — in 
 other words, the attempt of nature to dislodge it. 
 
 64 
 
850 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 There is not much elevation of temperature. I have never found the ther- 
 mometer to indicate more than 101.5°-102° F. shortly after the abatement 
 of the paroxysm. 
 
 Laryngoscopic examination will disclose considerable hyperemia and tume- 
 faction of the mucous membrane, especially of the ventricular bands, so that 
 these may lie over the true vocal cords and the latter appear narrower. The 
 vocal cords themselves may have a tumefied and rosy appearance, the tume- 
 faction pertaining more particularly to their under surface. The mucous mem- 
 brane of the thyroid cartilages, of the ary-epiglottic folds, and of the trachea, is 
 considerably swollen, and either uniformly injected a deep red or hypersemic 
 only in spots ; the surface sometimes presents a grayish appearance, as if it had 
 been touched with caustic ; this is undoubtedly due to a swelling of the epi- 
 thelium. Incrusted mucus is also seen upon the interarytenoid mucous mem- 
 brane and along the posterior portions of the vocal cords. 
 
 Course and Duration. — The disease with proper attention usually runs a 
 mild course; the cough soon becomes loose and soft; there are no further 
 returns of the paroxysms, and in from five to fourteen days the child has 
 entirely recovered. It is well enough, however, to remember the fact, already 
 mentioned, that there is a tendency to a recurrence of the disease with every 
 fresh exposure. 
 
 Complications. — Bronchitis and broncho-pneumonia. 
 
 Diagnosis. — The diagnosis of pseudo-croup does not usually present any 
 difficulties. The brief invasion, the characteristic paroxysm with its sonorous, 
 barking cough, and the rapidity with which it passes, the time of onset, the 
 rather mild febrile movement, are features sufficiently distinctive to make error 
 almost impossible. The only two diseases with which it could be confounded 
 are laryngismus stridulus and true croup. From the former it is readily dis- 
 tinguished by the cough, the hoarseness in the voice, and the fever — phenomena 
 altogether wanting in laryngismus stridulus. From the latter, for which only 
 a very severe attack of spasmodic laryngitis could be mistaken, the differential 
 diagnosis can be made by remembering the following points : In true croup the 
 symptoms are at the outset very mild and gradually grow in intensity. This 
 increase in gravity continues both day and night. The difficulty in breathing 
 grows by degrees, and continues so to grow till the climax, marked dyspnoea, 
 is reached. The cough is harsher and more smothered. The voice is hoarse 
 and rather muffled. There is a high degree of fever and great disturbance of 
 the general economy. Furthermore, in 50 per cent, of the cases of true croup 
 false membrane can be seen upon the tonsils, uvula, fauces, or pharynx. In 
 pseudo-croup the suffocative attack comes on suddenly in the night, at once 
 with maximum intensity, and abates entirely in a very short time. The cough 
 is sonorous. The voice, soon after the paroxysm is over, regains tone, though 
 it may be somewhat hoarse. There is much less fever and much less dis- 
 turbance of the general economy. 
 
 Prognosis. — The prognosis is as a rule favorable ; no death from pseudo- 
 croup has ever been reported. Nevertheless, it should be a guarded one, for 
 the reason that this form of catarrhal laryngitis may, either from total neglect 
 or even insufficient attention to the child, progress into the grave form, or that 
 a pseudo-membranous laryngitis may supervene upon the catarrhal, the in- 
 flamed mucous membrane forming an excellent nidus for the lodgement and 
 propagation of disease germs. 
 
 Treatment. — Ordinarily the paroxysm per se does not require the atten- 
 tion of the physician ; it is usually over by the time he reaches the house. 
 Only in exceptional cases, where the paroxysm is very much prolonged, where 
 
CATARRHAL LARYXGITIS. 851 
 
 spasm of the laryngeal muscles has probably been excited by the laryngitis, 
 must special measures for its abatement be instituted. For this purpose the 
 child should be placed in a warm bath, temperature 100°-101.5° F., and 
 allowed to remain therein from ten to fifteen minutes, so as to obtain its full 
 relaxing effect ; or a hot mustard foot-bath may be given in its stead. A sponge 
 wrung out of hot water may be applied over the pomum Adami, as described 
 farther on. Or 20-25 drops of ether may be given to a child two years of age, 
 and if necessary it may be allowed to inhale a little. The ether acts by its 
 relaxing effect on the laryngeal muscles and its expectorant effect on the mucous 
 membrane. (For other remedial measures employed for this purpose see the 
 article on Laryngismus Stridulus.) 
 
 The treatment of pseudo-croup, with the exception above noted, is rather 
 simple. The remedy mainly indicated is one that has both expectorant and 
 relaxing properties, and the one that best fulfils these indications here is some 
 form of ipecacuanha. The formula I have employed with unvarying success 
 is this : 
 
 I^. Vin. ipecac f^j. 
 
 Tinct. aconiti TTL ij- 
 
 Syr. tolutan f^iij. 
 
 Liquor, ammonii acetat f^i. — M. 
 
 Sig. Teaspoonful every hour till cough is loosened ; then every two hours. 
 
 In children under two years I use the following formula : 
 
 3^. Liquor, ammonii acetat f^vj. 
 
 Tinct. aconiti Tftj. 
 
 Syr. ipecac f^iiss. 
 
 Syr. tolutan fgiss. — M. 
 
 Sig. Teaspoonful every two hours. 
 
 In these formulae we have the expectorant properties of the ipecacuanha 
 aided by those of the mild ammonium preparation and by the relaxing effect 
 of the aconite. The liquor ammonii acetatis has, furthermore, diaphoretic 
 properties very advantageous in the treatment of inflammations of the respi- 
 ratory tract. The aconite acts as a febrifuge and is reinforced by the ipecac- 
 uanha. 
 
 If after twelve to eighteen hours I find that the respiration is still accom- 
 panied by a sawing noise, is still somewhat stridulous or whistling, although 
 there is no dyspnoea present, I prescribe pilocarpine : 
 
 1^. Pilocarpin. hydrochlorat . . gr. J. 
 
 Acid, hydrochloric, dilut. - . . . . . . TTL v. 
 
 Aq. destillat. . . . f3iij. 
 
 Ext. ipecac, fl Tfljij- 
 
 (aut, vin. ipecac . f 3j . ) 
 
 Syr. scillse f*3iij . 
 
 Syr. tolutan fsss. — M. 
 
 Sig. Teaspoonful every two hours for a child two and a half years old. 
 
 I have never derived any benefit from the other preparations of ammonium 
 usually employed, the muriate and the carbonate, in any form of acute sub- 
 glottic laryngitis ; on the contrary, I have always found them, more especially 
 the latter, absolutely detrimental. I have had such uniform success with the 
 
852 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 described remedies and formulae that I have never had occasion to resort to 
 opiates ; and in this respect I agree with Bosworth that, as a rule, they should 
 be avoided. Emetics are never required. 
 
 Externally, an application of camphorated oil, as already described, may 
 be made, or a layer of fat bacon or a piece of fat salt pork, upon which some 
 pepper is sprinkled, may be tied around the throat. Sometimes benefit is 
 derived from the application of warm flaxseed poultices. 
 
 If rhinitis be present, it will be treated as already described in the pre- 
 vious section. 
 
 The child must be kept in a warm, well-ventilated room, and under no con- 
 sideration allowed to be taken out or to go out. After five or six days, if the 
 disease have progressed favorably and the weather be good, it can be taken 
 out for a couple of hours during the warmest part of the day. The diet must 
 be bland, but nutritious. The bowels must be kept soluble. 
 
 III. The Grave Form. (Laryngitis Hypoglottica Acuta Gravis; 
 Acute Subglottic Laryngitis, of Grave Form ; Spasmodic 
 Laryngitis, Severe Form ; Catarrhal Croup.) 
 
 Symptoms. — This form of catarrhal laryngitis is almost always an acute 
 progression of one or the other of the milder forms. This progression may 
 be slow, requiring from five to ten days till the climax is reached, or it may 
 be very rapid, thirty-six hours to two days. It is marked by an exagge- 
 ration of all the phenomena above described. The suffocative paroxysms are 
 of greater intensity and of longer duration ; in fact, once established, the 
 dyspnoea is continuous, with but temporarily diminished intensity during longer 
 or shorter intervals. Usually the onset is marked by increased frequency 
 of cough, which is short, hoarse, and markedly croupal ; it is a dry cough ; 
 it is painful, the child crying between the coughs and complaining that it 
 hurts him. The voice is very hoarse or altogether extinguished. The effort 
 at speaking is frequently painful, and the little patient will indicate his wants 
 by pantomimic motions. Then the respiration becomes somewhat difficult and 
 rather loud, and the child becomes restless and irritable, and wants to be held 
 upon the mother's arm or lap. After a longer or shorter period, preferably 
 in the night, the suffocative paroxysm manifests itself in all its severity. The 
 cough is continuous, hoarse, barking, short ; it is not sonorous, rather more 
 muffled ; the respiration whistling and long drawn ; the long-drawn, stridulous, 
 crowing, or hissing inspiration, interrupted by short, hoarse, rather muffled 
 coughs, and followed by the prolonged expiratory sound, can be heard at a dis- 
 tance. With every respiration the larynx makes marked excursions. All the 
 accessory respiratory muscles are brought into full play ; the sterno-cleido-mas- 
 toid, the pectoral, the serrati, and other muscles are observed acting energetic- 
 ally. With every inspiration the thorax is markedly elevated, whilst at the 
 same time the jugulum, the intercostal spaces, and the epigastrium sink in 
 deeply ; on the following expiration the thorax does not at once return to its 
 normal position, and the active efforts of the abdominal muscles are required 
 to effect this. The veins of the neck are distended and filled with dark blood. 
 The extremities are slightly cyanotic. The skin is somewhat turgid; perspi- 
 ration may be abundant over the whole surface, or only a cold, clammy sweat 
 cover both head and face. These symptoms persist, with perhaps somewhat 
 lessened intensity, throughout the night ; generally toward morning there is more 
 marked abatement; the child will fall asleep, gain a few hours' rest, and wake 
 up again with another suffocative attack. The cough is now almost toneless, 
 
CATARRHAL LARYNGITIS. 853 
 
 occurs at but long intervals, and is very short. If the voice was only hoarse 
 at the outset, it is now altogether abolished. The respiration is much more 
 difficult ; all the accessory respiratory muscles are in activity ; the whole atten- 
 tion and energy of the patient are directed to his breathing; the stridulous, 
 sawing noise accompanying inspiration is still more marked. The child can- 
 not lie down, but sits propped up in bed or upon the mother's lap. Gradually 
 there is an apparent relaxation in the patient's eiforts at breathing; he lies 
 back a little more; the pulse becomes small and thready and extremely rapid; 
 the face assumes a pale, cadaveric appearance ; the child becomes comatose or 
 delirious, and death supervenes either from asphyxia or in an attack of general 
 convulsions. 
 
 Exceptionally the laryngitis may be of the grave type from the outset, its 
 first manifestations being the severe suffocative paroxysm just described. 
 
 The course, however, is not always so stormy: in rare instances the pro- 
 gress of the disease is very insidious; the symptoms are of a comparatively 
 mild character, until suddenly, without any warning, death seems imminent. 
 The child has a laryngitis of mild type, to which no attention is paid, and he 
 is allowed to run around at pleasure. After a few days, perhaps a week, he 
 becomes aphonic ; there is but little cough, and that very much muffled and 
 dry. Suddenly the parents observe that the child, which has lain down, is 
 evidently unconscious ; the eyeballs are rolled up under the upper lids, the face 
 is cyanotic or of cadaveric paleness; the body is cool; the pulse very feeble, 
 nearly imperceptible; the respiration almost completely arrested. With an 
 effort the child may be recalled to consciousness for a few moments, but he will 
 quickly relapse into the state of stupor, from which he may never awake. 
 
 The fever, except in the class of cases last described, is always very high ; 
 the thermometer ranges from 102° to 103° F. at the onset, and from 104° to 
 105° and higher at the period of greatest intensity. There is generally great 
 thirst, the patient constantly craving cold drinks, of which he will take but a 
 sip, on account of the interference with respiration. The appetite is completely 
 gone, and it is with greatest difficulty that the child can be persuaded or made 
 to take a little milk or beef-tea. 
 
 When the disease tends toward recovery the severity of the symptoms 
 gradually abates, and when convalescence is fully established they have all 
 disappeared, with the exception of the aphonia, which frequently continues for 
 a considerable time ; or, even if the voice be regained soon, it will have a 
 husky tone for quite a long time. 
 
 Laryngoscopic examination discloses an exaggeration of the picture described 
 in the previous section. The mucous membrane of the whole larynx and 
 trachea is markedly hypersemic and swollen ; the ventricular bands are greatly 
 injected; the vocal cords are either pinkish or normal in color; beneath 
 these, projecting into the line of vision, can be seen the deep-red or almost 
 purplish rounded masses of tumefied subglottic tissue, bellying out far beyond 
 the line of the true vocal cords and narrowing the glottis down to a slit. On 
 the free border of these folds of infiltrated subglottic tissue the muco-purulent 
 secretion collects, becomes inspissated, and forms ragged and jagged incrusta- 
 tions, which tend to still further aggravate the stenosis. As the disease abates 
 these incrustations disappear, and the folds diminish in size and become pale 
 in color. 
 
 Course and Duration. — The course and duration of the disease depend 
 to a great extent upon the degree of intensity developed, upon the period at 
 which medical treatment is resorted to, whether early or late, and upon the 
 mode of treatment. Usually with a sufficiently energetic treatment the acute 
 
854 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 symptoms subside in from two to three days. They never last over five days. 
 The duration of the disease from its onset to its definite cure may occupy a 
 period of from two to three weeks. 
 
 Complications. — Bronchitis, broncho-pneumonia, convulsions. 
 
 Prognosis. — The prognosis will depend in a great measure upon the period 
 at which the physician first sees the case. If at an early period, before the 
 pathological process has involved the submucous tissues, before the disease has 
 reached its climax, a favorable prognosis can usually be made at once. If, 
 however, he is called at a late period, when the laryngeal stenosis is already 
 very marked, it should be very guarded, and more especially so if the con- 
 dition be due to too early exposure after measles. In my experience these have 
 been the hardest to deal with, and I have seen such cases die despite trache- 
 otomy, despite intubation. Then it must be remembered that one or the other 
 of the complications mentioned may develop and carry off the patient. 
 
 Treatment. — In the early stage, when the grave form is just developing, 
 when, although the voice is very hoarse or altogether lost, the short cough is 
 still somewhat sonorous or but slightly muffled, the respiration is still com- 
 paratively easy, without very much stridor, excellent results will be obtained 
 with very small doses of tartar emetic : 
 
 1^. Antimonii et potassii tartrat gr. J- J. 
 
 Syr. tolutan f^ss. 
 
 Aq. destillat f giss. — M. 
 
 Sig. One teaspoonful every two hours, for children from two to four years 
 old. If this dose produces emesis or nausea, but one-half to one-third 
 of a teaspoonful are subsequently given. 
 
 When the disease is fully developed and the dyspnoea great, energetic 
 treatment is required. 
 
 It is in this form of catarrhal croup that the emetic finds its justification, 
 and should be promptly administered. 
 
 The preferable one here again is tartar emetic : 
 
 ty. Vin. antimonii 
 
 Oxymel. scillae aafgss.— M. 
 
 Sig. One-half to one teaspoonful every ten or fifteen minutes till emesis 
 results. 
 
 Or it may be combined with ipecacuanha : 
 
 1^. Vin. antimonii f^iij. 
 
 Syr. ipecac f^v.— M. 
 
 Sig. One-half to one teaspoonful every ten or fifteen minutes till the de- 
 sired effect is obtained. 
 
 Or the compound syrup of squills may be emploved, though the stimulating 
 character of the squills and senega contained therein makes it less desirable 
 than the preceding formulae. If the effect be delayed, it can be hastened by 
 tickling the fauces with the finger or with a feather. After this the antimony 
 is continued in fractional doses, as above described. 
 
 If, despite free emesis, the dyspnoea continues marked and threatening, the 
 app ication just above the manubrium sterni, or the jugulum, of from two to six 
 leeches according to the age of the child, is recommended by some authors, 
 inougn bleeding is not favored by many podiatrists, nevertheless in children 
 
CATARRHAL LARYNGITIS. 855 
 
 of full habit, and if care be taken to arrest the haemorrhage promptly as the 
 leeches fall off. the measure will undoubtedly be of great benefit. If the 
 stridor in the respiration continues marked, though the dyspnoea has greatly 
 abated, the application of a blister to the neck at the side of the larynx, 
 followed by a dressing of unguentum hydrargyri, is likewise recommended by 
 some writers. 
 
 If the bowels are confined, they should be freely moved, and for this pur- 
 pose a dose of calomel, alone or in combination with sodium bicarbonate, may 
 be prescribed ; and if its action be tardy, it can be hastened by an enema of 
 water or of glycerin. 
 
 J. Forsyth Meigs recommended the following formula as one that had given 
 him good results : 
 
 ]^. Hydrarg. chloridi mitis gr. vj. 
 
 Antimonii sulphuret. praecipitat gr. j. 
 
 Potass, nitrat gr. xij-xxij. — M. 
 
 Ft. pulv. et divide in part, aequal. No. xij. 
 Sig. Powder every two hours. 
 
 He also stated that in some cases where, despite emetics, bleeding, and 
 antimony, the dyspnoea had gone on for four or five days, it yielded rapidly 
 under the sedative and cathartic effect of four grains of calomel administered 
 in one-grain doses every hour. 
 
 Rauchfuss reports some cases that he treated with calomel in small doses 
 internally, and inunctions of mercurial ointment, with excellent results. 
 
 In addition to the measures already described, inhalations from a steam 
 atomizer or sprays of a solution of sodium bicarbonate, with the addition of a 
 little carbolic acid, 1 will prove of great advantage. 
 
 During the paroxysm counter-irritation by means of mustard plasters can 
 be resorted to, or the measure so highly recommended by Trousseau may be 
 employed : A sponge is dipped in water as hot as can be borne, placed under 
 the chin, and gradually pressed out, so as to have the hot water flow over the 
 larynx ; in ten or fifteen minutes the process is repeated. Rauchfuss also 
 recommends cleansing the pharynx and the vestibulum laryngis by means of the 
 finger, brush, or the cotton-holder wrapped with cotton, and believes that by 
 the coughing and choking thereby excited better results are obtained than with 
 an emetic. Or the administration and inhalation of ether, as already described, 
 may be resorted to. 
 
 Warm drinks, especially warm milk, should be freely given. Even when 
 the child has fallen asleep after the subsidence of the most threatening symp- 
 toms, it should be awakened every few hours and a warm drink given it, and, 
 if it be old enough, an inhalation, to keep the parts moist and thus prevent a 
 return of the paroxysm. 
 
 When, despite these measures, the dyspnoea grows greater and asphyxia is 
 imminent, as indicated by stupor, and by rolling up of the eyeballs underneath 
 the upper lids ; or if these symptoms have already supervened at the time the 
 physician is called, intubation or tracheotomy should be at once resorted to. 
 
 1 R . Sodii bicarb 3J. 
 
 Sodii benzoat. . ■ yiss. 
 
 Acid, carbol. cryst Hl % xij. 
 
 Glycerin f^j- 
 
 Aq. destill fgij.— M. 
 
 Sig. Two teaspoonfuls with an equal quantity of water in cup of steam atomizer. 
 
856 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 After the imminent danger has been averted one or the other method of 
 treatment can be employed. If antimony be selected, it should be the wine 
 that is directed, and in such small doses that it cannot produce retching or 
 emesis, so as not to dislodge the tube. Intubation is, in my opinion, to be 
 preferred to tracheotomy for the middle and poorer classes, as it is almost im- 
 possible for them to give the necessary attention to the patient that is required 
 after the operation. The tube can be removed in from twelve to twenty-four 
 hours. 
 
 During the attack the child must be kept in bed in a well-ventilated room, 
 the atmosphere of which should have a certain amount of moisture ; after sub- 
 sidence of the attack, although he may be allowed to be up in the room, great 
 care must be taken that he shall not run out or expose himself in any way. 
 
 Convalescence being fully established, the warm drinks may, to a great 
 extent, be withheld and the 'moisture of the room markedly lessened. The 
 inhalations can be continued for some time, a weak astringent solution (alum 
 1 per cent.) taking the place, later, of. the soda solution. 
 
 An accompanying bronchitis or coryza must not be neglected. 
 
 Prophylactic Treatment. — With children who have a tendency to catar- 
 rhal affections of the upper respiratory tract a prophylactic treatment should 
 be instituted early. They should be accustomed in the summer months to 
 cold bathing, cold sponging, and cold frictions. If possible, they should be 
 taken to the sea-shore or to the mountains for the summer. In winter, after 
 being washed with warm water, the face, neck, and hands should be sponged 
 off with cold water (just as it flows from the hydrant) ; after their warm bath 
 (which should always be given in a warm room) the body should be well rub- 
 bed with cold water or cold alcohol and water, and thoroughly dried. They 
 should not be allowed to keep on topcoats or hats or shawls whilst in the house, 
 or to run out of the house insufficiently clad. They should be dressed properly 
 and not made sacrifices to the vanity of their parents, especial attention being 
 paid to their foot-gear that it be water-proof; during wet or snowy weather the 
 shoes should be changed two or three times in the day. Their diet should be 
 plain and wholesome, and not too stimulating. They must not be overburdened 
 with studies. They should be allowed sufficient exercise in the fresh air, even 
 on very cold days, but with the direction that as soon as tired they must come 
 into the house to rest : they must not rest out of doors. 
 
 If the children are anaemic or have a scrofulous taint, the proper remedies 
 must be administered. 
 
LARYNGISMUS STRIDULUS. 
 
 By H. ILLOWAY, M. D., 
 
 Cincinnati. 
 
 This condition — termed also Spasmus glottidis (spasm of the glottis) ; 
 Asthma Millarii ; Asthma thymicum Koppii (thymic asthma) ; Asthma rachiti- 
 cum — consists of paroxysms of spasmodic closure or narrowing of the glottis, 
 causing complete or almost complete arrest of respiration, and occurring at 
 longer or shorter intervals. 
 
 Laryngismus stridulus is a neurosis of the larynx, that organ being gener- 
 ally in a healthy state. It is an affection entirely distinct from spasmodic 
 laryngitis (pseudo-croup), with which it has been identified, especially by many 
 English writers. It is not to be confounded with true infantile asthma, which 
 is an entirely different disease. Neither must it be confounded with internal 
 convulsions (inward spasms), though it is true that spasm of the glottis may occur 
 in inward spasms, and, vice versd, inward spasms may occur in the course of a 
 protracted case of laryngismus ; in either instance, however, it is more in the 
 nature of a complication which adds to the dangers of the primary affection and 
 makes its prognosis more unfavorable. 
 
 The paroxysm sets in always during inspiration, and is produced by spastic 
 contraction of the muscles which normally possess the function of narrowing or 
 closing the glottis — the adductors, the two thyroarytenoids, the two lateral 
 crico-arytenoids, and the arytenoideus muscle. This abnormal muscular action 
 is the result of irritation, either direct or reflex, of the laryngeal recurrent 
 nerve, or of the vagus above the point where the laryngeal recurrent is given 
 off. 
 
 Escherich, in his address before the Tenth International Congress, clearly 
 indicates his belief that laryngismus stridulus is not a morbid entity, but merely 
 a symptom of another affection — namely, latent tetany. He claims to have 
 found the characteristic symptoms of the latter disease (Trousseau phenomenon, 
 etc.) in all the cases presenting themselves for treatment for laryngospasm. 
 Loos by his investigations confirms the views of Escherich. He also affirms 
 that in all cases coming under his observation for laryngospasm he found, like 
 Escherich, the characteristic symptoms of tetany. In his summary he says that 
 it remains to be proven whether we ever have laryngospasm independent of the 
 other symptoms of tetany. 
 
 The disease is somewhat frequent in France ; more prevalent in England 
 and Germany. From the latter country we have the greatest number of cases 
 reported. According to good authority, it appears to be much more frequent 
 in certain localities there than in others. In this country it is exceedingly 
 rare, and but few American physicians have the opportunity of studying it by 
 personal observation. This rarity is, I believe, readily explained by the fact 
 that pap-feeding to infants is almost entirely unknown here. 
 
 857 
 
858 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 Laryngismus stridulus is essentially a disease of infantile life, from birth to 
 the close of the first dentition — two and a half years. The period of most fre- 
 quent occurrence is, according to Friedreich, from the fourth to the fourteenth 
 month. Barthez and Rilliet have observed the spasm almost exclusively be- 
 tween the third week and the eighteenth month ; Flesh, between the fifth week 
 and twenty-first month. Of 226 cases of laryngospasm observed by Steiner, 
 174 were in their first year, 52 in their second or third year. Salathe saw four 
 cases of laryngospasm in new-born infants ; Bowen, a fatal case in an infant 
 six days old. The majority of cases occur undoubtedly between the fourth and 
 eighteenth months. This, however, does not preclude the occurrence of the 
 disease at a much later period of child-life : Steffen reports a case of spasm of 
 the glottis in a boy eight years old ; Salathe, one of a child of twelve years. 
 
 As regards sex, it is the consensus of observers that male children are more 
 liable to the disease than female children. This is very clearly demonstrated 
 by Steffen: of 554 cases compiled by him, 386 were boys and 168 were girls. 
 
 The greater number of children attacked are rather stout and present a 
 bloated appearance, as if they had undergone the stuffing process ; much less 
 frequently are really atrophic children affected. Most of them are markedly 
 nervous ; they do not sleep very well, cry a great deal and without cause, have 
 a tendency to holding-breath spells, have very bad tempers, and want to be 
 carried around the greater part of the time. 
 
 The disease is most prevalent in the cold months of the year, winter and 
 early spring, especially in March. Some would have this frequency due to the 
 greater prevalence of catarrhal conditions at these periods. According to Flesh, 
 it is due to the fact that children are kept much more confined to the house 
 during these months. The experience of Mr. Robertson seems to fully cor- 
 roborate this: he recommends "the free exposure of the infant out of doors 
 for many hours daily to a dry cold atmosphere, and, if the air be dry, the 
 colder the better." It is more frequent in northern than in southern latitudes. 
 
 Etiology. — The etiological factors of this disease can be properly divided 
 into two groups: the constitutional and the local. 
 
 Constitutional Causes. — Rickets. — Two-thirds of the children affected 
 with laryngospasm present the stigmata of rickets, and some of these can be 
 detected as early as the third month. The causal relation between the consti- 
 tutional state and the laryngospasm is therefore apparently established ; as to 
 its nature, opinions differ. Elsasser believed that it lay in the craniotabes. 
 This view has, however, been sufficiently controverted by the observations of 
 many that the paroxysms occur not only when the child is lying down, but 
 also when it is held up upon the arm or sitting up in its chair, and no pressure 
 upon the head made. Furthermore, in many cases craniotabes has been found 
 altogether wanting, although other symptoms of rickets were present. 
 
 In children afflicted with rickets the general nervous irritability is morbidly 
 exaggerated. This Steffen holds responsible for the laryngismus. Moreover, 
 by reason of the characteristic change in the shape of the thorax the respira- 
 tions are more superficial and necessarily more frequent. Now, if, by any cause, 
 as an attack of coughing, screaming, great fright, swallowing the food too has- 
 tily, sudden awakening or being awakened, sudden change of temperature 
 from warm to cold (when the child is carried from a warm to a rather cold 
 room), the uniform rhythm of respiration is interrupted, a hyperemia of the 
 brain and medulla is produced, and the conditions favorable to the production 
 of a spasm of the larynx developed. 
 
 Flesh admits the very frequent coincidence of laryngismus and rickets as 
 set forth, but does not believe in the causal relation of the latter to the former. 
 
LARYNGISMUS STRIDULUS. 859 
 
 For him, not the rachitis, but the factors that gave rise to the cachexia, are 
 the causes of the laryngeal spasm. " Faulty nutrition and injurious food, this 
 and nothing else, are the /cms et origo of spasm of the glottis." 
 
 Heredity. — Instances have been reported where the greater number or 
 nearly all of the children of one family were affected with this neurosis. An 
 hereditary predisposition has therefore been presumed. The cases, however, 
 really prove nothing more than a continuance of the same vicious mode of nur- 
 ture that called forth the disease in the first child ; for in other instances, where 
 already two or more children had been affected, better attention to hygienic 
 requirements and correct feeding kept all the subsequent children free there- 
 from. The supposed special hereditary influence as an etiological factor has 
 been discarded by most authors. 
 
 Local Causes. — Dyspepsia; over-filling of the stomach ; intestinal catarrh ; 
 over-distention of the intestines by faecal masses; great flatulence. Kopp's 
 theory that the disease is always due to enlarged thymus gland has been proven 
 untenable by Friedleben and others. In rare instances it may be the etiolog- 
 ical factor. Bronchial or tracheal glands enlarged or undergoing caseous 
 degeneration, diseases of the heart, and enlarged liver are occasional causes 
 of the spasm. Material diseases of the brain do not, according to Steffen's 
 observations, produce spasm of the glottis. Kyll quotes a case from Corrigan 
 of Dublin which, despite all treatment, had lasted over three months. Acci- 
 dentally it was discovered that pressure over the third and fourth cervical verte- 
 brae was very painful and produced loud cries from the child. Two applications 
 of four leeches, at an interval of two days, over the painful point removed all the 
 symptoms and the child made a perfect recovery. 
 
 Dentition is banished by many from the category of causes. Nevertheless, 
 it is not at all improbable that in such vitiated states of the system, with per- 
 version of many of the physiological functions, as the majority of the children 
 present, the process of teething has a certain causative influence in the produc- 
 tion of morbid phenomena. 
 
 Catarrhs of the larynx, trachea, or bronchial tubes cannot of themselves 
 produce spasm of the glottis by reflex irritation, but when they supervene in 
 cases where it already exists they will aggravate it, and even recall it if it be 
 disappearing. 
 
 Mantel reports the case of a rachitic infant eight weeks old, in whom a 
 very much thickened, congested, and elongated uvula appeared to be the cause 
 of the spasm ; its removal, after other measures had failed, was followed by per- 
 fect recovery. 
 
 J. H. Bryan reports the case of a child suffering since its second week with 
 tonic spasms of the larynx. The epiglottis was found irregular in outline and 
 bent backward over the laryngeal cavity. The child also had a phimosis, and 
 was fed upon undiluted cow's milk. The spasm was attributed to a binding of 
 the epiglottis, causing the aryteno-epiglottic folds to come almost into apposition, 
 so that a slight stridor was produced on inspiration. With reference to this last 
 point, it is well known that a certain amount of recurvation of the epiglottis is 
 normal in young children, and cannot .be regarded as a cause of the spasm. 
 This seems confirmed by the results of the treatment in the case just referred 
 to. On diluting the milk and relieving the phimosis by gradual dilatation the 
 respirations lost their spasmodic character and became normal. "Whether the 
 phimosis had any direct effect in the production of the cramp remains to be 
 determined by further observations: that it may give rise to morbid nervous 
 phenomena is well known. 
 
 In easily excitable children violent and prolonged crying, undue exertion 
 
860 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 in running so as to materially interfere with the respiration, are capable of pro- 
 voking a mild attack of spasm of the glottis. 
 
 In a small number of cases, and more particularly of those occurring after 
 the third year, no special cause for the cramp can be discovered. According 
 to my observation, a hot, vitiated atmosphere in the sleeping apartment, Avhole 
 families sleeping in one room, two, three, or more children in one bed, with 
 doors and windows tightly closed, will account for some of these. In support 
 of this view I would recall here the influence of this factor in the production 
 of trismus. 
 
 Pathology. — The structural changes found upon necropsy vary consider- 
 ably. In so far as the spasm itself is concerned, the results are entirely nega- 
 tive, nothing abnormal having as yet been discovered either in the nerves or 
 the muscles of the larynx. 
 
 In the majority of cases the rachitic changes in the bones and soft tissues 
 present themselves. Craniotabes is frequently found wanting. Various morbid 
 changes are found in the brain, mainly those due to the cachexia. In rare 
 instances softening of the medulla oblongata has been seen. In the larynx 
 traces of catarrh have been found ; occasionally a croupous exudation upon the 
 larynx and trachea; very rarely ulceration. Bronchial or tracheal glands 
 enlarged or undergoing caseous degeneration are sometimes found. The thy- 
 mus gland is occasionally voluminous and juicy. A variable degree of pul- 
 monary emphysema, as the result of the spasm, is always present. Various 
 cardiac lesions have been noted. 
 
 The stomach is not much affected. In the jejunum and ileum the solitary 
 glands and Peyer's patches are enormously swollen, broad, and pale ; concomi- 
 tantly we have hyperplasia and sometimes caseation of the mesenteric and retro- 
 peritoneal glands. The liver presents evidences of fatty degeneration. 
 
 Symptoms. — A typical paroxysm presents the following picture: Sud- 
 denly, without any prodroma on the part of the larynx or the other respiratory 
 organs, the child, who has just been sleeping nicely or has been lively and play- 
 ful upon its mother's arm, in its chair, or has perhaps been a little fretful and 
 crying, is seen to gasp for breath. It becomes rigid ; the head is thrown back 
 and the neck arched forward. The face, more particularly about the nose and 
 mouth, becomes pale, cyanotic, or dusky red. The alse nasi are distended, and 
 the forehead is covered with a cold perspiration. After a few seconds to a 
 quarter of a minute a few whistling or crowing inspirations are heard ; arrest 
 of respiration again follows, lasting from a few seconds to a minute, when the 
 whistling sounds are again heard. After two or three more repetitions of this 
 alternate crowing inspiration and arrest of respiration the crowing inspirations 
 are followed by expirations, the child can soon cry out lustily, normal respira- 
 tion is established, and the paroxysm is over. These whittling or crowing 
 sounds are made by the entrance of air through the narrowed glottis, and 
 are not followed by expiration until the spasm is over. In the milder forms 
 these crowing sounds are heard several times in each paroxysm ; in the very 
 gravest form they are heard only at the beginning and end of the paroxysm, 
 respiration being entirely arrested during the middle period. When the closure 
 of the glottis is complete, the thorax, diaphragm, and abdominal muscles 
 become immobile ; when it is incomplete, laborious respiratory attempts on the 
 part of the various muscles concerned may be noted. The heart's action is at 
 first stronger but irregular, then feebler and more frequent, and the pulse 
 becomes small, sometimes barely perceptible. The severer the seizure the ear- 
 lier there is loss of consciousness. Frequently there is involuntary discharge 
 of the urine and faeces. 
 
LARYNGISMUS STRIDULUS. 861 
 
 The paroxysms vary in severity. In the mildest form, which may pass 
 unnoticed by the parents, especially if it occur during the night, there is but 
 a momentary suspension of respiration, followed by a few whistling or crowing 
 inspirations, and the attack is over. 
 
 The number of seizures in the twenty-four hours varies from a few to as 
 many as thirty or forty. Frequently a few seizures will follow each other in 
 rapid succession ; then a longer period of rest and well-being for the child 
 ensues, to be interrupted again by a recurrence of the spasm. It has been 
 observed that the shorter the intervals between them the milder are the 
 paroxysms. A number of very mild attacks may be followed by a very severe 
 one. The spasm cannot last longer than two minutes at most without bringing 
 about a fatal issue. The paroxysms occur as frequently in the daytime as 
 during the night ; there is no special predilection for the night, as has been 
 supposed by some. "With the progress of the disease convulsive phenomena — 
 namely, tonic spasms in other parts of the body — generally make themselves 
 manifest. The earliest and most frequent are the so-called carpopedal spasms. 
 The thumbs are drawn into the palms and the fingers extended in various 
 directions. The great toe is adducted and drawn upward, and the other toes 
 spasmodically flexed. Sometimes the hands are bent upon the forearm and the 
 forearm upon the arm. The dorsum of the foot may be drawn up firmly 
 against the shin. The ocular nerves also become involved very soon, as 
 shown by the rolling up of the eyes. Clonic spasms occur only when a 
 general eclamptic seizure supervenes, which, according to Henoch, is not so 
 infrequent. 
 
 The disease is apyretic. When fever does set in it generally depends upon 
 some intercurrent affection. Symptoms of dyspepsia are almost always present : 
 eructations, flatulence, constipation, clay-colored stools ; very rarely diarrhoea 
 or vomiting. 
 
 In older children — i. e. after the third year — the tendency to laryngeal 
 spasm is markedly lessened. This may be accounted for upon the ground that 
 they have arrived at a period of greater digestive power, when the problem of 
 nutrition is very much simplified, and also one of greater stability of the nervous 
 system. The paroxysms, when they occur at this later period, are much less 
 severe, probably for the reasons above mentioned, and the further reason that 
 the larynx at this age has grown wider and the cartilages have become firmer. 
 W 7 hen these children feel the respiration becoming impeded they grow fretful 
 and want to lie down. The face becomes pale, never cyanotic or dusky red. 
 The whistling or crowing sounds are not very marked or do not occur at all, 
 and the only complaint is of a tightness about the throat and an inability to 
 swallow. The voice is feeble and speech labored. The cramp lasts at longest 
 but a few seconds, and when it is over the child is as cheerful and apparently as 
 well as before. 
 
 Course and Duration. — The course of the disease is rather irregular. It 
 may set in with great intensity, the paroxysms being very severe and recurring 
 at short intervals ; again, it may begin in a very mild fashion, a few rather mild 
 paroxysms recurring at longer intervals, with periods of entire freedom of from 
 ten to twelve days. Usually, however, it runs a circuit of aggravation, climax, 
 and diminution. Until the climax is reached seven to eight weeks may elapse. 
 There is also considerable tendency to relapse : even after an interval of 
 months of entire freedom, under the influence of exposure, of an inflammatory 
 attack of some part of the respiratory tract, or of a fit of indigestion, the spasm 
 may reappear, and with greater intensity than characterized it previously. The 
 duration of the disease is rather uncertain : the first attack may prove fatal ; 
 
862 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 it may prove fatal in a few hours or it may last for months. Flesh avers that 
 since he has recognized the true nature of the disease he has been able to effect 
 marked improvement in all his cases in a very short time, and cites a case 
 which was discharged well at the end of a month. 
 
 Complications. — The complications that may occur in the course of a case 
 of laryngismus are many. When the disease is of great severity, transuda- 
 tions between the membranes of the brain, into the ventricles, may occur, or 
 already existing effusions (of rachitic origin) may be dangerously increased. 
 We may have effusion of blood between the membranes or upon the brain 
 itself. 
 
 Whooping cough is a dangerous complication. Catarrhs of the larynx, 
 trachea, and bronchial tubes have been already mentioned. Inflammatory 
 affections of the lungs may supervene ; during their continuance the spasm 
 is generally much weaker or ceases altogether. 
 
 The most frequent complications are entero-colitis and eclampsia. 
 
 Diagnosis. — In uncomplicated cases the diagnosis is readily made. The 
 suddenness of the seizure, the brief duration of the apnoea, the intervals of 
 perfectly undisturbed normal respiration, the absence of fever, of cough, of 
 change of voice, are features so distinctive that it is not possible to mistake 
 the disease for croup, oedema of the glottis, or other organic disease of the 
 larynx. The only disease with which it could possibly be confounded is spas- 
 modic laryngitis (pseudo-croup), but spasmodic laryngitis has so different a 
 clinical history that the differential diagnosis is not difficult. From bilateral 
 paralysis of the glottis-dilators it is readily distinguished by the absence of 
 the constant and marked dyspnoea which attends that condition. If there 
 should be any doubt it can be readily solved by a laryngoscopic examination. 
 
 In complicated cases, especially where eclampsia follows in the wake of 
 laryngismus, the diagnosis may be more difficult, likewise in those cases where 
 a catarrhal affection of the larynx and trachea has supervened ; however, a his- 
 tory of the case from its onset will very soon enable us to arrive at a correct 
 conclusion. 
 
 Prognosis. — The prognosis should always be a guarded one, even in the 
 very mild cases. Older statistics show a great fatality. Of 289 cases observed 
 by Reid, 115 ended fatally. Rilliet and Barthez had 9 cases with 8 deaths ; 
 Herard, 7 cases with 6 deaths. Henoch, however, has had a more favorable 
 experience : he says that the majority of the cases recover. Flesh reports 
 that in the last twelve years he has lost but two cases. 
 
 Of course much will depend in any case upon the character of the surround- 
 ings of the child, the severity of the paroxysm, the degree of impairment of 
 the general health, and the intelligence of the parents. In children past thirty 
 months a favorable prognosis can generally be made. 
 
 Treatment. — This can best be considered under two heads : I. The tem- 
 porary relief of the spasm. II. The cure of the underlying pathological 
 condition. 
 
 I. From the brief duration of the spasm the physician is but rarely present 
 when it occurs ; and only accidentally, or if the paroxysms recur at short inter- 
 vals, may he happen to witness it. The treatment, therefore, for the temporary 
 relief of the spasm lies mainly in the hands of the mother or nurse, and she 
 should be properly instructed. In light cases it is not necessary to intervene 
 at all ; only when the paroxysm is of longer duration or when it is made up of 
 a series of attacks should measures for its arrest be instituted. The tongue 
 should be looked after to see that it is not curled back over the laryngeal 
 orifice, as occasionally happens. A large evacuating enema should be given at 
 
LARYNGISMUS STRIDULUS. 863 
 
 once. The child should be placed in a semirecumbent position, all clothing 
 loosened, and an abundance of fresh air provided. Cold water may be splashed 
 into the face and upon the chest, or sinapisms applied to the back of the neck 
 and to various parts of the chest to excite respiration. Apiece of ice wrapped 
 in a cloth and applied over the epigastrium and lower part of the sternum has 
 occasionally proved effective. Ammonia or ether may be held to the nose. 
 Chloroform inhalations, recommended by Simpson, West, and others, are not 
 regarded with much favor, probably for the reason that it is a dangerous 
 remedy to leave in the hands of laymen, and for the further reason that when 
 the respiration is completely arrested it can do no good. Morphia is highly 
 spoken of by Henoch. It is given until drowsiness is produced, then stopped. 
 A rectal injection of chloral hydrate, gr. v, in milk of asafoetida, f^ij, will 
 very frequently prove effective. Pressure on the pneumogastric nerve, on 
 the carotid arteries, is recommended. The fauces may be tickled with the 
 finger or with a feather until emesis results. Morrell Mackenzie recommends 
 putting a pinch of snuff into the child's nose to produce sneezing. 
 
 If the paroxysm be of great severity, cyanosis marked, and apncea persist- 
 ent, the child may be placed in a warm bath (temperature 95° F.), whilst cold 
 water is dashed from a height upon the head and face ; or the child's feet can 
 be placed in a hot mustard foot-bath and a cold compress applied to the head. 
 If the apparatus be at hand, the application of a strong induction current to 
 the phrenic nerve, or of a galvanic current to vertebrae and thorax or over 
 vertebrae and larynx, may prove beneficial. If the danger be imminent, intu- 
 bation should immediately be resorted to ; if that alone prove ineffective, air 
 can be blown into the lungs through the tube and expiration promoted by 
 pressure on the sides of the thorax. Tracheotomy is not in favor. 
 
 Flesh, who has had a large experience, deprecates, as a rule, all interfer- 
 ence with the child, with the exception of the evacuating enema. He asserts 
 that all the other various measures resorted to are not only not beneficial, 
 but positively injurious. 
 
 As soon as the child can swallow the best remedy to be administered is 
 musk, as tincture, in doses of 10-15 drops, or after the following formula 
 (Mackenzie) : 
 
 1^. Moschi gr. iss. 
 
 Sacchari albi 
 
 Pulv. acaciae da gr. i j . 
 
 Syr. aurantii florum TTLxx. 
 
 Aquae adfsj. — M. 
 
 Sig. For one dose, to be given every two hours. 
 
 Tincture of castor and tincture of valerian are also recommended. 
 
 In the interval, to prevent recurrence, or at least to modify the severity and 
 frequency of the paroxysms, numerous remedies have been recommended : 
 musk, castor, valerian, bromide of potassium, bromide of sodium, and chloral 
 hydrate are the most effective. The selection of the remedy will depend in 
 a great measure upon the condition of the child ; in feeble children chloral 
 hydrate should rather be avoided ; in dyspeptic cases the bromide of sodium 
 will be preferred. Scarification or lancing of the gums is of no benefit, and 
 therefore unnecessary. 
 
 Care must be had that the child be not vexed or irritated, especially for the 
 first forty-eight hours after instituting treatment ; its wishes should be com- 
 plied with and its whims humored. Some friendly face should be with the 
 
864 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 child when it goes to sleep, and more particularly when it is about to wake up, 
 so as to avoid all fright. Proper attention must be paid to the ventilation of 
 the room and to all other hygienic requirements. The child must be taken 
 out into the fresh air whenever the weather permits ; the experience of Robert- 
 son in this respect has been already referred to. 
 
 II. The principal point to be kept in view is undoubtedly the cure of the 
 underlying pathological condition. All authors agree that the diet must be 
 strictly regulated and all farinaceous food prohibited. All aliment must be given 
 in fluid form, as thin as water. The only articles permitted are milk and beef 
 tea. If the child be at the breast and the supply be ample, no other food must 
 be given. If bottle-fed, the bottle must be put aside and the child fed with a 
 spoon or feeding-cup. The milk must, at first, be diluted one half with water. 
 It is of the greatest importance that the number of meals and the intervals at 
 which they are given be properly regulated. 
 
 In children under four months six meals per day at intervals of three hours 
 are allowed ; over that age, only five meals per day are given. If possible, 
 nothing should be given in the night ; if the child wake up and cry for its 
 accustomed food, a little water can be given it, and after a while it will fall 
 asleep again, and thus in two or three nights the habit of taking food at night 
 may be broken up. As to quantity, at the outset not more than one half of the 
 normal quantity, according to the child's age, should be given at one feeding. As 
 the digestion improves, as shown by the improved character of the stools, the 
 milk is diluted but one-third, and the quantity gradually increased, until the 
 child gets about the full quantity for its age. When the stools have become 
 normal and have continued so for some time, Flesh recommends, for children 
 over six months old, the addition to the beef tea of a small quantity of boiled 
 lean beef finely chopped, and claims for it great restorative powers. After 
 there has been no recurrence of the stridor for weeks, and not till then, a lit- 
 tle zwieback or dry roll may be allowed ; at first but very little, and if well 
 borne gradually increased. No solid food must be given till after the child has 
 passed its second year. 
 
 The remedies employed in conjunction with this treatment are, in rachitic 
 cases, cod-liver oil and phosphorus. Of the latter agent Baginski says that in 
 some cases it has proved remarkably effective, inhibiting the paroxysms even 
 before any effect upon the rachitis was noted. Where marked anaemia exists 
 some preparation of iron is indicated. For enlarged glands the syrup of the 
 iodide of iron or iodide of iron and manganese must be prescribed. 
 
 Local causes must be properly attended to ; complications must be treated 
 according to their nature. 
 
FOREIGN BODIES IN THE LARYNX, TRACHEA, 
 
 AND BRONCHI. 
 
 By JOHN B. DEAVER, M. D., 
 
 Philadelphia. 
 
 The entrance of a foreign body into the larynx or any of the more remote 
 portions of the air-passages is, fortunately, a condition of somewhat rare occur- 
 rence. When such entrance does happen, it is, in the majority of instances, 
 bv way of the mouth, but it may also occur through penetration of the walls 
 of the larynx or trachea. The infrequency of such accidental lodgements as 
 may occur through the normal opening of the larynx is directly due to the 
 rapidity with which the orifice is closed by the epiglottis. 
 
 A foreign body having, however, entered the cavity of the larynx, it is very 
 likely to have its downward progress arrested by the apposition of the contig- 
 uous borders of the aryteno-epiglottidean folds and the true vocal cords, and to 
 be expelled from this position by the cough which its presence excites. On the 
 contrary, it may, owing to relaxation of the vocal cords, pass through the glottis, 
 and into the trachea or one or other of the bronchi. It is rather exceptional 
 for a foreign substance to enter the larynx during deglutition, except where 
 there is paralysis of the gustatory muscles, such as may follow diphtheria, or 
 where, as the result of ulceration, there is a partial or complete destruction of 
 the epiglottis. Strong inspiratory efforts while feeding or while the mouth 
 contains any substance are most frequently responsible for the entrance of par- 
 ticles of food or other material into the larynx. A sudden attempt to breathe, 
 laugh, or speak, a sneeze, or a sudden blow, all favor the occurrence of such 
 an accident through relaxation of the muscles. 
 
 The amount of obstruction occasioned by the entrance of a foreign body 
 into the air-passages depends upon the character as well as the size of the 
 object. If of organic nature, such as a bean, pea, or grain of corn, the 
 obstruction will be progressive, owing to swelling through absorption of 
 moisture. Of inorganic materials, the most frequently met with are pins, 
 needles, buttons, coins, and teeth. 
 
 The situation and mobility of the foreign body are dependent upon its 
 general characteristics, such as its shape, size, and weight, and the amount 
 of force with which it enters. Statistics show that the most common location 
 is in the trachea, next in the larynx, and lastly, in the right bronchus. The 
 right bronchus is more commonly the seat of obstruction than the left, for 
 the reason that it is the larger and arises higher, and that the septum at the 
 point of bifurcation inclines to the left. 
 
 Symptoms. — The symptoms excited by the entrance of a foreign body 
 into the air-passages are — violent convulsive cough, a sense of suffocation, fear 
 of impending death, and pronounced dyspnoea. If the body is retained 
 but does not entirely occlude the passage-way, these symptoms recur with less- 
 
 55 S65 
 
2,66 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ened severity in the form of a short, harsh cough attended with pain referred 
 to the lower part of the neck, and increased expectoration, which may or may 
 not be bloody. If the position of the foreign body is changed by respiration, 
 the symptoms recur at shorter intervals. The body not being expelled with 
 the subsidence of the symptoms is an evidence of impaction. A foreign body 
 which has been lodged in the air-passage for a considerable period may sud- 
 denly give rise to symptoms of obstruction due to displacement from the seat 
 of impaction. The symptoms excited by the presence of an irregular, angular, 
 or sharply-pointed mass are always more severe; the cough is increased, 
 the interval between the spasmodic attacks is shortened, and the pain is more 
 commonly referred to the larynx. In addition to these symptoms there are 
 evidences of inflammatory disturbance, such as elevation of temperature, in- 
 creased pulse-rate, increased secretion and expectoration, and dyspnoea with pain 
 and tenderness over the seat of lodgement. Symptoms suggestive of incipient 
 pulmonary tuberculosis consequent upon the presence of an unsuspected and 
 impacted body have suddenly abated upon the expulsion or removal of 
 the same. In case of impaction, constant pain, generally located in the upper 
 part of the chest, or a dragging sensation referred to either side of the 
 chest, coupled with the above symptoms, may aid in locating the body. 
 There may be also huskiness of the voice, stridulous breathing, and a cough 
 resulting from deep inspiration, which may be accompanied by mucous or 
 muco-purulent expectoration. If a bronchus be entirely occluded, the lung of 
 the corresponding side may collapse, in which case the normal respiratory phe- 
 nomena will be absent. As a result of the extension of the inflammation by 
 contiguity, the lungs may become involved, and the character of the expecto- 
 rated material will be changed, becoming darker and more offensive. Paroxysms 
 of cough, night-sweats, loss of sleep, and great depression will follow and death 
 from exhaustion probably result. When the foreign body is smooth, rounded, 
 and movable, but little inconvenience may be experienced from its presence, 
 and if in the person of a child old enough to describe his sensations, he may 
 complain simply of a feeling of something moving in the windpipe. 
 
 Diagnosis. — The character of the symptoms and a careful inquiry into the 
 history of the case will materially assist in forming a diagnosis. In the absence 
 of any history of the entrance of a foreign body, the abrupt onset of symptoms 
 of suffocation in a child previously well is sufficiently significant to suggest 
 the character of the obstruction. Acute laryngitis and croup are conditions 
 which may simulate to some extent obstruction by a foreign body, and may call 
 for careful examination in making a diagnosis. In the case of a foreign body 
 the voice is not necessarily changed unless the offending substance be located in 
 the larynx, in which case there is aphonia ; in croup the voice is harsh and 
 high-pitched. In croup or acute laryngitis there is stridulous breathing, which 
 becomes more marked as the case advances ; this is not true of a foreign body. 
 In the latter case, the respiratory embarrassment is more pronounced on expira- 
 tion, while in croup the difficulty occurs on inspiration. 
 
 To distinguish obstruction by a foreign body in the air-passage from one 
 in the pharynx or oesophagus, it will suffice to make a digital examination of 
 the pharynx or an exploration of the oesophagus with the oesophageal bougie. 
 In a case of impaction of a partial plate of artificial teeth in the commencement 
 of the oesophagus, where I was obliged to perform oesophagotomy for its removal, 
 the symptoms were believed to be due to its presence in the larynx. The intro- 
 duction of an oesophageal bougie immediately cleared up the doubt as to loca- 
 tion and position in this particular case. As symptoms of respiratory em- 
 barrassment and the expectoration of muco-purulent material were present, 
 
FOREIGN BODIES IN LARYNX AND TRACHEA. 867 
 
 it was found at the autopsy that an opening into the larynx had occurred as 
 the result of ulcerative perforation. 
 
 While oedema of the glottis may result from the presence of a foreign body, 
 vet it may arise as an independent condition, following injury to the larynx, or 
 the swallowing of chemical irritants of any kind, or it may accompany 
 tubercular, syphilitic, or some other form of ulceration. The diagnosis 
 between foreign body and oedema of the glottis rests largely on the history 
 of the case and upon digital examination, by which is detected swelling of 
 either the epiglottis, the glottis, or of both as the case may be. Further, 
 as mentioned before, the respiratory embarrassment in foreign body is more 
 marked on expiration, while in oedema of the glottis, if seen early, the 
 embarrassment occurs on inspiration only, and in the later stages during 
 both inspiration and expiration. 
 
 Laryngeal obstruction associated with lymphatic enlargement of the deep 
 chain of cervical glands gives rise to a series of symptoms, the onset of which 
 are gradual, and consist in the presence of a tumor of slow growth, with some 
 constitutional evidence of a tubercular diathesis. The symptoms of apparent 
 obstruction in this class of cases are not due so much to pressure upon the air- 
 passage as upon the laryngeal nerves. 
 
 The advantages to be derived from a laryngoscopic examination in children 
 are practically nil, unless anaesthesia be employed, and even under these con- 
 ditions may prove unsatisfactory. The urgency of the symptoms in the case 
 of a foreign body would contraindicate an examination of this kind in the 
 majority of cases, because the manipulation necessary to accomplish it would 
 be attended by more risk than the operation for removal. In those cases 
 where the immediate symptoms of obstruction subside consequent upon the 
 impaction or the lodgement of the body, an examination may be attempted. 
 Auscultation may be of value in locating the position of the mass, which, if 
 in the larynx, may create rough sounds synchronous with respiration. In con- 
 nection with the other symptoms of obstruction, if in the trachea, the body may 
 be detected moving with respiration, and even heard to strike against the wall 
 of the windpipe, while, if in a bronchus or one of the bronchial tubes, the 
 normal vesicular murmur upon the corresponding side is absent or modified. 
 
 Prognosis. — The presence of a foreign body in the air-passages subjects 
 the patient to great danger. For the first seventy-two hours at least the 
 greatest danger is from suffocation, as the body is liable to be forced into the 
 larynx and cause total obstruction. Thereafter the risk is from haemorrhage, 
 inflammation, ulceration or abscess, septicaemia, and death from exhaustion. 
 When the substance becomes impacted in a bronchial tube the irritation 
 excited by its presence may involve the parenchyma of the lung, causing a 
 local pneumonia which is sometimes followed by pulmonary abscess. Other 
 organs may become involved through the extension of inflammation by con- 
 tiguity of tissue — namely, the pericardium, the pleura, and the liver. 
 
 Treatment. — All cases of foreign body in the air-passages giving rise to 
 urgent symptoms call for prompt and, in most instances, radical treatment. 
 Nature alone should not be depended upon to expel the offending mass ; 
 neither should delay be encouraged in the event of the subsidence of the symp- 
 toms, granting that there be no doubt as to its presence. To induce vomiting 
 by the administration of emetics or by mechanical means, is fraught with, to 
 say the least, some risk, and may cause obstruction by impaction in the glottis. 
 If emetics be employed, everything necessary for immediate operation should 
 be in readiness. The practice of inverting the patient and employing succus- 
 sion with the hope of dislodging the body should be practised only under 
 
AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 exceptional circumstances, and resorted to only when no other means are at 
 hand. This form of treatment, like that by emetics, is open to the objection of 
 danger from immediate suffocation. The class of cases in which either of these 
 means is most likely to prove successful is where the obstruction is due to lodge- 
 ment of the mass in the pharynx or oesophagus. Here, however, if the body 
 cannot be extracted through the mouth or forced into the stomach by the intro- 
 duction of an oesophageal bougie, it is not likely that emesis or inversion and 
 succussion will succeed in dislodging it. 
 
 The diagnosis of the presence of a foreign body having been established, 
 the advisability of immediately opening the windpipe, in the event of 
 extraction through the mouth not being feasible, I believe cannot be too 
 strongly urged, as the imminent risk of suffocation is thus removed and 
 the safety of the patient increased. For if the body is not expelled after the 
 windpipe has been opened, impending suffocation is relieved. During the 
 time necessarily consumed in opening the windpipe the respirations, which are 
 already embarrassed, may cease. Should this occur, the operation is to be 
 hastily completed and artificial respiration resorted to. If possible, an anaes- 
 thetic, preferably chloroform, should be administered to prevent pain and allay 
 spasm. With the child anaesthetized the surgeon works to a better advantage, 
 both to himself and to his patient. If time is not a factor, the interval 
 between the paroxysms of dyspnoea is the most favorable for operation, as in 
 this period the child is comparatively comfortable, and the operator can work 
 without undue haste. The mere opening of the windpipe does not entail much 
 risk if performed during the period of calm ; in fact, less than when done for 
 other conditions. With the extraction of the foreign body the chief source of 
 danger is removed, and if done early the necessity for the introduction of a 
 tracheal tube may not be called for, thus simplifying the case, and lessening, 
 particularly, the chances of post-operative pneumonia. 
 
 On the location of the foreign body depends the choice of operation. If 
 diagnosed as occupying the larynx, laryngotomy is advisable on account of its 
 simplicity, the rapidity with which it can be performed, and its affording a 
 more thorough command of the interior of the larynx. If the body is too 
 large to be extracted through this opening, which may be the case in very 
 young children, the space may be enlarged by cutting the cricoid cartilage, 
 and, if necessary, prolonging it into the trachea, making a laryngo-trache- 
 otomy. The entrance of air through this opening may cause the body to be 
 expelled upon expiration through either the incision or the mouth. If the 
 mass is supposed to be located in the upper part of the trachea the high opera- 
 tion is preferable, while if situated lower down in the trachea or in a bronchus 
 the lower operation will be necessary. Occasionally the foreign body, if sharply 
 pointed and impacted, may be detected from without, and then an incision may 
 be carried directly down upon it. 
 
 In performing any operation on the air-passages the child should be brought 
 under the effect of the anaesthetic before being placed in the customary position. 
 A free incision should be made in the median line of the neck, and the 
 trachea or the crico-thyroid membrane exposed, as the case may be, by care- 
 fully dissecting down upon it. The mistake which I think is often made is 
 that of too small an incision through the skin and fasciae. A free incision not 
 only affords more room, but gives the operator a better opportunity of recog- 
 nizing the anatomical landmarks, and of completing the operation with 
 rapidity and safety. In the high operation of tracheotomy the middle lobe 
 (isthmus) of the thyroid gland is to be displaced downward or divided 
 between two ligatures. In the low operation the anomalous position sometimes 
 
FOREIGN BODIES IN LARYNX AND TRACHEA. 869 
 
 held by the vessels must be borne in mind ; also the difficulty which may be 
 experienced in dealing with the thyroid plexus of veins. Upon the exposure 
 and division of the tracheal fascia (the last layer of the structures overlying 
 the trachea) air enters between it and the trachea, giving rise to an emphy- 
 sematous condition by which is occasioned a sound not unlike the entrance of 
 air into the trachea when opened, and this may mislead the operator. A free 
 incision should also be made into the trachea, thus allowing the entrance of a 
 large volume of air, which favors the expulsion of the body. Immediately 
 upon opening the trachea there escapes a frothy mucus or a muco-purulent 
 secretion, depending upon the length of time the foreign body has been pres- 
 ent. The tracheal wound should be retracted, when, if the body is not seen 
 or expelled, an attempt to favor its expulsion should be made by exciting 
 cough by irritating the lining membrane with a feather or a camel's-hair brush. 
 If the body be not expelled by either of these means, an attempt to locate 
 and to extract it should be made. Should this fail, inversion and succussion 
 may be resorted to, this practice not being objectionable after the windpipe has 
 been opened. The finger, with well-smoothed nail, undoubtedly offers the 
 best means of locating the foreign body when the size of the windpipe is suf- 
 ficient. The sensation communicated to it is far more accurate than that 
 obtained through the medium of an instrument. When this manner of pro- 
 cedure is not feasible, the location of the foreign body may be attempted by 
 the introduction of an English catheter without the stylet, a tracheal probe, 
 or the curved laryngeal forceps. The body having been located, its extrac- 
 tion with a pair of laryngeal forceps should follow ; when it holds a transverse 
 position in the air-passage, a blunt hook may facilitate its removal. 
 
 If the foreign body be retained, despite all efforts for its removal, a 
 tracheal tube should not be introduced, but the wound in the trachea is to 
 be kept widely open by retractors retained in position ; or the edges of the 
 tracheal wound, including the skin and fascia, may be transfixed by sutures, 
 the ends of which are left long and tied at the back of the neck. During 
 this time the patient must be constantly watched, so that if the body 
 appears at the bottom of the wound, it can be removed. A foreign body 
 in the larynx too large to be extracted through the wound made in the crico- 
 thyroid membrane or the windpipe may call for partial or complete division 
 of the thyroid cartilage (thyroidotomy). The propriety of introducing a 
 tracheal tube after operation will depend upon the amount of injury the larynx 
 or trachea has sustained. When the operation is completed without the intro- 
 duction of a tube, I should advise against suturing the trachea. 
 
 If the foreign body occupies a bronchus, its extraction can only be safely 
 accomplished by means of low tracheotomy, and the subsequent use of Dur- 
 ham's flexible laryngeal forceps or a stout flexible wire bent in the shape of 
 a blunt hook. The hope of opening a bronchus through the chest-wall, as a 
 preliminary to extraction, has been clearly demonstrated by experiments upon 
 animals to be both a useless and a fatal procedure, especially in the light of the 
 cases where a foreign body has been expelled from a bronchus several days after 
 the operation of tracheotomy. 
 
TRACHEOTOMY. 
 
 By HENRY R. WHARTON, M. D., 
 
 Philadelphia. 
 
 The operation of tracheotomy consists in opening the trachea by an incis- 
 ion through the tissues in the anterior region of the neck, as nearly as possi- 
 ble in the middle line, and is a surgical procedure which is adapted for the 
 relief of dyspnoea due to laryngeal or tracheal obstruction. The operation 
 may be required to relieve the dyspnoea dependent upon membranous or diph- 
 theritic laryngitis, or oedema of the mucous membrane of the larynx or trachea 
 from inflammation due to burns or scalds, or to the inhalation of irritating 
 gases, or the swallowing of corrosive liquids. The operation may be indicated 
 to relieve dyspnoea arising from growths in the larynx or trachea; from growths 
 external to these organs, but causing pressure upon them ; and it may also be 
 required for the removal of foreign bodies from the larynx or trachea, as well 
 as for the relief of dyspnoea due to their presence. Tracheotomy may also be 
 called for in cases of fracture or laceration of the larynx or in cases of spasm 
 of the glottis. The indication for operation in all of these cases is a form of 
 obstructive dyspnoea which threatens life. 
 
 The most reliable symptoms of tracheal or laryngeal obstruction are reces- 
 sion of the anterior and lower portion of the -chest-walls, forcible retraction of 
 the tissues of the epigastrium and of the suprasternal notch, and of the supra- 
 clavicular and intercostal spaces during inspiration. Where these symptoms 
 are marked there exists some serious mechanical obstruction to the entrance of 
 air into the lungs. A child suffering from well-marked obstructive dyspnoea 
 has more or less suppression of the voice, and presents lividity of the lips, blue- 
 ness of the finger-tips, and, as the dyspnoea increases, becomes restless and 
 cannot breathe in a recumbent posture, is unable to sleep, sits up in bed, 
 clutches at his throat as if to remove the offending substance, and presents a pic- 
 ture of distress which, when it has once been observed, cannot well be forgotten. 
 By the change of position the auxiliary muscles of respiration are brought into 
 play ; and the restlessness and inability to sleep, except at short intervals, are 
 explained by the well-known fact that in normal sleep the action of the dia- 
 phragm is diminished, but, when obstructive dyspnoea is present, its action is 
 exaggerated, so that sleep is impossible. A mistake should not be made in 
 confounding labored breathing, which is always present in cases in which there 
 exists mechanical obstruction to the entrance of air into the lungs, with fre- 
 quent breathing, which depends upon diminished air-capacity of the lungs. I 
 call special attention to this symptom — labored breathing — as I am frequently 
 called to see cases to perform tracheotomy where the mistake is made in con- 
 founding these two forms of dyspnoea. 
 
 The operation of tracheotomy is considered by some surgeons a minor, by 
 others a major operation ; but my own experience leads me to consider it a 
 delicate and anxious one, for the condition calling for its performance is one 
 
 870 
 
TRACHEOTOMY. 871 
 
 which involves a vital function ; and, although the operator may often be sur- 
 prised at the facility with which the trachea is exposed and opened, yet in 
 other cases presenting apparently similar conditions he may at each step be 
 met with difficulties which render it a most formidable surgical procedure. I 
 think Mr. Marsh places the operation in its proper position when he says 
 that tracheotomy should be regarded as a delicate operation which requires 
 coolness and caution in its performance, rather than one which is very difficult 
 or dangerous. I am decidedly of the opinion that in this operation coolness 
 in the operator is a matter of the first importance, and that, in spite of the 
 alarming symptoms that may be presented, the judicious surgeon will not 
 allow himself to be unduly hurried in its performance, bearing in mind the fact 
 that in cases of obstructive dyspnoea, except in certain very rare instances, 
 death comes on slowly, that there is generally more time than at first appears, 
 and that precipitated action at the beginning of the operation may cause 
 much time to be lost before its completion. Tracheotomy is most frequently 
 called for in young children, and in this class of patients certain anatomical 
 conditions are present, such as shortness of the neck, abundance of adipose 
 tissue, great vascularity of the parts, a relatively larger size of the isthmus 
 of the thyroid gland, and the possible presence of the thymus gland; all 
 these conditions render the trachea difficult to expose and open. 
 
 The time at which tracheotomy should be performed in cases of obstruc- 
 tive dyspnoea is a point upon which there exists some diversity of opinion. 
 Some operators insist that it should be undertaken as soon as the dyspnoea is 
 well marked, while others postpone surgical interference until the symptoms 
 have become so urgent as speedily to threaten life. I am of the opinion 
 that the operation should not be performed until the dyspnoea is marked and 
 increasing, unless it be due to the presence of a foreign body or a growth 
 in the air-passages, or to an injury of the larynx or trachea, under which cir- 
 cumstances there is no reason to delay. In cases of dyspnoea due to mem- 
 branous laryngitis or inflammatory conditions of the larynx or trachea, I think 
 the surgeon should be largely guided as to the proper time for interference by 
 the urgency of the dyspnoea and the constitutional condition of the patient. 
 When a patient presents the marked symptoms of dyspnoea which have been 
 previously pointed out, and in addition exhibits extreme restlessness and ina- 
 bility to sleep, I think nothing is to be gained by delaying the procedure, for I 
 have never seen such cases recover without operative interference. If, how- 
 ever, he can sleep for a few minutes at short intervals, although the symp- 
 toms of obstruction are present — I am in favor of postponing the operation, 
 since under such circumstances I have seen very urgent cases recover without 
 tracheotomy. 
 
 Another question on which the surgeon is consulted is the advisability of 
 performing tracheotomy in very advanced cases. Here, if an examination of 
 the patient shows that he is not dying of cardiac failure and auscultation of 
 the chest reveals the fact that air is entering the lungs, even though there may 
 be evidence of extension of the membrane into the bronchial tubes, I consider 
 that the urgency of the symptoms presented certainly demands the performance 
 of the operation ; for in a number of these most unpromising cases, where the 
 patients have been apparently moribund at the time of operation, I have seen 
 recovery follow. The operation usually prolongs life even if it does not save 
 it, and generally prevents the patient from dying by a most distressing form 
 of death — strangulation — for in my experience death from recurrent obstruc- 
 tion after tracheotomy is comparatively rare, the majority of cases perishing 
 from pneumonia, from heart failure, or from general adynamia. Many cases 
 
872 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of croup are unquestionably allowed to die without operation where, possibly, 
 tracheotomy might have averted the fatal issue; for there is, unfortunately, 
 among the people a tendency to attribute death, if it results after the operation, 
 to the surgical procedure itself, and not to the disease which necessitated its 
 performance. It is often difficult for this reason to obtain the consent of parents 
 to have the operation performed upon their children, but this opposition may 
 generally be overcome by a candid statement as to what may be accomplished 
 by the procedure. I think there is also among the profession too much tend- 
 ency to look upon tracheotomy as a last resort, and after it has been performed 
 to relax the local and constitutional treatment of the case ; but this is mani- 
 festly unwise, for the operation simply fulfils one of the indications in the treat- 
 ment — viz. to remedy the imperfect air-supply ; and it does not supplant 
 previous appropriate constitutional or local measures. It may be laid down as 
 a safe rule of practice that tracheotomy is indicated in all cases of persistent 
 and increasing dyspnoea due to mechanical obstruction of the larynx or adja- 
 cent parts of the trachea. 
 
 Anatomy of the Anterior Region of the Neck. 
 
 In the operation of tracheotomy it is essential that the operator should bear 
 in mind the anatomical structure of the anterior region of the neck. In cut- 
 ting down upon the trachea in the middle line of the neck from the cricoid 
 cartilage to the sternum, as soon as the skin has been divided the superficial 
 fascia is exposed, and beneath this is the deep cervical fascia, w T hich encloses 
 the sterno-hyoid and sterno-thyroid muscles. The veins of the neck are most 
 important in their relation to tracheotomy, because they are often irregular in 
 distribution, and from the fact that in all forms of pulmonary obstruction 
 they become greatly distended, and injuries to them may be followed by very 
 profuse haemorrhage. Upon opening the superficial fascia a large superficial 
 venous branch, the superficial anterior jugular vein, may be met with, or there 
 may be two veins running parallel with the trachea on each side of the median 
 line, which communicate by a large transverse branch at the lower part of the 
 neck ; they are usually placed one on each side of the median line ; one may 
 be larger than the other, or one may cross the median line and empty into its 
 fellow. A large plexus of veins also surrounds the thyroid isthmus, opening 
 above into the superior thyroid and below into the inferior thyroid vein. The 
 innominate vein on the left side occasionally rises above the level of the ster- 
 num, and has been exposed and injured during the operation of tracheotomy. 
 The sterno-hyoid and sterno-thyroid muscles are most important landmarks in 
 this operation. At their upper attachment they are not quite in contact, and 
 as they descend the neck they are further separated ; the space between them, 
 which occupies the median line of the neck, is a most important guide to the 
 operator. 
 
 The arteries of the neck which are of most importance in the operation are 
 the crico-thyroid artery, a branch of the superior thyroid, and the thyroidea ima, 
 an irregular branch from the aortic arch or from the innominate. In children 
 the innominate artery occasionally rises into the pretracheal space, and this 
 vessel was once exposed by Lucke below the isthmus of the thyroid in per- 
 forming tracheotomy. The isthmus of the thyroid gland is a very important 
 structure in the operation of tracheotomy, and varies much in size in different 
 individuals. It is generally largely developed in children, often covering the 
 second or third rings of the trachea, and in some cases extending higher and 
 covering the cricoid cartilage. The thymus gland, in children under two years 
 
TRACHEOTOMY. 873 
 
 of age, may be exposed in opening the trachea below the isthmus of the thyroid 
 gland ; I have myself seen it present in a number of cases in young children. 
 The trachea begins at the lower border of the cricoid cartilage and terminates 
 opposite the fourth dorsal vertebra, although its surgical limit is the upper 
 border of the sternum. It is most superficial near the cricoid cartilage, is sur- 
 rounded by loose cellular tissue or the tracheal fascia, and is more movable in 
 children than in adults. Its size varies in different individuals of the same 
 asre, being larger in male than in female children. The diameter of the trachea 
 under eighteen months of age is about 4 mm. ; from two to four years, 6 mm. ; 
 from eight to twelve years, 10 mm. 
 
 Tracheotomy in Diphtheritic or Membranous Laryngitis. 
 
 In children suffering from membranous or diphtheritic laryngitis obstruc- 
 tive dyspnoea is most common ; and it is in this class of cases that the surgeon 
 is most frequently called upon to perform tracheotomy. 
 
 Indications for Operation. — In diphtheritic or membranous laryngitis the 
 symptom calling for operative interference is a form of obstructive dyspnoea 
 characterized by suppression of the voice, great difficulty in inspiration, 
 lividity of the lips, depression of the suprasternal and supraclavicular spaces, 
 sinking of the lower part of the chest, inability to breathe in the recumbent 
 posture, great restlessness, and inability to sleep. These symptoms being 
 present and increasing, I think that the operation of tracheotomy is urgently 
 indicated. 
 
 Prognosis of Tracheotomy in Diphtheritic or Membranous Laryn- 
 gitis. — It is to be expected that the prognosis under the above conditions is 
 more unfavorable than in cases where the operation is undertaken for the relief 
 of dyspnoea due to simple inflammatory affections of the larynx or to the presence 
 of foreign bodies in the air-passages. This is not remarkable when we con- 
 sider the fact that, in addition to the local condition of the larynx or trachea 
 which necessitates the surgical interference, there exists a most grave consti- 
 tutional disease which is very fatal in childhood, even in cases where no symp- 
 toms of obstructive dyspnoea are developed. An examination of large collec- 
 tions of recorded cases best shows the results following tracheotomy in this class 
 of cases. Cohen, in the study of 5000 tracheotomies for croup and diphtheria, 
 found that about 1 case in 4 recovered after the operation. Kronlein reports 
 504 similar cases, with 29.2 per cent, of recoveries. Chaym, in 1000 trache- 
 otomies, gives the proportion of recoveries as about 1 in 4. Mastin, in a col- 
 lection of 863 tracheotomies for diphtheritic croup in the United States, shows 
 that the recoveries were about 26 per cent. At the Children's Hospital of 
 Philadelphia the percentage of recoveries in all cases of croup operated upon to 
 the present time has been about 43 per cent. Lovett and Munroe, in a col- 
 lection of 21,853 tracheotomies for diphtheria and croup, drawn from all 
 sources, show that there were 6135 recoveries and 15,552 deaths, or about 
 28 per cent, of recoveries. The statistics of individual operators are often more 
 favorable in a limited number of cases, some being able to show more than 
 50 per cent, of recoveries ; but such statistics are manifestly unreliable, as addi- 
 tional cases would probably very markedly diminish the proportion of successes. 
 In a series of 5 tracheotomies for diphtheritic laryngitis I have had 4 re- 
 coveries, while in 6 operations preceding this series the result was uniformly 
 fatal. In 15 tracheotomies recently performed at the Children's Hospital there 
 were 8 recoveries — a result which even the most enthusiastic advocate of the 
 operation could not hope to sustain with additional cases. In recent years it 
 
874 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 seems the results of tracheotomy for diphtheritic laryngitis have been more 
 favorable, depending possibly upon better judgment as to the time of the 
 operation and the greater care which is exercised in the details of after-treat- 
 ment, as well as upon the improved constitutional treatment of the disease. 
 By comparison of a large number of operations for diphtheritic or membranous 
 laryngitis, it will be seen that the proportion of recoveries is very similar ; that 
 is, about 1 recovery in every 4 cases. 
 
 Age in the Prognosis. — The age of the patient is a very important factor 
 in the prognosis. In infants and very young children recoveries are not very 
 numerous after the operation, yet there have been enough successful cases to 
 show that age alone is not a contra-indication to tracheotomy in this class of 
 patients. A successful case is reported by Scoutetten in an infant of six weeks, 
 one at two months by Steinmeyer, at three months by Annandale, at five months 
 by Croft, at six months by Kisler ; and from this age to two years a number of 
 successful results have been reported. Kronlein, in 85 cases of tracheotomy in 
 children under two years of age, reports 11 recoveries. Chaym, in 997 cases 
 in children two years of age and under, found that only 15.5 per cent, recovered. 
 Archambault, of the Children's Hospital of Paris, presents some statistics bear- 
 ing upon the results of this operation at different ages : 
 
 Of 976 cases in children from 1 to 3 years of age, 104 recovered. 
 . u §22 " " " " 3 " 4 " " " 175 « 
 
 " 736 " " " " 4 " 5 " " " 174 " 
 tt 497 " << " <■<■ 5 " q a " a i4g " 
 
 " 547 " " " over 6 years of age, 198 
 
 It will be seen from these facts that very early age affects the prognosis unfavor- 
 ably, but it also must be borne in mind that the disease for which the operation 
 is performed is itself more fatal in infants and young children. 
 
 Instruments Required for Tracheotomy. — In an emergency tracheotomy 
 may be performed with very few implements, but if the surgeon has the choice 
 he will find it convenient to have the following; instruments at hand : 
 
 2 Small scalpels, 1 Pair of tracheal forceps, 
 1 Short grooved director, Tracheal dilator, 
 
 1 Tenaculum, Tracheotomy-tubes and tapes, 
 
 3 Aneurism needles, which may be used Flexible catheter, 
 
 as retractors, Ligatures, 
 
 1 Pair of artery forceps, Needles, 
 
 4 Hemostatic forceps, Feathers, 
 
 2 Pairs of dissecting forceps, Sponges, 
 1 Sharp-pointed tenotome, Sutures. 
 
 The scalpel should be small and narrow in the blade, so that it shall obscure 
 as little as possible the operator's view of the wound. The grooved director 
 should be shorter and slightly broader than the one generally used (Fig. 1), 
 and it should have a bevelled extremity, which allows it to pass with ease 
 through the different layers of tissue. The ordinary director is usually too 
 long to use with satisfaction in the short necks of children. 
 
 Haemostatic forceps are most useful to temporarily secure vessels which 
 bleed profusely ; they may also be useful in clamping the isthmus of the thy- 
 roid gland on either side, where it is to be divided to expose the trachea under 
 similar circumstances. 
 
 Tracheal forceps may also be of great use after the trachea has been opened 
 or the tube has been introduced, (Fig. 2), to remove loose shreds of membrane. 
 
TRACHEOTOMY. 
 
 875 
 
 Fig. 1. 
 
 A sharp-pointed tenotome is the knife I prefer in opening the trachea ; its sharp 
 point enables it to be thrust easily into the trachea, and its short 
 cutting surface and narrowness of blade are additional advantages, 
 as they enable the operator to see exactly where he is cutting. Of 
 tracheal dilators, either Golding-Bird's (Fig. 3) or Trousseau's 
 (Fig. 4) are the best forms. They can be slipped into the tracheal 
 wound, and thus its edges can be held apart until the trachea is 
 cleared of membrane before the tube is introduced. Golding-Bird's 
 dilator, which is a self-retaining one, is, I think, a very valuable 
 instrument. Tracheal dilators may be improvised from bent hair- 
 pins or pieces of wire, which may serve the purpose when ordinary 
 dilators cannot be obtained. Silk or silver sutures may also be 
 passed through the edges of the tracheal wound and used as dila- 
 tors. Soft or pliable feathers may be introduced into the trachea 
 or larynx to remove mucus or membrane with little risk or injury 
 to the parts. The best feathers for this purpose I have found 
 to be the tail feathers of the turkey. 
 
 Tracheotomy-tubes. — Tubes of various sizes should be at hand; 
 and it is well to remember that the best tracheotomy-tube is one 
 which fits the trachea neatly and inflicts the least possible injury 
 upon it. To ensure this, the part of the tube within the trachea 
 should lie exactly in the axis of the trachea, and its free extremity 
 should be capable of as little movement as possible. The instru- 
 ment now in general use is a quarter-circle tube, which is made of 
 silver and consists of two tubes — an outer one which is attached to 
 a movable collar which fits to a shield, to which tapes are fastened to secure it in 
 position, and a movable inner tube which closely fits the outer tube. The mov- 
 
 Author's Tra- 
 cheotomy 
 Director. 
 
 Fig. 2. 
 
 Fig. 3. 
 
 Tracheal Forceps. 
 
 Golding-Bird's Trach- 
 eal Dilator. 
 
 able collar, which allows the tracheal portion of the tube to change its position 
 during the movements of the trachea and neck, was suggested by M. Roger, 
 and is a modification which has ensured both comfort and safety in the wearing 
 of this instrument. I usually employ a tracheotomy-tube which is of the same 
 calibre throughout, and does not taper toward the lower extremity, as is the 
 case with many of those sold in the shops.' I also prefer the non-fenestrated 
 tube ; the ordinary instrument usually has a fenestra in the outer tube, but I 
 have never been able to see any advantage in this, as it is generally placed 
 at such a position that it is not continuous with the tracheal canal when the 
 tube is in position ; and I think its presence is even a decided disadvantage, 
 as it may be difficult to introduce the inner tube by the bulging of the 
 tissues into it. The tube which I have found most satisfactory is the quar- 
 ter-circle tracheotomy-tube made of silver, as above described, and pro- 
 vided with a fenestrated guide, which materially facilitates its introduction 
 (Fig. 5). 
 
876 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 To diminish the risk of erosion of the trachea or mucous membrane many 
 other forms of tracheal tube have been devised, notably those of Durham, 
 
 Fig. 5. 
 Fig. 4. 
 
 Trousseau's Tracheal Dilator. „ , 
 
 Cohen's Tracheotomy-tube, with fenes- 
 trated guide. - 
 
 Parker, Morant, and Baker. The latter has devised and used flexible tubes 
 made of vulcanized red rubber. Professor Little recommends a non-fen estrated 
 tube constructed of aluminium, which has the advantage of great lightness. 
 Tracheotomy-tubes constructed of hard rubber have also been recommended by 
 some surgeons, but in my experience they are too bulky and are not adapted 
 for use in recent cases, though they may be employed with advantage in cases 
 where the tube has to be worn for a long time. 
 
 The size of the tracheotomy-tube to be employed in an individual case is 
 a matter of some importance, as the calibre of the trachea varies with the 
 age and sex of the patient, being smaller in female children than in males 
 of the same age. The safest rule of practice is to introduce a tube which fits 
 the trachea comfortably. I usually find that a No. 2 tracheotomy-tube fulfils 
 this condition in children under two years of age ; in those from two to four 
 years of age a No. 3 or 4 will usually be found satisfactory. The fear of in- 
 jury to the trachea by the continued presence of a tube has caused some sur- 
 geons to substitute for it a tracheal dilator made of wire ; such devices have 
 been suggested by Watson, Bigelow, and Packard. The latter surgeon has 
 constructed such a dilator which is self-retaining and has somewhat the mechan- 
 ism of the eye-speculum. Experience with the use of these substitutes has 
 been very limited, and I am inclined to think they will prove only of value for 
 temporary use. 
 
 Choice of Operation. — There are two points at which the trachea may be 
 opened, constituting respectively the high and low operations. In the high 
 operation the trachea is opened above the isthmus of the thyroid gland, and in 
 the low operation the opening is made below this structure. The high opera- 
 tion is generally selected in children, because at this point the trachea is most 
 superficial, and for this reason is more readily exposed and opened. In the high 
 operation the cricoid cartilage is frequently divided with the upper rings of the 
 trachea. The low operation cannot be executed so rapidly, and is certainly 
 much more difficult in its performance, because of the relatively greater depth 
 of the trachea, the large size and number of veins exposed, and the proximity 
 to the large arterial trunks. In young children the extreme shortness of 
 the neck sometimes prevents the satisfactory adjustment of the tracheotomy- 
 tube when the low operation is performed. I call to mind the case of a young 
 child in whom I did a low operation, where the lower extremity of the tube 
 came in contact with the bifurcation of the trachea, and it was only after 
 I had the tube shortened that the child could wear it with comfort. Many 
 operators prefer the low operation : Cohen expresses himself decidedly in its 
 
TRA CHEO TOMY. 877 
 
 favor in case the tube is to be worn for a long time or where the operation 
 is done for a foreign body impacted in the bronchus. I am myself decidedly 
 in favor of the high operation in cases of diphtheritic or membranous laryngitis 
 when the tube is to be worn only for a short time, and I would therefore 
 recommend those who have had little experience with the procedure to employ 
 the high operation, on account of the greater ease and safety of its perform- 
 ance, save in the exceptional conditions referred to by Cohen. 
 
 Position of the Patient for Tracheotomy. — In the operation of trache- 
 ctomv it is a matter of the first importance that the patient be placed in such 
 a position that the neck shall be brought into the greatest prominence, to 
 render the trachea more superficial and give the greatest amount of space 
 between the sternum and the chin ; and it is surprising with how much more 
 ease the operation will be accomplished if the patient be placed in this posi- 
 tion. The most satisfactory exposure of the neck may generally be obtained 
 by laying the child upon his back upon a firm table and placing beneath the 
 shoulders a small round cushion or an empty wine-bottle or an ordinary 
 wooden roller-pin wrapped in several towels (Plate XVIII). In this position 
 the head is allowed to drop down, coming in contact with the table ; the trachea 
 is pushed upward, and becomes more prominent, and the anterior portion of 
 the neck is more accessible to the surgeon. The nurse or an assistant should 
 secure the head by applying the hands to its lateral aspects, thus preventing 
 the child from moving it during the operation, and an assistant should also 
 control the movements of the body and arms of the child by holding them 
 firmly against the table. This is much better than securing the arms by 
 pinning a binder around the chest, and does not restrict the already embar- 
 rassed respiratory movements. The same result may be obtained by drop- 
 ping the child's head over the edge of the table and having it held in this 
 position. 
 
 Use of Ansesthetics in Tracheotomy. — As to the use of anaesthetics 
 in the operation there is much difference of opinion among surgeons : many 
 operators of large experience express themselves as decidedly opposed to the 
 use of an anaesthetic on the ground that it is unnecessary and its employment 
 increases the danger of the operation. On the other hand, many surgeons of 
 equally large experience commend anaesthesia, not only as facilitating the ope- 
 ration, but also as not interfering with the success of the procedure. My own 
 experience leads me to agree with the former class of surgeons, and I think 
 there is a growing tendency to discard the use of anaesthetics in this operation. 
 In operating in cases of diphtheritic or membranous laryngitis, I never use an 
 anaesthetic. I have seen cases, which were breathing fairly well before its 
 administration, after its use suddenly become so much obstructed that the 
 operation had to be much hurried, and the trachea opened rapidly even before 
 it was thoroughly exposed — a procedure which is always attended with danger. 
 The unfortunate cases in which I have seen death occur during the operation 
 have generally been those in which an anaesthetic had been used, and in which 
 the above-named complication occurred, necessitating the hurried opening of 
 the trachea, often followed by profuse haemorrhage. Tracheotomy itself is not 
 painful when the dyspnoea is well marked, and after the incision in the skin is 
 made little pain is experienced in the subsequent steps of the operation. In 
 this connection I mention the observation made by Brown-Sequard that an incis- 
 ion of the tissues of the anterior region of the neck causes anaesthesia of the 
 surrounding parts, and hence it is only the first incision which gives rise to pain 
 in tracheotomy. Mr. Hewitt in a recent paper very well explains the danger 
 in the use of an anaesthetic in cases of obstructive dyspnoea. He says that 
 
878 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 "in such cases cyanosis is kept at bay, not only by compensatory increase in 
 the activity of the nerve-centres which preside over normal respiratory move- 
 ments, but also by the co-operation of the centres which preside over muscles 
 which take little" or no share in ordinary breathing. During ordinary sleep 
 the activity of the diaphragm is lessened, the centres which preside over it 
 enj oying comparative rest ; while in obstructed dyspnoea the patient to a 
 greater extent depends upon the increased action of the diaphragm, so that 
 natural sleep is generally impossible except at short intervals. These vicarious 
 centres will certainly fall victims to the anaesthetic sooner than the automatic 
 or superior centres. The anaesthetic will not therefore respect vicarious func- 
 tion, and the muscles will become paralyzed in the usual sequence, and the 
 patients will become more embarrassed in their breathing or the breathing 
 will cease altogether." 
 
 If an anaesthetic be used, chloroform is probably preferable to ether, as it 
 is not so apt to cause vomiting, and it may be used with safety in operating at 
 night, when close approximation of a light may become necessary. 
 
 The Operation of Tracheotomy. — The child being placed in the position 
 described, the head steadied, and the movements of the body controlled by 
 assistants, the operator should take his position either on the right side of the 
 patient, or, as I prefer, at the head of the patient, for in this position it is 
 easy to keep the incision exactly in the median line of the neck. The surgeon 
 then should make himself familiar with the landmarks of the neck ; and having 
 located the position of the cricoid cartilage with the finger, he makes an 
 incision in the median line two or two and a half inches in length, the position 
 of the cricoid cartilage being the middle point. There is no disadvantage in 
 a long incision, which gives the operator a good view of the tissues through 
 which he is to pass ; there are many disadvantages in a too short incision. 
 
 The first incision should divide the skin and expose the superficial fascia ; upon 
 exposing this the operator will occasionally see parallel with or directly under 
 the line of incision a large vein lying in the superficial fascia, the superficial 
 anterior jugular vein. This should be displaced, and next the fascia should be 
 picked up with forceps, nicked with the point of a knife, raised upon a director, 
 and divided freely. In the early steps of the operation the surgeon should take 
 care to see that the wound is kept directly in the median line of the neck, for 
 this is the line of safety, and he should be careful also, as the wound increases 
 in depth, not to make the incisions so short that it becomes funnel-shaped, so 
 that a sufficient space of the trachea cannot be exposed to view. When the 
 deep fascia is reached, it should be picked up and divided upon a director, and 
 any large veins in the line of the wound should be carefully displaced, or, if 
 this be impossible, should be clamped by haemostatic forceps or ligatured 
 on each side and then divided between the forceps or ligatures. The operator 
 should next search, having the wound well sponged, for the muscular space 
 between the sterno-hyoid and stern o-thyroid muscles : this can generally be 
 found without difficulty, and the muscles should then be separated with a 
 director or the handle of a knife, and the isthmus of the thyroid gland will be 
 exposed. The muscles should then be held aside with retractors placed one on 
 each side, the aneurism needles previously mentioned serving well for this 
 purpose. 
 
 In regard to the use of retractors at this point, a caution is not out of 
 place : the operator should place them himself and allow the assistant to hold 
 them. I once almost lost a case in which, after exposure of the trachea, 
 while I had turned aside to pick up a knife, my assistant replaced one retractor 
 which had slipped ; in doing so the movable trachea was caught in the grasp 
 
TRA CHEO TOMY. 879 
 
 of the retractor and drawn to one side, completely shutting off respiration. 
 When I attempted to find the trachea to open it, I could simply feel the 
 anterior surface of the vertebrae at the bottom of the wound, and it was only 
 when I lifted the retractor and allowed the trachea to spring back to its 
 normal position that I was able to open it. Other operators have had the same 
 experience. Mr. Durham mentions a case, and Mr. Howard Marsh also one, in 
 which the trachea and great vessels were held aside by an assistant until the 
 surgeon had exposed the cervical vertebrae. It is well for the operator to con- 
 stantly explore the wound with his finger, to locate exactly the position of the 
 trachea, and to ascertain the presence of any anomalous arterial branch. 
 
 The isthmus of the thyroid gland being exposed, it is generally found sur- 
 rounded by a venous plexus, and occupies a position over the first three tracheal 
 rings, or it may extend even higher and cover the cricoid cartilage. At this 
 point of the operation the surgeon may find that the isthmus of the thyroid 
 gland, if large, bulges up and fills the whole wound, and he should endeavor to 
 displace it either upward or downward ; this it is often possible to do without 
 difficulty. But should it be found firmly fixed, and the trachea cannot be ex- 
 posed either above or below it, it may be cut through after being ligatured or 
 clamped on each side to prevent haemorrhage. A procedure recommended by 
 Bose, which I have employed with advantage in several cases, may also be 
 made use of — namely, a transverse incision is made across the cricoid cartilage 
 to divide the layer of cervical fascia by which the isthmus is bound down, and 
 a director is then passed in, and the isthmus is displaced downward without 
 difficulty. After displacing the isthmus of the thyroid gland upward or down- 
 ward, as the case may be, the trachea, yellowish-white in appearance, covered 
 by its fascia, should be exposed. This fascia should be torn through with a 
 director or the handle of a knife, so as to bare the surface of the trachea. On 
 this point all authorities agree — namely, the importance of thoroughly clear- 
 ing the trachea of its fascia before opening it, as by so doing it is easier to 
 incise it and to introduce the tracheotomy-tube. In breaking up this fascia 
 the operator can feel it crepitate under the finger from the suction of air drawn 
 in with each inspiratory movement. 
 
 When the surgeon has the trachea exposed, he may then take time to see 
 that the wound is free from haemorrhage, and may replace the retractors so as 
 to expose as large a portion of the trachea as possible ; for, be the case ever so 
 urgent, he now feels assured that he can open the trachea in a moment if the 
 breathing should cease. The trachea should next be fixed with the point of a 
 tenaculum introduced a little to one side of the median line ; and an incision 
 made in the median line from below upward for a distance of half to three- 
 fourths of an inch. Some surgeons object to the use of a tenaculum to fix the 
 trachea, as it arrests respiratory movements, but prefer to use the tip of the 
 finger as a guide to steady the trachea before it is incised. I always use the 
 tenaculum in this way, and see no disadvantage in its use if the trachea is not 
 fixed for too long a time before the opening is made. The operator may find it 
 of advantage, especially in cases where the trachea is deeply situated, after 
 fixing it with a tenaculum, to lift it slightly from its bed, thereby bringing it 
 more prominently into view and making it more superficial in the wound, thus 
 facilitating its safe incision. 
 
 I prefer in opening the trachea to employ a sharp-pointed tenotomy knife: 
 the sharp point allows it easily to be thrust into the trachea, and the narrow 
 blade obscures the operator's view of the wound to the least possible extent. 
 The knife should not be introduced so deeply into the trachea that the posterior 
 wall or the oesophagus may be injured: both of these accidents have occurred by 
 
880 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 a too deep thrust of the blade. The operator should also be careful not to make 
 a too superficial incision, which might divide only the trachea and the mucous 
 membrane, while the false membrane, if it be present, is not divided; and 
 the cavity of the trachea therefore not opened : under such circumstances, 
 if the tracheotomy-tube is hurriedly introduced, it may pass between the 
 trachea-wall and the false membrane, and no relief from the dyspnoea will be 
 obtained. I have seen this accident occur and death result from it. I have 
 already spoken of the importance of keeping in the median line in exposing the 
 trachea, and I think it of equal importance to have the incision into the trachea 
 itself in the median line, for these wounds are said to heal more promptly ; and, 
 if the wound be made to either side of the median line of the trachea, the tube 
 does not fit well, and its lower extremity may cause damage to the lateral 
 aspect of the trachea. It is often a matter of great difficulty to introduce the 
 tracheotomy-tube in a case where the tracheal incision is far out of the median 
 line ;~ and if this is found to be the case, I think it is wiser to make a second 
 incision in the median line, disregarding the previous one, which generally heals 
 without difficulty. 
 
 As soon as the trachea is opened there is usually thrown from the wound, 
 with the first expiratory effort, mucus or false membrane; this should be wiped 
 away with a sponge, and the tracheal dilator introduced. It is well to remem- 
 ber that the tenaculum should not be removed until the tracheal dilator or 
 tracheotomy-tube is placed in position, as it is often difficult to introduce either 
 of them into the movable trachea after the tenaculum has been removed. It 
 is not unusual, after the trachea has been opened, to have a sudden arrest of 
 respiration ; the entrance of a large body of air, according to Cohen, seems, as 
 it were, to surprise the lungs. This is apt to produce great alarm to one not 
 familiar with the circumstance, as it looks like a cessation of breathing ; it is 
 especially trying to the operator when he is about to congratulate himself upon 
 the completion of an anxious operation. This arrest of respiration is usually 
 only momentary, and if the child's face and chest be slapped with a wet towel, 
 or artificial respiration be employed, normal respiratory movements will soon 
 be re-established. 
 
 The trachea being opened and the tracheal dilator being introduced, any 
 membrane which appears at the wound should be removed with a sponge or 
 forceps, and the trachea should be explored both above and below the wound 
 for the presence of false membrane, which should be removed with forceps, a 
 feather, or a camel's-hair brush. This removal of membrane from the trachea 
 has been urgently insisted upon by Pilcher, Parker, and others ; and I think 
 that it is largely owing to the great care which is exercised in this particular 
 that the results of tracheotomy in diphtheritic cases in the last few years has 
 been so much more encouraging. 
 
 Mouth-suction of the wound, which has been frequently employed by sur- 
 geons to restore respiratory movements and clear the trachea of membrane, has 
 been so often followed by disastrous results that it cannot be too strongly con- 
 demned. This procedure is no more efficient in removing membrane or re-es- 
 tablishing respiration than the use of the forceps, brush, or feather, or the 
 employment of artificial respiration made in the ordinary manner. For the 
 purpose of clearing the trachea Parker has devised a tracheal aspirator, which 
 consists of a glass or celluloid cylinder three or four inches in length by three- 
 quarters of an inch in diameter, to the one extremity of which is attached a 
 flexible tube and to the other an India-rubber tube with a mouth piece at the 
 end. The cylinder may be packed with antiseptic cotton, which will act as a 
 filter and prevent any infected material from reaching the operator's mouth. A 
 
TRACHEOTOMY. 881 
 
 flexible catheter may be employed for the same purpose with good results. The 
 membrane is usually loosely attached, and can be removed with forceps or a 
 flexible feather, particularly if a little of Parker's soda solution be brought in 
 contact with the inner surface of the trachea. The peroxide of hydrogen may 
 also be employed with satisfaction for the same purpose. 
 
 After removing the membrane, Mr. Watson Cheyne recommends that the 
 raw surface be touched with a solution of bichloride of mercury 1 : 500 ; he 
 also introduces into the trachea or larynx above the tube strips of lint sat- 
 urated with a solution of bichloride of mercury 1 : 2000, and washes the wound 
 with a similar solution of 1 : 500. 
 
 Having cleared the trachea of membrane, the tracheotomy-tube should be 
 introduced. This can be accomplished without difficulty if a fenestrated guide 
 be employed, and if the wound in the trachea has been made in the median 
 line ; the tube is secured in position by the tapes attached to the shield, which 
 are tied around the neck. The tapes should be firmly tied by several knots, 
 so that there may be no possibility of the child untying them when not watched 
 by the attendant, as in such an event the tube may become displaced when 
 there is no one at hand competent to replace it. These knots should be tied 
 on either one or other side of the neck, and not posteriorly, where their pres- 
 ence would cause the child discomfort as he rests upon his back. 
 
 The immediate results of the operation are, as a rule, most encouraging : 
 the patient, who previously exhibited the most distressing symptoms by reason 
 of his extreme dyspnoea, now becomes quiet; the color improves, the respi- 
 ration becomes natural, and it is not an unusual occurrence to have him fall 
 into a quiet sleep before he is removed from the operating table to his bed. 
 
 Complications at the Time of Operation. — The principal complication at 
 the time of operation is haemorrhage, which may be either arterial or venous. 
 Haemorrhage should be prevented by great care in avoiding the wounding of 
 any vessels of considerable size : if their injury is unavoidable, they should be 
 immediately ligatured, or, if the case is too urgent to admit of delay, they 
 should be secured by haemostatic forceps, and after the trachea has been opened 
 they can be permanently secured by ligatures. 
 
 Sudden Arrest of Respiration. — Cessation of the respiratory act during 
 the operation is a most dangerous symptom, and one which calls for prompt 
 action on the part of the operator. The surgeon's duty under the circumstance 
 is to open the trachea as rapidly as possible — even through a pool of blood, as 
 described by Mr. Durham — introduce the tracheal dilator, and make artificial 
 respiration : by such prompt action many cases may be saved, and bleeding 
 vessels may be ligatured or secured by forceps after the trachea is opened. Mr. 
 Durham very wisely says that in those reported cases in which much blood is 
 lost during the operation, and which are abandoned before opening the 
 trachea because of the cessation of respiration, death is not the result of 
 haemorrhage, but of failure to complete the operation. Blood in the tra- 
 chea after the operation may seriously embarrass the breathing, but if the 
 tracheal dilator is introduced, it may be removed by the use of a brush or 
 feather. 
 
 After-Treatment of Cases of Tracheotomy. — The operation of trache- 
 otomy relieves the patient of the immediate danger of death by strangulation, yet 
 there still exist the same indications for local and constitutional treatment as 
 were present before it. This fact is often overlooked by physicians, who, ob- 
 serving the improved condition of the patient after the operation, are too apt to 
 relax their efforts in this direction. I know of no cases in which a successful 
 i sue more directly depends upon care and watchfulness in their after-treatment 
 
 56 
 
882 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 than those in which tracheotomy has been performed to relieve the obstructive 
 dyspnoea consequent upon diphtheritic or membranous laryngitis. The patient 
 should be under the charge of an attendant or nurse who is skilled in the 
 management of such cases, and is able to recognize and meet such complica- 
 tions as may arise. After the operation the patient should be placed in a room 
 free from draughts, with a temperature of 70° to 75° F., and the air of the 
 room should be rendered moist and warm by a vapor of steam. At the Chil- 
 dren's Hospital of Philadelphia there is an apartment especially arranged for 
 the treatment of cases after tracheotomy ; it is fitted with a steam apparatus, 
 by means of which in a few minutes it can be filled with a vapor of steam and 
 maintained at an even temperature. I think the large number of successful 
 results of the operation at that institution is greatly due to this feature of the 
 after-treatment. In private practice it is difficult to obtain these conditions, 
 and as a substitute a framework may be fastened over the bed, over which 
 sheets can be stretched, forming a tent ; under this water may be kept boiling 
 in a pan or vessel, or lime can be slaked ; the vapor from the latter Cohen con- 
 siders one of the most efficient solvents of the false membrane. A steam or 
 hand atomizer should be used at frequent intervals, the spray being directed 
 over the opening in the tracheotomy-tube. I have found great advantage 
 from the use of Parker's soda solution, which is as follows : 
 
 1^. Sodii carbonatis 3J-.5ij- 
 
 Glycerini f§ij. 
 
 Aquae q. s. ad f^vj. — M. 
 
 To this solution a small quantity of carbolic acid may be added, without in any 
 way affecting its solvent action on the false membrane or mucus. I am so 
 firmly convinced of the utility of this solution that in all cases I have it con- 
 stantly used in the steam or hand atomizer, and also have it introduced into the 
 tracheal tube by means of a feather or brush. The use of the steam spray and 
 the soda solution is especially important in cases in which there is little tend- 
 ency to expectorate mucus or false membrane — dry cases — or in those in which 
 the inner tube is found clogged with inspissated mucus or membrane. Peroxide 
 of hydrogen in 15-volume solution, either used in full strength or diluted 
 to one-half, one-third, or one-fourth, is also used with advantage in these cases. 
 It has a decided action upon the membrane, and it may be applied with a brush, 
 feather, or spray. It is a good omen if the child coughs or expectorates false 
 membrane after the tracheotomy-tube is introduced, for moist cases in which 
 these conditions obtain, as a rule, are much more favorable than dry cases or 
 those in which there is little tendency to expectoration. This clinical observa- 
 tion was, as far as I know, first made by Cohen some years ago, and I have 
 since personally seen numerous instances which attested its accuracy. In a 
 series of cases reported by Lovett and Monroe all those in which there was 
 suppression of the discharge from the tracheotomy-tube, which were classed as 
 dry cases, terminated fatally. My own experience has been the same, with one 
 exception. This was in the case of a girl three years of age, who was admitted 
 to the Children's Hospital in September, 1887, with extreme dyspnoea from 
 diphtheritic laryngitis. I performed tracheotomy : when the trachea was opened 
 there was no expectoration, and it seemed to be a typical dry case ; an unfavor- 
 able prognosis was accordingly given. This condition continued for fourteen 
 hours, when, under the persistent use of steam spray and soda solution, and 
 frequent moistening of the trachea through the tube by means of a feather 
 dipped in the soda solution, the child began to expectorate mucus and shreds 
 
TBA CHEO TOMY. 883 
 
 of membrane, and continued to do so for several days. She finally recovered, 
 the tube being removed on the tenth day. 
 
 Care of the Tracheotomy-tube. — The nurse or attendant having charge of 
 the case should remove the inner tube of the tracheotomy-tube every hour or 
 half hour for the first twenty-four hours, and after this time at less frequent 
 intervals, and thoroughly cleanse it with a feather or brush dipped in soda solu- 
 tion, removing any membrane or mucus which adheres to its inner surface. 
 She must be cautioned not to allow the inner tube to remain out more than a 
 few minutes at a time, for I have seen cases in which it was carelessly allowed 
 to remain out for several hours, where, owing to the tendency of the mucus to 
 become inspissated in the outer tube, it could not be reintroduced and the outer 
 tube had to be removed from the wound and cleaned before it could be re- 
 placed. The nurse should also be instructed to introduce a soft feather moist- 
 ened with soda solution into the tube every half hour, if the case be one in 
 which there is little discharge from the tube ; if there is membrane or mucus 
 loose in the trachea or tube, as evidenced by noisy respiration, this manipula- 
 tion will facilitate its removal. If a portion of membrane becomes impacted 
 in the tube, its presence will be shown by more or less marked dyspnoea ; this 
 can generally be relieved by removing the inner tube and cleansing it. If the 
 membrane is in the trachea below the tube, it may be extracted by means of a 
 feather or the curved tracheal forceps. If all these means fail and the breath- 
 ing becomes more embarrassed, the surgeon should remove the tracheotomy- 
 tube, introduce the tracheal dilator, and search for and remove the obstructing 
 membrane, after the removal of which the tube should be replaced. 
 
 Changing the Tracheotomy -tube. — If no indication exists for removing the 
 tracheotomy-tube earlier, it should be removed on the third or fourth day and 
 replaced by a fresh one. At this time the surgeon may take the opportunity of 
 testing the breathing capacity through the larynx by placing a pad of moist 
 lint over the wound in the neck ; if the child breathes comfortably without the 
 tube, it may be kept out of the wound for a few minutes while it is being 
 cleansed and fresh tapes attached, or a fresh tube may be prepared, and it 
 should then be introduced. There is usually little difficulty experienced in 
 introducing a tube at this time, for the tissues in the region of the wound have 
 become glued together by inflammatory lymph, leaving a sinus leading down to 
 the wound in the trachea. If there is not any special indication for its removal, 
 the tube need not be again changed for two or three days ; and at this time it 
 can be left out of the trachea for a longer period if the child breathes comfort- 
 ably without it and there is evidence that air passes freely through the larynx. 
 I consider it a good plan to permit the nurse or attendant to introduce the tube 
 under the surgeon's direction, so that in the event of its accidental displace- 
 ment or necessary removal on account of obstruction by membrane, she will 
 have learned the way into the trachea and will feel confident of her ability to 
 replace it. It is often well, as the case progresses, to close the opening in the 
 tube by a cork, which may be kept in place for a short time, and thus test the 
 permeability of the respiratory tract above the wound. 
 
 Permanent Removal of the Tracheotomy -tube. — When it is found that the 
 child can breathe comfortably with the tube stopped, showing that air is passing 
 through the larynx, it is advisable to attempt the permanent removal of the 
 tube. The permanent removal of the tube is most important if there is no 
 further indication for its use, for its presence may set up tracheitis, which is 
 evidenced by the profuse discharge of glairy mucus ; and it is a well-estab- 
 lished fact that tracheotomy-tubes which are retained for a long time are, in 
 many cases, finally removed with the greatest difficulty. 
 
884 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 It is difficult to fix a definite time for the permanent removal of the trache- 
 otomy-tube in all cases, as the procedure depends largely upon the state of the 
 patient and upon the local condition of the trachea and larynx. I have seen 
 tubes permanently removed as early as the third and as late as the sixtieth day, 
 and there are numerous recorded cases in which it has been impossible to remove 
 them for months or even years. In cases of tracheotomy for diphtheritic or mem- 
 branous laryngitis I think the tube can usually be removed permanently from 
 the eighth to the fifteenth day. The wound, after the removal of the trache- 
 otomy-tube, contracts rapidly, but for a few days the breathing is carried on 
 through both the wound and the nose and mouth. Usually from the fifth to 
 the eighth day after the removal of the tube the wound is so far healed that no 
 air passes through it. The superficial wound may be dressed with a piece of 
 lint spread with boracic ointment, and held in position by a strip of adhesive 
 plaster until it is completely healed. 
 
 Too much care cannot be exercised in the thorough cleansing of tracheot- 
 omy-tubes which have been used. Before they are employed in other cases 
 they should be boiled in soda solution for fifteen minutes, and then dried and 
 polished. 
 
 ' Feeding of Patients after Tracheotomy. — It is the general experience of 
 surgeons that children wearing tracheotomy-tubes take their nourishment well 
 and have no difficulty in swallowing fluids, so that they can be given a milk 
 diet or one of semi-solids, or even one of solids if, for any reason, the latter is 
 considered desirable. It is also important to remember that such cases should 
 be given the most nutritious diet ; if the appetite fails or the child refuses to 
 take a sufficient quantity of nourishment, alcohol in some form should be 
 administered, and rectal feeding or the injection of fluids into the stomach by 
 means of an oesophageal tube should be resorted to. Regurgitation of fluids 
 through the tube or wound sometimes occurs a few days after the operation, 
 owing to paralysis of the muscles of the palate ; under such circumstances the 
 patient should first be given a diet of semi-solids, and if this be regurgitated 
 through the tube, the nourishment should be given by means of the oesophageal 
 tube, and rectal feeding should be employed at the same time. If the diet is 
 restricted to semi-solids or solids, the thirst may be allayed by allowing the 
 patient to swallow small pieces of ice, or by the use of enemata of water ; care 
 should be taken that small quantities only are given at a time. Regurgitation 
 of fluids through the tube or wound is not a favorable symptom ; but an un- 
 favorable prognosis should not be given from this symptom alone, as I have 
 seen a number of cases in which this complication existed both before and after 
 the removal of the tube, but in which, by careful feeding, recovery followed. 
 
 Causes of Death after Tracheotomy. — After the operation of tracheot- 
 omy many cases do well for a time and then terminate fatally from septicaemia, 
 from diphtheritic poisoning, from pneumonia, from heart-clot, from recurrent 
 obstruction due to extension of the membrane below the seat of the operation 
 into the trachea and bronchial tubes, and from diphtheritic paralysis. Death 
 from any of the above causes, except recurrent obstruction, is usually devoid of 
 the signs of suffering, and the operation may be credited with prolonging life 
 and rendering the mode of death much less distressing. Many cases die of 
 heart-clot or pneumonia, and it is a question whether deaths from this compli- 
 cation are more frequent after tracheotomy than in cases of diphtheria in which 
 the operation has not been performed. In diphtheritic cases the open wound 
 exposes a surface for the absorption of the poisons, as is seen by the occasional 
 development on the wound of diphtheritic membrane, and in this way the ope- 
 ration may be said to introduce a small additional element of danger ; but it is a 
 
TRA CHEO TOMY. 885 
 
 comparatively insignificant one, and is not to be compared with the immediately 
 dangerous symptom for the relief of which it was undertaken. 
 
 Croup supervening upon the exanthemata is not, as a rule, amenable to 
 tracheotomy, according to Cohen. Lovett and Munroe mention 17 cases in 
 which tracheotomy was performed during the course of some one of the exan- 
 themata: 10 of these, in which croup complicated measles, gave 5 recoveries; 
 in the other 7 cases, in which croup complicated whooping-cough, mumps, or 
 scarlet fever, the operation foiled to save life. I have had 1 successful result 
 out of 3 tracheotomies performed for croup complicating measles in a very fatal 
 epidemic of this disease in the Children's Home in Philadelphia. My own 
 experience with this class of cases has been such that I do not refuse to operate 
 if the svmptoms calling for operation exist. 
 
 Complications after Tracheotomy. — Diphtheritic infection of the wound 
 is a complication which is occasionally seen after tracheotomy for diphtheritic 
 laryngitis, and it is one which is not necessarily fatal, although it adds some- 
 what to the gravity of the case, for I have seen patients recover in whom this 
 condition was well developed. In the treatment the local application to the 
 wound of 1 part of hydrochloric acid to 2 parts of glycerin has been followed 
 by good results. Peroxide of hydrogen may also be applied to the surface of 
 the wound, or the membrane may be scraped away with a curette, and the sur- 
 face then swabbed with a solution of bichloride of mercury 1 : 500. Diph- 
 theritic infection of the wound should not be confounded with sloughing of 
 the wound, with a discharge of thin, offensive pus — a condition which is some- 
 times seen in poorly-nourished and weak children. 
 
 Inflammatory oedema of the neck is apt to occur in ill-nourished children, 
 and it is only a source of danger when it becomes well marked ; for in the 
 majority of cases of tracheotomy it exists in the immediate neighborhood of 
 the wound to a limited extent. It may, however, involve the tissues of the 
 neck to such an extent that the tube is lifted out of the tracheal wound by the 
 swelling of the tissues, and dyspnoea occurs, in which event a longer tube should 
 be introduced. The treatment of this complication consists in the application 
 of lead-water and laudanum to the inflamed area, and if there is evidence of 
 diffused abscess a free incision should be made at the earliest opportunity. 
 
 Erysipelas also may attack the tracheotomy wound ; it is generally super- 
 ficial, but may involve the deeper parts. The treatment is the same as for ery- 
 sipelas complicating other wounds. 
 
 Secondary haemorrhage is a rare complication after tracheotomy, but may 
 arise from vessels divided or injured during the operation, or from ulcerative 
 perforation of the trachea from pressure of the lower extremity of a badly- 
 fitting tracheotomy-tube, causing erosion of some of the great vessels of the 
 neck. I have seen two cases in which death resulted from haemorrhage after 
 the operation: in one case a profuse consecutive haemorrhage occurred six 
 hours after the operation, and speedily proved fatal. I assisted in the opera- 
 tion in this case, and although there was free venous haemorrhage at the 
 time, it was thoroughly controlled before the tracheotomy-tube was intro- 
 duced ; and the unfortunate result, in my mind, can be accounted for only by 
 the displacement of one of the several ligatures which had been applied to 
 the injured vessels. The other was that of an infant six months old, in whom. 
 at the time of the operation, there was free venous bleeding, which was con- 
 trolled by ligatures. In this case on the sixth day profuse haemorrhage 
 took place from the tracheotomy wound and tube, and rapidly proved fatal. 
 M. d'Heilly reports a fatal case in a child in whom haemorrhage arose from an 
 ulceration of the trachea, which had extended to the innominate artery, and was 
 
886 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 caused by the end of the tracheotomy-tube. Dr. Hutton reports a similar case 
 in which death occurred from haemorrhage ; and several other cases, in which 
 the innominate artery was opened in the same manner, have been recorded. 
 If the bleeding arises from smaller vessels, it is often possible to control it by 
 the application of ligatures or by the use of the galvano-cautery ; but haemor- 
 rhage from the innominate artery is so profuse that it has always rapidly 
 proved fatal before any attempt could be made to control it. 
 
 Surgical emphysema, starting from the region of the wound, is occasionally 
 met with after tracheotomy : the presence of air in the tissues is explained by 
 the fact that during the violent inspiratory efforts in obstruction of the larynx 
 there is more or less of a vacuum produced in the chest, and the air is sucked 
 into the cellular tissues of the neck and diffused throughout the tissues gener- 
 ally. It is said to be more common after tracheotomies in which the incision 
 in the treachea is not in the median line and does not correspond with the wound 
 in the soft parts in front of the trachea. A moderate amount of emphysema in 
 the immediate neighborhood of the wound is not uncommon, but sometimes the 
 condition is developed to such an extent that the cellular tissues of the neck, 
 face, arms, chest, and abdomen become greatly distended with air. I once saw 
 a case in which these parts were all involved, and the crepitation of the air in 
 the cellular tissue at the ends of the fingers could be distinctly felt. In this 
 case there was also recurrent dyspnoea, which was probably due to mediastinal 
 emphysema. Champneys has reported 28 cases in which autopsies had been 
 made after tracheotomy, in which the operation was performed for diphtheritic 
 laryngitis. In 16 of these cases emphysema of the mediastinum was present. 
 This condition has also been found in patients dying from diphtheria in whom 
 tracheotomy had not been performed. Emphysema, when developed to a 
 moderate extent, seems to do no harm, as the air is usually quickly absorbed ; 
 but when it becomes general and the mediastinum is involved, marked dyspnoea 
 is apt to develop and the prognosis is extremely grave. 
 
 Granulations about the tracheal wound occur in certain cases where there 
 seems to be a peculiar hypersensitive condition of the mucous membrane of the 
 trachea. These granulations are most commonly seen in cases where tubes have 
 been worn for a long time, and are often one cause of difficulty in their 
 permanent removal. The presence of granulations may be suspected if the 
 child coughs up blood-stained secretions after the tube has been changed. 
 Withdrawal of the tube and inspection of the wound will often disclose the 
 presence of granulations attached to the edges of the tracheal wound or grow- 
 ing from the trachea in the region of the wound. The treatment of this con- 
 dition consists in the application of a 30-grain solution of nitrate of silver ; or 
 they may be touched with a solid stick of nitrate of silver; or the wound may 
 be freely exposed by the introduction of a tracheal dilator, and the granula- 
 tions seized with forceps and removed with scissors, or scraped away with a 
 curette. 
 
 Ulceration of the trachea may arise from improperly-shaped or badly-fitting 
 tracheotomy-tubes ; it may be suspected when the tube, if a silver one, becomes 
 blackened, and there are fetor of the breath and expectoration of purulent 
 and blood-stained discharge. This complication is not so apt to occur at the 
 present time under the use of the improved tracheotomy-tubes which are now 
 employed. The treatment of this condition consists in first removing the badly- 
 fitting tube and replacing it by a properly-fitting one, and, further, in the appli- 
 cation to the ulcerated surface of a 10-grain solution of nitrate of silver. 
 
 Difficulties in the Permanent Removal of the Tracheotomy-tube. — In 
 the great majority of cases the tracheotomy- tube can be permanently dispensed 
 
TBA CHEO TOMY. 887 
 
 vith in from eight to fifteen days, yet there are ' occasionally met instances in 
 which this cannot be accomplished for months or even years ; a few cases have 
 been recorded in which its final removal was never satisfactorily accomplished. 
 The difficulty of the permanent removal of the tracheotomy-tube is due, in some 
 cases, to mechanical causes, such as the growth of granulations in the trachea 
 or wound or in the larynx, inflammatory hypertrophy of the vocal cords, 
 adhesion between the cords, paralysis of the posterior crico-arytenoid muscles, 
 spasm of the glottis, or stenosis of the trachea at the seat of operation. Dr. 
 Emil Kohl, in an exhaustive article upon this subject, mentions, as also causes 
 of delay or difficulty in removing the tracheotomy- tube, prolonged diphtheria, 
 re-formation of the diphtheritic membrane, changes in the shape of the trachea 
 or larynx from the operation or from the wearing of the tube, and relaxations 
 of the anterior wall of the trachea. Where the difficulty in the permanent 
 removal of the tube is due to the presence of granulations in the trachea or 
 larynx, after their removal by some of the methods before mentioned the phy- 
 sician is usually able to dispense with the tube. Where stenosis of the trachea 
 or larynx exists and prevents the permanent removal of the tube, the parts 
 may be gradually dilated by the use of bougies, or, better, by the introduction 
 of an intubation-tube after the removal of the tracheotomy- tube: the wound in 
 the neck can then be plugged with a nipple attached to a shield (Fig. 6), or with 
 
 Obturator for Tracheotomy Wound. 
 
 Obturator for Tracheotomy 
 Wound. 
 
 an instrument shown in Fig. 7, to keep the wound from healing until it is cer- 
 tain that there will be no necessity for the reintroduction of the tracheotomy- 
 tube. The intubation-tube may be worn for some days or weeks, and then re- 
 moved, and if the breathing is satisfactorily carried on with the wound in the 
 neck plugged, as above described, the shield with the nipple may be removed, 
 and the wound be allowed to heal. By this method of treatment I have 
 been able to finally remove tracheotomy-tubes which had been worn for a long 
 time. I have had recently under my care a child of eighteen months of age 
 in whom I was only able to remove the tracheotomy-tube permanently after 
 sixty days by the use of an intubation-tube and obturator; and another case 
 where a patient was finally able to dispense with a tube after having worn 
 it for four years. In young children I have seen difficulty in the permanent 
 removal of the tube from the fact that the trachea is very flexible, and from 
 the fact that the wound in the soft parts in healing had become attached to 
 the tracheal wound, and in inspiration assumed a valvular form, allowing 
 little air to enter the trachea. 
 
 If the tracheotomy-tube is removed before the larynx is clear, or while there 
 is irregular action of the laryngeal muscles, dyspnoea soon becomes marked and 
 necessitates its reintroduction. This can best be overcome by removing the 
 tube from time to time, and trying to induce the child to learn again to breathe 
 
888 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 through the larynx, or by introducing the intubation-tube for a time, and keep- 
 ing the tracheal wound from healing until the breathing is again satisfactorily 
 accomplished through the larynx. 
 
 Mr. Thomas Smith has shown that tracheotomy is apt to cause undue irri- 
 tability and disorderly action of the muscles of the glottis, so as to interrupt 
 their usual rhythm. Cohen says that the explanation of this phenomenon 
 resides in the fact that the laryngeal muscles have lost their habit of contract- 
 ing harmoniously with the needs of respiration, the patients being somewhat 
 in the condition of those with paralysis of the vocal cords. Some pa- 
 tients can breathe comfortably without the tracheotomy-tube except during 
 sleep. In explanation of these cases Mr. Thomas Smith suggests that the 
 influence of the will may be necessary to regulate and secure due action of 
 these muscles, the perfection of whose movements has been impaired, and 
 that on this account inspiration through the larynx during sleep is impos- 
 sible. 
 
 Mental agitation plays an important part in preventing the removal of the 
 tube in many cases, for we often see children who can breathe comfortably 
 through the larynx when the tube is plugged, but who, when it has been 
 removed and the tracheal wound has been closed with a pad or obturator, 
 exhibit great mental agitation and develop such alarming symptoms of dyspnoea 
 that the reintroduction of the tube becomes necessary. It is remarkable to 
 observe how even a young child soon learns to depend upon the presence of the 
 tube for breathing, and how he will resist its removal ; he will often get into 
 such a rage if it is withdrawn, that the rhythmical respiratory action may 
 become so seriously embarrassed as to require its immediate replacing. Cases 
 have been recorded where, even after the wound had healed, children could 
 breathe comfortably only by having the tracheotomy-tube tied around the 
 neck. Stevenson has made the observation that fright, upon the removal 
 of the tracheotomy-tube in children, produces a nervous, excitable condition, 
 irregular respiration, and sobbing, seeming to induce spasm of the glottis. 
 The permanent removal of the tube, if there be no mechanical difficulty 
 present, can usually, in most cases, be finally accomplished by gaining the 
 confidence of the child, and by patience and perseverance in withdrawing the 
 tube at intervals of gradually increasing length. 
 
 Post-tracheotomic Vegetations. — Under this title there have been 
 described vegetations or granulations which occur in the trachea after the 
 wound has cicatrized. These growths are more apt to occur in male children, 
 and appear fifteen days to a month after the wound has healed. The most 
 marked symptoms of this affection are embarrassed respiration with progres- 
 sive dyspnoea. The first case of this kind was reported by Gigon, aud since 
 that time fourteen cases have been collected by Ross. Denger reported a case 
 which died two weeks after the wound had healed, and in which an autopsy 
 revealed a tumor of granular tissue in the trachea at the seat of the trache- 
 otomy wound. The treatment of these growths consists in again performing 
 tracheotomy, exposing them, and removing them with scissors or knife, 
 cauterizing their bases, and introducing the tracheotomy-tube ; if, after a short 
 time, they show no tendency to recur, the tube should be removed and the 
 wound allowed to heal. 
 
 Tracheotomy without Tubes. — Some surgeons, recognizing the amount 
 of attention which patients require while wearing tracheotomy-tubes, and 
 possibly over-estimating the dangers in their use and the difficulty which 
 is sometimes experienced in their final removal, have recommended and prac- 
 tised the operation of tracheotomy without the use of the tube. Dr. Martin 
 
TRA CHEO TOJIV. 889 
 
 has reported several cases in which he dispensed with the tracheotomy-tube, 
 the edges of the tracheal wound being fastened to the skin by sutures. 
 Other surgeons have recommended the removal of a small portion of the 
 trachea on each side of the incision when no tube is to be used. I think 
 there is little danger in the use of the tracheotomy-tubes which are now 
 employed, if the precaution be taken to see that they fit the trachea well. 
 The objection that more care is required in the after-treatment of the case 
 while wearing the tube is not a valid one, as it seems to me that an equal 
 amount of attention is required whether the tracheotomy-tube be used or 
 dispensed with. The removal of a triangular portion of the trachea from 
 each edge of the wound I do not recommend, as stenosis of the trachea at the 
 point of operation is apt to result. The number of cases in which the use of a 
 tracheotomy-tube has been entirely dispensed with has been so small that we 
 cannot yet fairly judge of the value of the procedure. Personally, I am 
 decidedly of opinion that the use of a well-fitting . tube is a most important 
 factor in a case of tracheotomy, and as such would most strongly recommend 
 its employment. 
 
 Thermocautery in Tracheotomy. — The dread of haemorrhage has led 
 certain surgeons to substitute a thermo-cautery knife for the scalpel in the 
 operation of tracheotomy. In 1870, Amussat first employed the galvano-cau- 
 tery in tracheotomy, and this method also has been employed by Verneuil, 
 Krishaber, and others. 
 
 Rapid Tracheotomy. — Fear of troublesome haemorrhage has not deterred 
 some surgeons from recommending a rapid tracheotomy by a single cut. Saint- 
 Germain claims to have performed a number of such operations without a single 
 serious accident. Mr. Durham has recommended a rapid tracheotomy, which he 
 performs in the following manner : The surgeon stands upon the right side of the 
 patient, and places his forefinger on the left side of the trachea and his thumb 
 on the other side, so as to include between them the spot at which the trachea 
 is to be opened. Firm pressure is made, and the trachea can be felt between 
 the thumb and finger ; the safety of the great vessels is ensured, as they are 
 outside of the line of incision. By a succession of careful incisions the operator 
 cuts down on the trachea, and when it is exposed he may open it directly 
 or fix it with a tenaculum before opening it. Mr. Durham claims to have 
 operated on a number of cases without any untoward results. This rapid 
 method of performing tracheotomy has not been very generally employed, and 
 I cannot appreciate its superiority over the slower and safer method of dissect- 
 ing carefully down to the trachea and opening it, except in certain rare cases 
 of great urgency. I therefore am of the opinion that rapid tracheotomy will 
 never supersede the latter operation, which has the advantage of enabling the 
 surgeon to recognize and avoid structures the wounding of which would be 
 dangerous. 
 
 Condition of Patients after Recovery from Tracheotomy. — The con- 
 dition of patients after recovery from tracheotomy performed for diphtheritic or 
 membranous laryngitis is a matter of great interest. As far as my personal 
 observation goes, the voice in these cases seems to be unimpaired, and they do 
 not seem to be more liable to laryngeal affections than those in whom recovery 
 has occurred without operative interference. The rare occurrence of post- 
 tracheotomy vegetations has been already referred to. Drs. Lovett and Munroe 
 have made some very valuable observations bearing upon this subject: in 56 
 cases where tracheotomy had been performed more than a year previously, 
 which they investigated with reference to the effect of the operation upon the 
 voice and general health of the patient, 53 were in good health, and none of 
 
890 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 them had had a second attack sufficient to call for surgical aid. The voice was 
 clear in all but 4 cases ; 6 patients were liable to sore throat ; 3 were not in 
 good health, 1 having phthisis, but without any laryngeal symptoms, 1 had 
 a hoarse and croupy voice, and the third was a delicate boy who was con- 
 stantly ill. 
 
INTUBATION OF THE LARYNX. 
 
 By HENRY R. WHARTON, M. D., 
 
 Philadelphia. 
 
 Intubation of the Larynx is an operation by which a metallic tube is 
 passed through the mouth into the larynx for the relief of dyspnoea resulting 
 from laryngeal stenosis. This procedure for the relief of dyspnoea depending 
 upon croup was first employed by Bouchut of Paris in 1858. He used a hollow 
 metallic cylinder about an inch in length, which was pressed into the larynx 
 and allowed to remain, and had attached to it a silken thread to facilitate its 
 removal and to prevent its passing down into the trachea. Although, as far 
 as known, this was the first formal method of treating dyspnoea in cases of 
 croup by the introduction of a metallic tube into the larynx, the procedure of 
 introducing a tube into the larynx to relieve dyspnoea arising from other 
 causes, known as catheterization of the larynx, had been employed by many 
 surgeons before this time. The results of Bouchut's cases were not sufficiently 
 satisfactory to recommend its general adoption, and the procedure fell into dis- 
 use. Dr. Joseph O'Dwyer of New York, in 1880, after numerous experiments 
 upon dead subjects in the autopsy-room of the New York Foundling Asylum, 
 finally reintroduced this operation as a means of dealing with dyspnoea result- 
 ing from laryngeal stenosis. Numerous modifications of the tube were made, 
 and it is due to the patient and careful work of O'Dwyer that the operation 
 has become recognized by the profession as a legitimate procedure in the treat- 
 ment of the symptoms arising from laryngeal obstruction. The operation of 
 intubation of the larynx, which has been employed in many thousands of cases 
 in this country and abroad, has now taken its place with tracheotomy as a well- 
 recognized surgical procedure in the treatment of obstructive dyspnoea. 
 
 Indications for Intubation. — The indications for intubation of the larynx 
 in cases of diphtheritic or membranous croup are similar to those which are 
 recognized as indications for the operation of tracheotomy in the same affec- 
 tion — namely, labored breathing, retraction of the lower ribs and supracla- 
 vicular spaces, retraction of the tissues of the suprasternal notch, cyanosis, rest- 
 lessness, inability to sleep, or, in other words, marked symptoms of obstructive 
 dyspnoea. 
 
 Prognosis in Intubation. — An examination of large numbers of reported 
 cases of intubation of the larynx shows that the number of recoveries follow- 
 ing the operation is very similar to the number following tracheotomy. Ball, 
 in a collection of 4217 cases of intubation gathered from American and Euro- 
 pean sources, found that there were 1285 recoveries, or about 30.4 per cent. 
 Ball also presents some statistics bearing upon the age of the patients. In a 
 total number of 1540 cases, tabulated according to age, there were 474 recov- 
 eries, or 30.7 per cent. The percentage of recoveries at each age is shown 
 
 in the following table 
 
 S91 
 
892 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 60 cases under 1 year of age, 11 recoveries, or 18.3 per cent 
 
 253 
 
 u 
 
 it 
 
 2 yea 
 
 rs of age, 48 
 
 306 
 
 u 
 
 i( 
 
 3 
 
 67 
 
 326 
 
 u 
 
 u 
 
 4 
 
 98 
 
 231 
 
 li 
 
 U 
 
 5 
 
 93 
 
 127 
 
 u 
 
 u 
 
 6 
 
 48 
 
 83 
 
 u 
 
 u 
 
 7 
 
 37 
 
 80 
 
 " 
 
 a 
 
 8 
 
 41 
 
 26 
 
 " 
 
 " 
 
 9 
 
 13 
 
 23 
 
 " 
 
 u 
 
 10 
 
 7 
 
 7 
 
 u 
 
 CI 
 
 11 
 
 3 
 
 7 
 
 It 
 
 a 
 
 12 
 
 4 
 
 11 
 
 u 
 
 over 
 
 12 
 
 4 
 
 or 19.0 
 or 21.9 
 or 30.0 
 or 40.0 
 or 37.8 
 or 44.5 
 or 51.2 
 or 50.0 
 or 30.0 
 or 42.8 
 or 57.1 
 or 36.3 
 
 From the above table it will be seen that intubation gives better results than 
 tracheotomy in the first and second years of life ; from this age the difference 
 between the two operations, as far as recoveries go, is not very marked. It 
 must be remembered, however, that the statistics of intubation as compared 
 with tracheotomy are not entirely to be relied upon, for many operators per- 
 form intubation at a time when the dyspnoea is not extremely urgent, whereas 
 the same operator would hesitate to recommend tracheotomy ; so that it is prob- 
 able that many of the milder cases are intubated, whereas many of the very 
 urgent ones are reserved for tracheotomy. 
 
 Instruments required for Intubation. — Instruments required for intu- 
 bation are : 
 
 Intubation-tubes of various sizes. 
 
 An introducer. 
 
 An extractor. 
 
 A mouth-gag. 
 
 A gauge. 
 
 Fine braided silk. 
 
 The intubation-tubes (Fig. 1) for children are usually six in number, of 
 different sizes, adapted to children from one to twelve years of age. The tube 
 
 The Intubation-tube and Introducer 
 
 now generally employed consists of a metal cylinder which bulges near its 
 centre, and is provided with a collar or head to rest upon the false vocal cords ; 
 it is irregularly quadrangular, one angle resting between the arytenoid car- 
 tilages, and its opposite angle bevelled so as to better allow of the closure of 
 the epiglottis over the aperture of the tube ; the tubes are gold-plated, and 
 each is provided with an obturator, which has a blunt extremity. Just below 
 the head the tube is of small diameter to avoid injurious pressure on the vocal 
 
IXTUBATIOX OF THE LARYNX. 
 
 893 
 
 Fig. 2. 
 
 cords. About midway the wall of the tube is increased to its greatest diame- 
 ter, which bulging serves to maintain it in position during coughing and 
 increases the weight to be expelled. Through the edge of the collar on each 
 tube there is a small perforation through 
 which the strand of fine braided silk is 
 passed, which serves to remove the tube 
 if in its introduction it should be passed 
 into the pharynx or oesophagus instead 
 
 of the larynx, or if from sudden ob- ^sw « >\£^ 
 
 struction it has to be hurriedly with- *\ N3$m 
 
 drawn. 
 
 The introducer (Fig. 1) consists of 
 a handle and a staff which is curved 
 to a right angle at its extremity, which has a screw that attaches it to the 
 
 Mouth -gag. 
 
 Fig. 3. 
 
 The Extractor. 
 
 Fig. 4. 
 
 iS<-4 
 
 obturator, and a sliding gear for detaching the obturator from the tube when 
 it is placed in the larynx. 
 
 Mouth-gags of various kinds may be used : the one generally supplied 
 with intubation sets is that shown in Fig. 2, which is a self-retain- 
 ing instrument. 
 
 The extractor is also curved on a right angle, and has at its 
 extremity a small forceps with duckbill blades, which are made to 
 separate and apply themselves to the interior surface of the tube 
 with sufficient firmness to withdraw it (Fig. 3). 
 
 The gauge is to determine from the age of the child the size of 
 the tube to be employed (Fig. 4). 
 
 Preparations for Intubation. — It is important that the fol- 
 lowing preparations should be made, so that the actual introduc- 
 tion of the intubation-tube may occupy as little time as possible, 
 for it should be remembered that when the intubation-tube enters 
 the larynx breathing is arrested until the obturator is removed, and 
 therefore everything should be in readiness and all manipulations 
 should be as rapid as consistent with accuracy. The time usually 
 required after the mouth-gag has been adjusted for the introduc- 
 tion of the intubation-tube and withdrawal of the obturator is from 
 five to ten seconds. 
 
 Before attempting to introduce an intubation-tube the surgeon 
 should select a tube of suitable size for the age of the patient, and 
 should have a strand of fine braided silk about two feet in length 
 passed through the eyelet and secured with a knot. Having 
 attached the tube by means of the obturator to the introducer, he should next 
 see that it can be freed from the obturator by working the trigger. The niouth- 
 
 1 — 
 
894 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 gag should also be examined to see that it is in proper working order, and this, 
 with the tube and introducer, should be placed in a basin of warm water. The 
 surgeon should next protect the index finger of the left hand, which is to be 
 passed into the mouth of the patient, by wrapping it for an inch or an inch and 
 a half in the region of the second joint with rubber or adhesive plaster, or a 
 metal shield may be employed. This is an important precaution to prevent the 
 patient from biting the finger in case the mouth-gag should slip, for a bite from 
 the teeth, which are often very foul in these cases, is liable to be followed by 
 serious consequences : a case has been recorded of a fatal result following such 
 an injury received while performing intubation. 
 
 Position of Patient for Intubation. — The child should be taken upon 
 the lap of the nurse and wrapped in a blanket, which should swathe it from 
 the neck to the heels, and the nurse should grasp the child's elbows outside of 
 the blanket and hold them firmly, but should not press them against the chest 
 in such a way as to embarrass the respiratory movements ; at the same time the 
 legs of the patient are secured by being held between the knees of the nurse. 
 The head of the patient should next be secured by being held between the 
 open hands of the assistant placed upon the sides of the head and cheeks ; the 
 left hand of the assistant may also be used in steadying the mouth-gag after it 
 has been introduced (Plate XIX). 
 
 The patient should be held straight, and should not be allowed to lean 
 back so as to get out of the operator's reach. North rup well describes the 
 proper position of the child for intubation when he says : u The position of 
 the child should be as though it hung from the top of the head." This is un- 
 questionably the best position in which to place the child for intubation, but 
 it is possible to introduce the tube with the child in the recumbent posture : 
 this I have done on several occasions when, from the condition of the circula- 
 tion, I did not think it advisable to lift the child to a sitting posture ; and in 
 the Boston City Hospital, Dr. Lovett reports that intubation has also been per- 
 formed in a number of cases with the patient supine ; but under ordinary cir- 
 cumstances the position described above will be found most convenient. 
 
 Operation of Intubation. — The child being held as described above, 
 facing the surgeon, who sits upon a chair within easy reach of the patient, 
 the assistant fixes the head, and the surgeon opens the mouth and introduces 
 the blades of the mouth-gag between the molar teeth on the left side ; the 
 blades are next opened by compressing the handles of the gag, and the assist- 
 ant should then hold the gag steady with the fingers of the left hand. Chil- 
 dren often struggle at this time and resist the introduction of the mouth-gag ; 
 hence it is better to open the jaws with the handle of a spoon introduced between 
 them, even with the exercise of some force, and to introduce the gag, than to 
 allow the child to become exhausted by struggling against ineffectual attempts 
 to introduce it without the use of force. When the mouth has been opened 
 the surgeon passes the index finger of the left hand into the pharynx and feels 
 for the epiglottis, which is hooked forward by the end of the finger. The tube 
 attached to the introducer is next passed into the mouth and carried back to the 
 pharynx, the operator being careful to see that it hugs the base of the tongue 
 in the middle line, that the handle is depressed well upon the child's chest, and 
 that the silken thread is free. When the extremity of the tube comes in contact 
 with the end of the finger holding the epiglottis, the handle should be raised 
 as it engages in the larynx and descends into this organ ; and as it is pushed 
 downward into place the finger is placed upon the head of the tube to fix it and 
 prevent its being withdrawn with the obturator ; the trigger is next pressed, and 
 the introducer and obturator are drawn from the mouth by depressing the handle 
 
PLATE XIX. 
 
 INTUBATION. (Inserting the Tube.) 
 
INTUBATION OF THE LARYNX. 895 
 
 upon the chest, and at the same time the tube should be pressed well down into 
 the larynx with the finger which rests upon its head. A caution should here be 
 given as to the importance of using little force in pressing the tube home after 
 it engages in the larynx : no more force should be used than in passing the 
 catheter or bougie into the urethra ; and if it is found that the tube is too large 
 to be passed into the larynx without the exercise of great force, it should be 
 withdrawn and a smaller one attached to the instrument and introduced. As 
 soon as the obturator has been withdrawn .the child makes a deep inspiration : at 
 the first expiratory effort there is generally coughed up false membrane or muco- 
 purulent matter, and when the tube has become cleared of this the respiration 
 is usually satisfactorily carried on. If, on the other hand, after withdrawing 
 the obturator, the dyspnoea is not relieved by the expiratory efforts of the child, 
 the tube should be removed by means of the thread and examined. If its 
 canal is clear, showing that no mass of membrane is occluding it, and the dys- 
 pnoea does not decrease, it is pretty good evidence that the obstruction exists 
 below the point to which the intubation-tube extends : it is therefore better to 
 make no further attempt to introduce the intubation-tube, but to perform 
 tracheotomy promptly. Before removing the mouth-gag it is well to intro- 
 duce the index-finger of the left hand to feel that the tube is in place and has 
 not been disturbed by the coughing efforts. 
 
 The management of the silken thread attached to the tube is a matter of 
 some importance. Some operators, as soon as the tube is properly placed, cut 
 the loop of thread, and, with the finger resting upon the head of the tube, pull 
 upon one end of the loop and withdraw it. This is done to relieve the irrita- 
 tion of the fauces which the thread sometimes causes, and to prevent the child 
 seizing it and pulling out the tube. Other operators prefer to leave the thread 
 in place for some hours or days, securing the loop around the ear so that it can- 
 not become loose ; and in the event of the tube becoming blocked with mem- 
 brane and not being coughed out, it can be removed by traction upon the 
 thread. To prevent the irritation of the fauces and gagging which the thread 
 sometimes causes, it may be passed through the posterior nares and brought 
 out at the anterior nares, and secured to the ear or the face by a strip of plas- 
 ter. I usually leave the thread in place for twelve or twenty-four hours, bring- 
 ing it out of the mouth and attaching it by the loop around the ear, and placing 
 a few strips of adhesive or rubber plaster over the thread from the ear to the 
 angle of the mouth, to prevent the child grasping it and displacing the tube. 
 Where it is possible, I also pass the thread between the molar or premolar teeth 
 to prevent the child from biting it in two. When the child shows a tendency 
 to grasp the thread, it is well to enclose the hands in stockings and secure them 
 around the wrists. 
 
 It is quite possible in introducing an intubation-tube to pass it into the 
 pharynx ; and if this happens, as soon as the obturator is withdrawn the error 
 is discovered and the tube should be removed and reattached to the introducer, 
 and another attempt made to pass it into the larynx. This error, I am sure, 
 often occurs in the hands of inexperienced operators by not being careful to 
 hug the base of the tongue closely with the end of the tube, by not keeping 
 strictly in the median line, and by disregarding the position of the tip of the 
 index finger of the left hand, which is held in contact with the epiglottis and 
 is a guide to the opening of the larynx. 
 
 Accidents during" and after Intubation. — It is well for the operator to 
 remember that certain accidents may occur during the operation of intubation, 
 such as pushing a mass of membrane down into the trachea before the tube. 
 or a too deep insertion of the tube, so that its head passes below the vocal 
 
896 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cords : these accidents have been reported, but I must confess that I have never 
 had a serious accident occur during the operation. The pushing of a mass 
 of membrane down before the tube is likely to embarrass the respiration so 
 seriously that in the violent respiratory efforts of the child the tube is apt to 
 be forced out of the larynx ; if the tube is not forced out, it should be removed 
 by means of the thread, and if the respiration is still embarrassed, tracheotomy 
 should be resorted to. The accident of pushing the tube too deeply into the 
 larynx is not likely to occur if a proper-sized and proper-shaped tube is em- 
 ployed. A tube which is too small may be easily forced between the vocal 
 cords, or may be drawn downward by the inspiratory efforts of the child. Should 
 this accident occur, the tube can usually be removed by traction upon the thread, 
 and if a subsequent downward displacement occurs after the removal of the 
 thread, it would be necessary to perform tracheotomy for its removal. Several 
 instances have been reported in which this accident occurred and a resort to 
 tracheotomy was necessary. In certain cases, after the tube has been retained 
 for a few days, it is coughed up, and upon being replaced the same accident 
 occurs : a larger tube should then be tried, and if it cannot be tolerated by the 
 larynx, further attempts at intubation should be desisted from, and, if dyspnoea 
 is still marked, tracheotomy should be resorted to. Another accident which 
 sometimes occurs is the coughing up and swallowing of an intubation-tube 
 which is not attached to a thread. The tube is usually passed through the ali- 
 mentary canal without difficulty, and I know of no fatal result following the 
 swallowing of an intubation-tube. Although I have never personally seen any 
 accident happen during the operation of intubation or while the intubation-tube 
 was in place, I always have at hand during the operation my tracheotomy case, 
 so that I can promptly open the trachea if the indication exists, and would advise 
 all operators to be similarly prepared. 
 
 After-treatment of Cases of Intubation. — Cases in which an intubation- 
 tube has been introduced require most careful watching by a nurse who is com- 
 petent to meet any emergency that may arise. If dyspnoea suddenly develops 
 from the obstruction of the tube by a piece of membrane too large to pass, the 
 nurse should be instructed to remove the tube, if the thread is still attached ; 
 or if the thread has been withdrawn she should invert the child, and by striking 
 over the posterior portion of the chest she may be able to dislodge the tube. 
 A case has been recently reported in which this manipulation by the nurse 
 saved the patient's life. In the after-treatment of cases of intubation I have 
 great faith in the efficacy of steam spray of Parker's soda solution (p. 882) or a 
 spray of peroxide of hydrogen for its effect in dissolving membrane and lique- 
 fying the secretions. I usually have the spray used every half hour, or more 
 frequently if there is little tendency to expectoration ; in cases described as dry 
 the use of the spray, I think, is most important. 
 
 Feeding of Intubation Cases. — The most difficult portion of the after- 
 treatment of cases of intubation is the satisfactory feeding of the patient. 
 From the interference with the act of deglutition caused by the presence of the 
 tube and the imperfect action of the epiglottis, liquid nourishment is apt to 
 pass into the larynx and set up coughing, which interferes with the taking of 
 a sufficient quantity of nourishment. As many cases in which this operation is 
 employed require large quantities of food from the nature of the disease for 
 which the operation is performed, I think the difficulty of properly nourishing 
 the patient constitutes the most serious objection to this operation. Children, 
 as a rule, while wearing an intubation-tube, have difficulty in swallowing 
 liquids, but there are occasionally seen cases in which liquids are swallowed 
 without difficulty ; therefore it is well to make a trial as to the feeding before 
 
PLATE XX. 
 
 METHOD OF FEEDING INFANT AFTER INTUBATION, WITH THE HEAD LOWER 
 
 THAN THE BODY. 
 
INTUBATION OF THE LARYNX. 897 
 
 a special diet is ordered for any individual case. It is remarkable to observe 
 how some children wearing intubation-tubes will learn to swallow with the 
 tube in place. I have seen children who at first were unable to take liquid 
 nourishment in a few days change their manner of swallowing, so that liquids 
 could be taken without discomfort. If, upon trial, it is found that there is 
 difficulty in swallowing liquids, I first order a diet of semi-solids, such as corn- 
 starch, mush, milk-toast, rennet, puddings, soft-boiled eggs, and, as patients 
 soon experience thirst, I order for them pieces of ice to be swallowed, or give 
 enemata of water, an ounce to an ounce and a half, repeated at intervals. In 
 young children, in whom a milk diet is essential, it will often be found that the 
 child can swallow well if fed from a nursing-bottle, the head being dropped over 
 the nurse's lap, so that it is lower than the body (Plate XX). 
 
 This useful expedient was suggested by Casselberry of Chicago, who found 
 that with the patient supine and the head lower than the body fluids could not 
 pass into the larynx, but would be forced up the oesophagus into the stomach. 
 If, however, all expedients fail as regards methods of feeding, as will be found 
 in some cases, recourse must be had to the introduction of food by nutritious 
 enemata. 
 
 Removal of Intubation-tubes. — The tube usually remains in place for 
 some days, and is often coughed out as the swelling of the laryngeal tissues 
 subsides. If the breathing is carried on satisfactorily, it need not be re- 
 placed ; but it is well to remember that for a few days the dyspnoea is liable 
 to return, so that the reintroduction of the tube may be necessitated ; and the 
 surgeon should be within reach during this time. If the tube has not been 
 coughed out and the child's general condition is improved, the temperature 
 having a tendency to reach the normal mark, at the end of three or four days 
 I usually remove the tube ; and if there is no return of the dyspnoea I do not 
 reintroduce it, but have the case carefully watched, for the patient is not safe 
 from recurrent dyspnoea for two or three days. If dyspnoea be present upon 
 the withdrawal of the tube, I replace it promptly, and do not make another 
 attempt at its permanent removal for two or three days. Usually in from five 
 to ten days it can be dispensed with, although I have recently had a case in 
 which the tube could not be permanently removed until the fifteenth day. 
 After the expulsion or removal of the intubation-tube I continue to use the 
 soda spray for two or three days, and the child must be carefully watched, so 
 that it is not exposed to cold. I have noticed that in all cases in which 
 recovery has followed intubation of the larynx there was present a considerable 
 amount of hoarseness of the voice ; but this in a few weeks finally disappears. 
 
 As the same intubation-tube may be used in many different cases, I think 
 it most essential that every tube which is used should be thoroughly sterilized 
 as soon as it is removed from the patient by being cleansed and boiled for a 
 few minutes. 
 
 The removal of the intubation-tube is, I think, often more difficult than its 
 original introduction. The child should be placed in the same position as 
 described for its introduction ; the mouth-gag should be used to separate the 
 jaws; the index finger of the left hand, being protected, should be passed 
 into the mouth and placed upon the head of the tube ; the extractor should 
 then be passed into the mouth, and with the finger on the head of the tube as 
 a guide, the blades should be passed into the opening of the tube. The tube 
 is grasped by pressing the lever which separates the blades, and. having a firm 
 hold upon the tube, it is withdrawn by depressing the handle upon the chest of 
 the patient. It is sometimes difficult to pass the blades into the opening in the 
 tube, and during the withdrawal the blades may slip, losing their hold upon the 
 
 57 
 
898 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 intubation-tube. If this accident occur, the tube can usually be hooked out of 
 the mouth by the finger, which should follow it during its withdrawal. 
 
 Intubation of the larynx has added another very valuable surgical pro- 
 cedure to the treatment of dyspnoea arising from diphtheritic or membranous 
 laryngitis and oedema or spasm of the glottis, and, although it does not 
 entirely supersede the operation of tracheotomy in all cases, it is now employed 
 in many cases where tracheotomy was formerly resorted to. Cases which seem 
 to me favorable ones for intubation are those of membranous or diphtheritic 
 laryngitis, where the obstruction comes on rapidly, and is probably largely 
 due to oedema of the mucous membrane of the larynx. Children under two 
 years of age are usually better subjects for intubation than for tracheotomy. 
 Intubation also seems well adapted for cases of dyspnoea due to oedema of the 
 larynx from burns or scalds or from the swallowing of corrosive liquids or the 
 inhalation of irritating gases, unless there is at the same time marked oedema 
 of the epiglottis and fauces. Cases unfavorable for intubation are those of diph- 
 theria, in which there is much swelling of the tonsils and fauces, with profuse 
 deposit of membrane ; also those in which the dyspnoea comes on slowly, point- 
 ing to a gradual deposit in the larynx of a well-organized membrane. The 
 great advantages offered by intubation are, that the operation itself is com- 
 paratively free from danger, it is a bloodless operation, and the consent of the 
 parents for its performance can usually be obtained without difficulty ; the 
 inspired air enters the lungs warm and moist; and if this operation fails to 
 relieve the patient it does not preclude a subsequent tracheotomy. Although 
 some statistics have been presented from the Boston City Hospital showing 
 that the prognosis in cases of tracheotomy after intubation is not favorable, 
 my personal experience has been different, for I have resorted to tracheotomy 
 in a number of patients in whom a fair trial of intubation had failed to relieve 
 the dyspnoea, and the results following the operation were in no wise less satis- 
 factory than those in which tracheotomy had primarily been performed. 
 
 Intubation in Stenosis of the Larynx. — The introduction of an intuba- 
 tion-tube for the purpose of relieving chronic stenosis of the glottis has been 
 employed successfully in many cases ; it has been proven that the tube in these 
 cases can be worn for a considerable time without harm or inconvenience. It 
 has been employed in cases of chronic syphilitic stenosis, in cases where there 
 is difficulty in dispensing with the tracheotomy-tube from granulations growing 
 in the region of the tracheal wound (see p. 888), in cases of cicatricial stenosis, 
 swelling of the mucous membrane of the larynx below the cords, bilateral 
 paralysis of the abductors, paresis of the cords from disease, or where there is 
 dread of having the tracheotomy-tube removed. In such cases the manipula- 
 tion for the introduction of the intubation-tube is similar to that in acute cases, 
 with probably the difference that more force is justifiable in the introduction. 
 The tube should be changed at intervals, a larger size being required from 
 time to time. In chronic cases little difficulty is usually experienced in feeding 
 the patients, as liquids are generally taken without difficulty after the first day 
 or two. 
 
POSTNATAL ATELECTASIS. 
 
 By SAMUEL S. ADAMS, M. D., 
 
 Washington, D. C. 
 
 Post-xatal Atelectasis is a condition of the lung in which the once- 
 inflated alveoli become emptied and collapsed from partial or total absence of 
 air in them. It occurs in weakly infants and young children, and varies in 
 extent from a few lobules to an entire lobe or even a whole lung. It is 
 claimed by some that it is a common condition in foundlings and in wasted 
 infants who die during the first year of life. 
 
 Etiology. — The predisposing causes of post-natal atelectasis are such as 
 weaken the constitution, whether they operate before birth, as inherited 
 vices, such as syphilis, scrofulosis, malformations, etc. ; at birth, as premature 
 delivery or injuries received during parturition; or after birth, as rachitis, 
 improper feeding, neglect, exposure, as in foundlings, unsanitary habitations, 
 and debilitating diseases. 
 
 The exciting causes are such as prevent air from entering the alveoli, and 
 permit them to collapse after the residual air has been rarefied, absorbed, or 
 expelled. They may be classified as intrathoracic and extrathoracic. The 
 most frequent intrathoracic cause is bronchial catarrh, more especially of the 
 smaller subdivisions, in which the lumen of the tube is obstructed by the 
 resulting exudation and the ingress of air prevented. Gairdner of Glasgow 
 has explained the mechanical action of a plug of mucus in a bronchiole in 
 gradually diminishing the entrance of air to the area supplied by it, and the 
 resulting collapse of the alveoli. This ball-valve shuts out the air at every 
 inspiration, but allows the expulsion of that within the alveoli. If this obstruc- 
 tion be not displaced, the pressure exerted by the atmosphere upon the thoracic 
 walls and the contractile force of the pulmonary tissues cause the alveoli to 
 collapse. It may also be caused by whooping-cough, the paroxysms expelling 
 the residual air and decreasing the power of the inspiratory forces. Measles is 
 cited by some as an etiological factor, but the more immediate cause is probably 
 the attendant bronchial catarrh. Effusion into the pleura or pericardium may 
 cause collapse of the pulmonary alveoli in varying degrees proportionate to the 
 pressure exerted by the fluid and the resistance of the lung. The lodgement 
 of foreign bodies, as beans, peas, seeds, or metallic or porcelain substances, in 
 a bronchus may prevent ingress of air and lead to alveolar collapse. ■ 
 
 Among the extrathoracic causes are spinal curvature, deformity of the chest- 
 wall, constricting clothing, and solid or fluid tumors in the abdominal cavity. 
 Any one of these might be sufficient to compress the lung to the degree of col- 
 lapse by diminishing the capacity of the thoracic cavity. It may also be of 
 cerebral or spinal origin. Disease of the brain, cord, or nerves which paralyzes 
 or over-stimulates the respiratory centres or prevents the transmission of nerve- 
 force may produce atelectasis by impeding the inspiratory or increasing the 
 
 899 
 
900 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 force of the expiratory muscles of respiration in a weakly or rachitic infant. 
 Finally, it may originate independently of affections of the air-passages, as from 
 the exhaustion of long-continued illness, constant dorsal decubitus, diarrhoea, 
 or ileo-colitis. 
 
 Pathology and Pathological Anatomy. — Post-natal atelectasis, unlike 
 the congenital form, is a pathological condition in which the expanded lung- 
 alveoli return to the ante-natal state, from arrest of function owing to some 
 mechanical impediment to the ingress of air. The extent of the collapsed area 
 is either circumscribed or diffused, depending upon the calibre of the obstructed 
 bronchus. It is usually situated at the postero-inferior margin of the lung 
 parallel to the spinal column ; or it may involve a whole lobe or a whole lung. 
 When it complicates bronchial catarrh, it occurs in small, scattered areas, cor- 
 responding to the ramifications of the obstructed bronchus. In pericardial and 
 pleuritic effusions of moderate extent the lower lobes are involved, but if the 
 exudation is abundant the entire lung may be collapsed from compression. 
 
 The atelectatic lung-tissue, being devoid of air, is shrunken, depressed 
 below the level of the surface of the lung, is of irregular outline, and dark- 
 brown, violet, or reddish-blue in color. On section the collapsed tissue appears 
 dark-red and smooth, and a serous or bloody fluid exudes from it. From its 
 resemblance to flesh it is called " carnification." It is firm, dense, tough, 
 without crepitation, airless, and sinks in water. If the collapse be recent, the 
 alveoli can be re-inflated by removing the obstruction and blowing into the 
 bronchial tube. If bronchial catarrh be present, the mucous membrane is 
 swollen, soft, and hyperaemic, and the tube is filled with thick, tenacious muco- 
 pus forming a complete plug. Around the affected areas are air-vesicles in a 
 state of compensatory dilatation. This physiological emphysema is only found 
 when the child has had sufficient strength to increase the inspiratory efforts, 
 and is but rarely seen in the feeble. 
 
 Symptoms. — The atelectatic areas may be so small, so scattered, or so 
 obscured by the adjacent compensatory emphysema as to be wholly overlooked, 
 although frequent and careful physical examinations may be made. This is 
 especially true of cases in which there is no recession of the chest-wall, and 
 where the neighboring alveoli are so distended as to increase the vesicular 
 murmur and intensify the percussion resonance. 
 
 As post-natal atelectasis usually happens to emaciated and puny infants, 
 the general symptoms vary according to the extent of the lesion. In mild 
 cases the infant is indifferent to its surroundings, gives vent to a whining ex- 
 piration, is slightly cyanosed, and refuses its nourishment ; but these symptoms 
 quickly disappear upon the dislodgement of the occluding mucus plug. In 
 severe cases restlessness and sleeplessness are well marked ; there is evidence 
 of distress and exhaustion depicted upon the face ; the features are pinched ; 
 the eyeballs are sunken and without shimmer, and the livid eyelids droop ; the 
 mouth is drawn and the lips are livid ; and the head and face are bathed in a 
 profuse, cold, clammy perspiration. The tongue is dry, swollen, and purple ; 
 the appetite is lost, the infant refusing to nurse, suck the bottle, or take food 
 from a spoon ; the bowels are normal, unless there be some gastro-intestinal 
 derangement. Collapse is often rapid and pronounced, but is not always fatal. 
 There may be convulsions, in one of which the infant may die, though they 
 are not necessarily fatal. The pulse is accelerated and small, and its tension 
 decreases as the atelectatic area increases. Cough, though not always present, 
 is due to bronchial catarrh. The integument is dusky, and becomes livid and 
 clammy as the disease progresses. The temperature is normal or subnormal 
 even when atelectasis occurs during the course of a febrile disease. 
 
POST-NATAL ATELECTASIS. 901 
 
 Physical Signs. — It is not surprising that this disease is so frequently 
 confounded with pneumonia, when we remember that its physical signs are 
 indicative of more or less consolidation of lung-tissue, with a catarrhal inflam- 
 mation of the bronchial mucous membrane. So the physical signs vary with 
 the extent of tissue involved. 
 
 Inspection. — The nares dilate with the respiratory movements, which are 
 superficial and rapid, varying from 60 to 90 per minute, and their normal ratio 
 to the pulse is lost. Inspiration is slower and more labored than expiration, 
 and is followed by a pause. Retraction of the chest-wall varies with its elas- 
 ticity and the extent of the collapsed lung beneath. If a considerable area of 
 lung is involved, the chest-wall yields to atmospheric pressure, resulting in 
 depression of the supraclavicular and intercostal spaces, with a deep furrow 
 over the affected area. The deformities of the chest-wall are exaggerated if 
 spinal curvature or rachitis exists. 
 
 Auscultation. — The vesicular murmur is feeble or absent unless there is 
 compensatory emphysema around the atelectatic areas. Bronchial respiration 
 and bronchophony are present when a large collapsed area surrounds a bron- 
 chus. When fine crepitant rales are present, they indicate an extension of the 
 catarrhal process to the neighboring bronchioles and alveoli. 
 
 Percussion. — Dulness is usually found at the base of the lung posteriorly, 
 but is often slight or entirely absent, and if the neighboring alveoli are em- 
 physematous the percussion resonance may be greatly exaggerated. The dul- 
 ness may extend upward parallel with the spinal column ; it may remain station- 
 ary, or it may be transient or change with the position of the infant. If it is 
 due to compression from a collection of fluid in the pericardial, pleural, or 
 abdominal cavity, the signs of this causative factor may be defined. 
 
 If it is coincident with bronchial catarrh, whooping-cough, diarrhoea, 
 typhoid fever, or any exhausting ailment, the symptoms of the primary affec- 
 tion will be present. 
 
 Duration. — The duration of life is uncertain, and in some infants it is 
 surprisingly long. Some die very early from asphyxia or in a convulsive 
 attack, while others linger for weeks or months to die of slow asphyxia or 
 exhaustion. 
 
 Diagnosis. — If the atelectasis is in scattered areas, it is seldom recognized, 
 and even if large areas are involved, it may be overlooked unless frequent and 
 careful examinations are made. It is most common in the feeble and emaciated 
 infant, and is directly caused by some disease which impedes the respiratory 
 movements. It frequently accompanies broncho-pneumonia, pertussis, measles, 
 or some long-continued and exhausting disease. The respirations are rapid and 
 shallow, dyspnoea is progressive, cyanosis marked, and exhaustion increasing. 
 Auscultation reveals an absence of vesicular breathing and the presence of 
 bronchial respiration and bronchophony, and there is dulness on percus- 
 sion over the affected area. A differential diagnosis is generally difficult, 
 owing to the similarity of post-natal atelectasis to other diseases. Some of the 
 physical signs of croupous or broncho-pneumonia are often observed in 
 atelectasis, but the characteristic general symptoms of these two diseases are 
 either indistinct or absent. In pneumonia the temperature is high, and is 
 frequently accompanied by delirium or convulsions ; the pain is acute : the 
 face is flushed ; the skin is hot and dry ; there are fine crepitant rales and per- 
 cussion dulness over a large area ; and retraction of the chest-wall during 
 inspiration is absent. In atelectasis there is a normal or subnormal tempera- 
 ture ; pain is absent ; the face is livid ; the skin is cold and wet ; rales are 
 
902 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 only present when bronchial catarrh exists ; dulness is in small scattered areas ; 
 and the chest-wall retracts during inspiration. 
 
 While it is possible to confound atelectasis with acute miliary tuberculosis, 
 still there are so many well-defined symptoms, as the previous history, cough, 
 great fluctuation of the daily temperature, emaciation, and exhaustion, which 
 precede the stage of solidification in tuberculosis, that the differentiation should 
 be made with a degree of certainty. 
 
 Atelectasis should not be mistaken for pleuritic eifusion, as the absence of 
 bronchial breathing, bronchophony, and vocal fremitus, taken in conjunction 
 with the alteration of the line of dulness with the changing position of the 
 patient, will settle the diagnosis. In doubtful cases aspiration would be the 
 determining factor. 
 
 Prognosis. — The prognosis is always grave, and recovery is extremely rare, 
 owinor to the low vitality of the infant. If it complicate bronchial catarrh or 
 broncho-pneumonia in a puny, rachitic infant, atelectasis is fatal. Convulsions 
 greatly jeopardize life. If somnolence, increasing cyanosis, superficial and 
 hurried respirations, and refusal to take nourishment supervene, the prognosis 
 is unfavorable ; but if intelligence return, cyanosis disappear, the respirations 
 become stronger and deeper, and the child take nourishment liberally, the 
 chances are favorable to recovery. 
 
 When complicated by whooping-cough, general pulmonary emphysema, 
 broncho-pneumonia, tuberculosis, or pleurisy, it is fatal. When caused by 
 compression, as in hydro-, pyo-, or pneumo-thorax or tumors, the prognosis 
 depends upon the removal of the cause. When dependent upon the presence 
 of a foreign body in a bronchus, recovery is conditioned upon its dislodgement. 
 It must be remembered, however, that in some cases the infant may recover 
 from the immediate effects of atelectasis to die later of cheesy pneumonia or 
 phthisis. 
 
 Treatment. — This being a disease which is superinduced by the lack of resist- 
 ance of the enfeebled infant, the prime factor in the treatment is to improve 
 the general health so as to enable it to repel all causes that depress the vitality. 
 To this end personal and domiciliary hygiene should be carefully regulated. 
 In seasonable weather the infant should be taken in his perambulator into the 
 open air ; removal into the country, or, when practicable, to the mountains or 
 seashore, is advisable. An occasional tepid, alcoholic, or moderately cool 
 sponge-bath will prove beneficial. Sleep should be encouraged at stated times, 
 care being taken not to permit too much. The clothing must be of the proper 
 quality and quantity, and should permit of the freest movements of the chest. 
 Very feeble infants may be wrapped in cotton-wool. The domicile must be 
 scrupulously healthful in having pure air by free ventilation and the best sani- 
 tary equipment. The temperature of the room must be from 70° to 75° F. 
 
 Care should be taken in supervising the quality and quantity of the infant's 
 food. If the nursing infant has progressively emaciated and weakened, the 
 mother's milk needs attention. If bottle-fed, the management is even more 
 perplexing, but the proportion of albuminoids, fat, and sugar can be changed 
 until a combination is found that will be digestible and nutritious. Broths and 
 beef-juice may prove valuable adjuvants to the milk diet. If the infant be too 
 weak to nurse, or even to swallow, gavage or stomach-feeding is indicated. 
 W hen the stomach will not retain food, the strength must be sustained by con- 
 centrated nutritious enemata. 
 
 There are no specifics for the cure of atelectasis, but its different phenomena 
 must be met promptly and energetically. When secondary, the treatment must 
 be directed to the primary affection. If a foreign body be lodged in a bronchus, 
 
POST-NATAL ATELECTASIS. 903 
 
 its removal by operation is recommended. If the obstruction is a plug of ropy 
 muco-pus. it may be removed by active emesis induced by teaspoonful doses of 
 syrup of ipecacuanha, one or two grains of the sulphate of copper dissolved in 
 water, or the hypodermatic injection of apomorphia. 
 
 Cardiac and respiratory depressants, especially preparations of opium, must 
 be positively interdicted, while cardiac and respiratory stimulants must be 
 judiciously administered. The cardiac stimulants of most importance are 
 strophanthus, sparteine, nitro-glycerin, camphor, musk, and ammonium car- 
 bonate. Brandy, in frequently repeated doses, is one of the most efficient 
 stimulants. The force of the respiratory movements can be increased by yj-g- 
 to 2-0-0 g ra i n of atropine sulphate, which stimulates the respiratory centre. 
 Compressed air or oxygen may be inhaled, but neither has proved to be par- 
 ticularly beneficial. Convulsions must be treated by hot mustard baths and 
 antispasmodics. Finally, to ensure any hope of success, the infant requires 
 the most careful handling, the most rigid regimen, and the most judicious 
 dosage. 
 
BRONCHOPNEUMONIA. 
 
 By WILLIAM PEPPER, M. D., 
 
 Philadelphia. 
 
 Broncho-pneumonia — also known as catarrhal pneumonia, lobular pneu- 
 monia, and capillary bronchitis — is an inflammatory disease of the terminal 
 bronchioles and air-vesicles of the lung, affecting scattered groups of lobules. 
 Though in the main a catarrhal inflammation of the bronchioles and air-sacs, 
 the interventricular and peribronchial tissues are also involved, and the term 
 "catarrhal pneumonia" is therefore not altogether accurate, nor are the other 
 terms by which it has been designated wholly appropriate in all cases. The 
 disease varies widely in its course and duration, often proving fatal in a few 
 days, at other times becoming a lingering chronic affection, leading to secondary 
 changes or creating a tendency to subsequent tuberculous infection. 
 
 Etiology. — Broncho-pneumonia is in the great majority of cases a sec- 
 ondary disease, and, as a rule, bronchitis is the primary cause. This may 
 be either a simple bronchitis or that which occurs as a part of infectious 
 diseases, prominent among which are measles, whooping-cough, diphtheria, 
 influenza, and typhoid fever. The manner in which a bronchitis affecting the 
 smaller tubes might lead to a broncho-pneumonia is readily appreciated, but 
 will be considered more minutely in the description of the morbid anatomy. 
 A most important cause is tuberculosis affecting the bronchi and lungs. In 
 all cases of chronic phthisis there occur from time to time attacks of localized 
 broncho-pneumonia, from which the patient recovers, or there may be more 
 widespread and fatal attacks. The primary focus of tuberculosis is sometimes 
 so small as to have escaped detection, and in such cases the broncho-pneumonia 
 is apt to be looked upon as of the ordinary type. Broncho-pneumonia may 
 also arise without bronchitis as a primary disease of obscure origin, or as a 
 result of inspiration of irritants from the mouth, nose, or upper respiratory 
 passages, and in the new-born it may be the result of respiration of the liquid 
 secretions of the genital tract during birth. 
 
 The specific cause of the inflammation is probably, in most cases, the 
 pneumococcus of Frankel, but the staphylococcus and streptococcus pyogenes, 
 the bacillus of Friedlander, or, as we have seen, the tubercle bacillus, may be 
 the excitant in certain cases. 
 
 Of the predisposing causes of catarrhal pneumonia, by far the most 
 important is the age of the patient. A study of mortality statistics of young 
 children shows pneumonia to be second only to infantile "diarrhoea as a cause 
 of death, and in children under five years it is the lobular form of pneumonia 
 which is found in the great majority of cases. It is especially during primary 
 dentition that broncho-pneumonia occurs, and most of the fatal cases in par- 
 ticular occur before the age of two years. The preponderance of this form of 
 pneumonia during the early years of life is to be explained partly by the 
 anatomical condition of the lungs, and partly by the marked tendency to 
 catarrhal processes generally in infants. 
 
 904 
 
BB OXCHO-PNE UMONIA . 905 
 
 In addition to age, malhygienic surroundings exercise a powerful influence 
 on the prevalence of the disease, and particularly is this the case in times of 
 epidemics of measles, diphtheria, and whooping-cough, when children of the 
 poorer class are especially exposed and are apt to suffer from improper care. 
 The disease is most common during the winter and spring, and particularly at 
 times when the weather is changeable. Previous conditions of health, aside 
 from the infectious diseases, exercise some influence, and children suffering 
 with rickets or scrofula are prone to be attacked by the disease in its most 
 fatal form. 
 
 Morbid Anatomy. — As stated before, the more important part of the 
 pathological changes is the catarrhal inflammation of the lining of the smaller 
 bronchioles and air-vesicles, the epithelial cells rapidly desquamating and 
 accumulating within. As a rule, the cells are cast off singly, and lie inter- 
 mingled with a smaller number of leucocytes or red corpuscles. In more 
 rapid and virulent cases the epithelial lining may be detached in large flakes, 
 and sometimes there is considerable diapedesis of red blood-corpuscles, giving 
 the section a decidedly hemorrhagic appearance. The latter, however, is rare. 
 As the disease continues the cellular desquamation and exudation increase, 
 and at the same time a more or less copious outpouring of mucous secre- 
 tion occurs, until the bronchioles and air-vesicles become completely filled. 
 Beginning in the terminal bronchi, the inflammatory process advances, 
 and invades the adjacent air-vesicles in several ways. In the first place, 
 there is always a direct extension of the inflammation to the surrounding 
 peribronchial tissues, which are seen to be invaded by round cells and to be 
 the seat of active cellular proliferation. The secondary peribronchial inflam- 
 mation gradually spreads to the walls of the adjacent air-vesicles. Thus it is 
 seen that the peribronchial and perivesicular involvements are important 
 elements in the morbid anatomy, and in cases where the disease becomes 
 chronic these secondary changes lead to the induration processes characteristic 
 of chronic broncho-pneumonia. The extension from the bronchioles to the 
 alveoli is, however, also effected in other ways. There may be a continuous 
 inflammation extending along the epithelial lining, or the irritating matters 
 within the tubes may be directly conveyed by the, strong inspiratory efforts 
 following a paroxysm of coughing. These inspired substances may directly 
 excite vesicular inflammation, or by obstructing the terminal bronchial tubes 
 may first produce areas of collapse of the lung-tissue. The occurrence of 
 pulmonary atelectasis in the course of bronchial catarrh and broncho-pneumo- 
 nia is entirely a mechanical result of the obstruction of the tubes. In some 
 cases the obstructing material acts as a ball valve, permitting the air to pass 
 out, but not re-enter the affected area. More frequently the expiratory efforts 
 expel the air through partially obstructed tubes, but the weaker inspiratory 
 force proves inadequate to refill the vesicle ; and finally, in cases where there 
 has been complete obstruction of the tubes, the air enclosed within is gradually 
 absorbed. In any case, the vesicular structure collapses, the blood-vessels 
 become surcharged with blood, and the most favorable conditions for inflamma- 
 tory action are thus supplied. 
 
 When the disease begins to undergo resolution the cellular material within 
 the vesicles suffers fatty degeneration, and with the mucous secretion is 
 expectorated or absorbed coincidently with resolution of the peribronchial 
 inflammation. In cases, however, in which chronic pneumonia results, the 
 peribronchial connective-tissue hyperplasia undergoes fuller organization, and 
 induration follows in consequence. The bronchial walls are thickened, and 
 
906 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEX. 
 
 not rarely show fusiform dilatations, the result of traction of the newly-formed 
 connective tissue. 
 
 The macroscopic appearance is highly characteristic in most cases. The 
 involvement of scattered lobules of both lungs in itself is a most distinctive 
 condition, though sometimes by confluence a whole lobe may be affected. In 
 such cases the distinction from "croupous pneumonia becomes one of great diffi- 
 cultv if, as sometimes happens, the vesicles contain fibrinous exudate and the 
 incised surface presents a granular appearance. Even in these cases, however, 
 it will be noted that the process is not entirely a uniform one, and that there 
 is a certain tendency to lobular limitation. Examination of the pleural sur- 
 face of the lung shows a moderate deposit of lymph over areas which have 
 reached the periphery. The inflamed lobules project slightly from the surface, 
 and have a dark-red 'or in later stages a grayish appearance, which at once dis- 
 tinguishes them from the depressed, blue-black, and indurated spots of atelec- 
 tasis. The latter may be small and lobular or more extensive, and they are 
 most frequently seen posteriorly along the spinal column or anteriorly in the 
 middle lobe of' the right lung or the lingula of the left. In the early stages 
 they may usually be distended by inflating the lungs through a tube, but later, 
 as inflammatory changes occur within them, this becomes difficult or impossible. 
 The incised surface of the lung presents a similar picture. The distinct lobular 
 invasion is again quite evident, and the atelectatic areas are recognized by the 
 same characters as on the pleural surface. The lung is smooth and airless in 
 the -affected portions, or in rare cases may be slightly granular when the 
 exudate contains fibrin. The smaller bronchi are distended with clear viscid 
 mucus or turbid yellowish muco-pus. The lobules adjacent to the affected 
 ones are emphysematous, as are also the anterior margins and the upper lobes 
 of the lungs, and occasionally subpleural emphysema may be seen. In one 
 instance I found pneumothorax resulting from rupture of the pleura in such a 
 case. 
 
 AVhen resolution takes place, the inflamed lobules become lighter in color, 
 the exudate softens, and is finally removed. More rarely abscess or gangrene 
 may result, or chronic broncho-pneumonia may occur in lingering cases. The 
 termination in cheesy pneumonia, of which much was formerly written, is per- 
 haps always the expression of tubercular infection, either primary or consequent 
 upon the broncho-pneumonia. 
 
 Symptoms. — The onset of broncho-pneumonia is rarely marked by decided 
 symptoms. If the primary measles or whooping-cough has not been entirely 
 recovered from, a slight increase of the existing fever, with acceleration of the 
 pulse, dyspnoea, and a change of the cough to a short and hacking character, 
 may be the only symptoms to indicate beginning trouble. In cases in which 
 broncho-pneumonia arises primarily the same symptoms follow an initiatory 
 stage of bronchitis. The fever rises gradually, reaching the maximum in 
 three or four days, and is throughout the disease markedly irregular, the 
 diurnal excursions ranging from three to four degrees. In ordinary cases the 
 evening maxima are from 103° to 104.5° F.. but it is not unusual to find 
 higher temperatures, and in one case which recovered I have seen it reach 107°. 
 The decline of the temperature, like the ascent, is gradual, and for a long time 
 during convalescence feverishness may be noted toward evening. With in- 
 crease of the fever the pulse-rate accelerates to 130 or 140 beats per minute, 
 and in exceptional cases a rate of 200 may occur. Dyspnoea, however, is a 
 more decided symptom, the ratio between the respiration and pulse not infre- 
 quently becoming 1 to 2. or even less than 2. The alge of the nose dilate 
 with each inspiratory effort, the base of the chest sinks in, and the child mani- 
 
BR OXCHO-PNE UMONIA . 
 
 907 
 
 fests bv its expression that pain is felt in the side. When areas of the lung 
 collapse, there are paroxysms of more decided dyspnoea, the expiration becomes 
 more grunting, and duskiness or decided cyanosis of the skin makes its appear- 
 ance. The cough at first is sharp and short, and is attended by grimaces and 
 a cry of pain ; later it is heard to be looser, and in children over seven years 
 of age there may be muco-purulent expectoration. In younger children the 
 
 Fig. 1. 
 
 Chart of Temperature, Pulse and Respiration of Broncho-pneumonia in a patient two years and two 
 
 months old; recovery. 
 
 sputa are swallowed. With the fever and dyspnoea there is nearly always a 
 complete loss of appetite, but excessive thirst. Nursing infants are unable to 
 retain hold of the nipple for more than a moment or two on account of dyspnoea, 
 and older children refuse food entirely. The child becomes fretful and irritable, 
 but sometimes the urgency of dyspnoea may be such that it suffers itself to be 
 taken up or examined without complaint. The general strength rapidly 
 declines, and, as the interference with respiration continues, a soporose or 
 somnolent condition or complete stupor presages an early death unless relief 
 be afforded. Not infrequently vomiting is present at the onset or during the 
 course of the disease, and with diarrhoea may still further add to the general 
 depression and the unfavorable outlook. 
 
 In cases in which resolution occurs the symptoms gradually ameliorate, the 
 fever subsides, and in the course of a few days or a week convalescence is 
 established. In less favorable cases, after subsidence of the urgent symptoms. 
 the disease may linger and become chronic, or from the start it may assume a 
 
908 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 chronic type. In such cases there is persistent, irregular pyrexia, with cough, 
 dyspnoea, and acceleration of the pulse, and the general health of the patient 
 becomes more and more depressed. 
 
 Physical Signs. — At the inception of the disease the physical signs of 
 bronchitis affecting the smaller tubes will nearly always be present. At first 
 there are heard on auscultation numerous dry rales throughout both lungs; 
 later, coarse moist rales make their appearance, but the pulmonary resonance 
 remains unaffected. The physical signs of the developed disease are by no 
 means distinctive. Defective expansion and an up-and-down type of breath- 
 ing are manifest, and with each inspiratory effort the base of the chest may be 
 seen to recede. At the same time, careful percussion of the lateral and pos- 
 terior portions of the lungs may detect localized patches of dulness, but this 
 is by no means constantly the case. In not a few the percussion note is hyper- 
 resonant, perhaps from associated emphysema of the unaffected lobules, or, on 
 the other hand, the extent of dulness is rendered considerable by coexistence 
 of large areas of atelectasis. Vocal fremitus is slightly increased over the con- 
 solidated areas when the bronchial tubes are not unduly filled with mucus, but 
 over the collapsed portions it is usually wholly absent. Auscultation shows the 
 continuation of the preceding bronchitis, but in addition to these coarser dry 
 and moist rales there is also heard fine moist crackling over the consolidated 
 areas. These fine sub crepitant rales are heard on inspiration and expiration, 
 and are perhaps the most suggestive sign of the disease. The breath-sounds 
 themselves vary widely with the condition of the terminal bronchi and the 
 degree of distention. Sometimes the sounds are weak and faintly blowing, at 
 other times harsh and clear, but only rarely do we find the distinct bronchial 
 breathing of croupous pneumonia. It will be noted, then, that the signs of 
 broncho-pneumonia are in no sense characteristic ; but when to the rales of 
 bronchitis there are superadded fine subcrepitant rales, with harsh or somewhat 
 blowing breathing, and areas of even indistinct impairment of resonance at the 
 postero-inferior portions of the lungs, the evidence is fairly clear as far as 
 physical examination is concerned. 
 
 Complications and Sequels. — As has been said in the description of the 
 pathological anatomy, pulmonary collapse is a more or less constant factor in 
 the disease, and is therefore hardly to be looked upon as a complication. Yet 
 in some cases the extent of the atelectatic areas is so great, and the attending 
 dyspnoea and appearance of suffocation so severe, as to merit the place of com- 
 plicating symptoms. It is in such cases that the old title " suffocative catarrh" 
 finds a not inapt application. Pleurisy, so commonly present in slight degree, 
 rarely becomes a troublesome complication, though some observers, among them 
 myself, have met with purulent effusion. Abscess and gangrene rarely follow 
 broncho-pneumonia, but are most apt to do so in aspiration and deglutition pneu- 
 monias, in which the inflammation from the beginning may take on a serious 
 character. Subpleural emphysema and pneumothorax are rare complications. 
 The most dreaded sequel of broncho-pneumonia is tuberculosis. In some of 
 the cases the broncho-pneumonia is undoubtedly tubercular from the beginning, 
 but in any case the vulnerability of the system is so heightened by the attack 
 that subsequent infection becomes an easy matter, and frequently occurs. The 
 marked nervous symptoms during the course of broncho-pneumonia or toward 
 its termination may suggest meningitis, but it is more probable that in the 
 majority of such cases the symptoms are due to hyperemia of the meninges or 
 the toxemic state of the patient rather than to actual meningitis. 
 
 The termination of protracted cases in chronic pneumonia has been alluded 
 to before. 
 
BR ONCHO-PNE UMONIA . 909 
 
 Diagnosis. — In the first place, it is essential to recognize the development 
 of pneumonia during acute bronchitis at the very earliest moment. It may be 
 suspected when there has been a sudden increase of fever and acceleration of 
 the pulse and respiration, but such might occur independently of broncho- 
 pneumonia. If, however, in addition to these symptoms, fine subcrepitant rales 
 and blowing breathing be heard, and percussion detects small areas of impair- 
 ment of resonance, pneumonia may be diagnosticated with considerable cer- 
 tainty. 
 
 The disease when fully developed may readily be confounded with croupous 
 pneumonia in cases in which the confluence of lobular involvement has led 
 to a considerable area of consolidation. This, however, is rarely the case, and 
 even when it does occur the consolidation is not so definitely localized in one 
 lobe, and scattered patches will probably be found in the other lung. In 
 ordinary cases the dulness, the vocal fremitus, and bronchial breathing are not 
 developed to nearly the degree which they commonly attain in croupous pneu- 
 monia, and in typical cases there could scarcely be the possibility of confound- 
 ing the one disease with the other. The difficulty, however, of making accurate 
 physical examinations in young children is often considerable, and in such 
 cases the history of the disease is of greatest assistance. The gradual onset 
 and the marked irregularity of the fever, the existence of a preceding bron- 
 chitis, and the character of the sputa when present, are in all cases highly 
 suggestive of broncho-pneumonia, as the abruptness of the attack and the 
 greater regularity of the temperature curve give strong evidence of croupous 
 pneumonia. 
 
 The diagnosis from pleurisy with eifusion presents little difficulty, altogether 
 aside from the fact that the latter disease is rare in children under six years. 
 The coexistence of moderate pleuritic eifusion may, however, be difficult to 
 recognize. In such cases the decided dulness and the variation of its outlines 
 with changes in the position of the patient, and the more distant and muffled 
 character of the breath-sounds, may serve to indicate the actual pathological 
 conditions ; but the complication so rarely occurs that its recognition hardly 
 merits further study. More commonly, plastic pleurisy accompanies broncho- 
 pneumonia, and may confuse the physical signs, but careful study of the degree 
 of dulness, compared with the auscultatory phenomena, will in these cases 
 usually point to the proper diagnosis, and the evidence of great pain in the side 
 would still further strengthen this opinion. 
 
 In cases in which nervous symptoms or gastro-intestinal disorders become 
 prominent, it may happen that the underlying pneumonia is wholly overlooked. 
 Such an error can only be avoided by a critical study of the symptoms in every 
 case, particularly by close observation of the rate of the pulse and respirations 
 and by careful and repeated examination. 
 
 Prognosis. — Broncho-pneumonia is always a most serious disease, the 
 mortality ranging from 30 to 50 per cent., according to the nature of the cases 
 and the surrounding conditions. It is most fatal in children under two years. 
 and the form which occurs in the new-born from aspiration of irritating or 
 infectious particles during the transit through the maternal passages is almost 
 invariably fatal. In children over two years of age the mortality grows pro- 
 gressively less with the age of the patient. The cases which complicate 
 whooping-cough are most apt to be fatal or lingering. Rickets or other debili- 
 tating diseases and the occurrence of gastric disturbances, diarrhoea, marked 
 nervous symptoms, and pyrexia, all make the prognosis highly unfavorable. 
 
 Duration. — The duration of ordinary cases is generally from fifteen to 
 twenty-five days; milder cases may terminate in a week or ten days. Chronic 
 
910 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 broncho-pneumonia is uncertain in duration, ranging from a few to many 
 months. 
 
 Treatment. — It is difficult to lay down fixed rules for treatment in a disease 
 in which so much depends upon the actual extent and nature of the pathological 
 changes and upon the reaction of the patient. 
 
 In many cases of bronchitis or of infectious diseases attended with bron- 
 chitis, it will be possible to prevent the development of broncho-pneumonia by 
 careful attention to hygiene and by strict insistance upon every detail of treat- 
 ment. It will be necessary in such cases to maintain an even temperature of 
 70° or 72° in the sick-room, to avoid all drafts, and to adapt the clothing of 
 the patient according to his powers of resistance. In very young children the 
 mouth should be carefully cleansed with some simple mouth- wash like glycerin 
 and boric-acid solution, and older children should in addition be directed to 
 expectorate the sputa. 
 
 When pneumonia has actually become established, the hygienic details of 
 the sick-room must be still more strictly maintained. The temperature of the 
 room must be kept as nearly as may be at an even point, and it is always well 
 to have the air moistened by allowing water to steam at the hearth or over a 
 flame. In severe cases a tent of sheets may be erected over the bed and steam 
 from a boiler be directed into it. A light woollen shirt should be worn, and 
 the chest will require special protection. Formerly flaxseed poultices were in 
 common use in the treatment of pneumonia, but they are so apt to become cold 
 and disordered, and their constant application is attended by so much risk and 
 disturbance of the patient, that their use is now generally abandoned. The best 
 protection is afforded by a jacket of cotton or wool batting, lightly quilted and 
 covered on the outside with oiled silk. This may be so constructed as to be 
 easily applied and removed without the slightest disturbance of the patient, 
 and it is so light as to cause little discomfort by its weight. Practically 
 the same thing is accomplished by stitching cotton batting on the inside of a 
 light merino shirt, and oiled silk outside, but the jacket is more convenient. It 
 is unnecessary in ordinary cases to change the jacket oftener than every seven 
 or eight days. The use of counter-irritants, such as turpentine stupes, mus- 
 tard plasters, and blisters, while occasionally advisable, has, as a routine treat- 
 ment, fallen into disrepute ; but the repeated application of tincture of iodine 
 diluted with alcohol, so as not to prove too irritating, is often attended by good 
 results. 
 
 The diet of the patient should be at once light and nutritious, so that the 
 digestive functions may be kept in the best possible condition, and at the same 
 time the patient's strength preserved. Milk, gruels, light broths, arrowroot, 
 and egg albumin dissolved in water or milk answer the requirements, and are 
 the most suitable foods obtainable. In addition to proper regulation of the 
 diet, it is sometimes desirable to administer a mild laxative at the onset or dur- 
 ing the course of the disease if constipation be present ; but it must be remem- 
 bered that gastro-intestinal irritation is apt to complicate the case, and noth- 
 ing must be done which might invite its occurrence. Minute doses of mercury 
 with bicarbonate of sodium or Dover's powder, or the mildest salines, may be 
 of value, and in certain cases may exercise a happy regulating influence on the 
 gastro-intestinal system, provided that free purgation is not induced. 
 
 For the condition of the lungs themselves expectorants are highly important. 
 During the early stage, when bronchitis is marked and the sputa tenacious, small 
 doses of ipecacuanha or apomorphine, in combination with alkalies like citrate 
 of potassium, are useful. Such a combination as the following is readily taken 
 by children, and rarely fails to render the mucous secretion less tenacious : 
 
JBB ONCHO-PNE UMONIA . 9 11 
 
 R. Potassii citratis giiss. 
 
 Syr. ipecac f §ss. 
 
 Syr. liroonis 
 
 Aquae da q. s. ad f.liv. — M. 
 
 Sig. Two teaspoonfuls every three or four hours, for a child of five years. 
 
 A small dose of apomorphine — a sixteenth or a twenty-fourth of a grain — < 
 may be added with advantage in case the mucus is unusually tenacious. 
 Generally, however, recourse must soon be had to the more stimulating expec- 
 torants. The ammonium salts, the chloride and carbonate, in combination 
 with squills or senega, are the most desirable. In cases in which depression is 
 marked the carbonate is preferable to the chloride, and when painful cough 
 is urgent minute doses of morphine or paregoric may be added to the mixtures. 
 Opium, however, should never be given with such freedom as to benumb the 
 sensibility, and in the later stages of the disease should be avoided if possible. 
 In some cases, where the stomach is particularly irritable, the aromatic spirits 
 of ammonia may be better retained than other preparations, and is acceptably 
 administered in combination with brandy or other stimulant. 
 
 The following combination is especially valuable for children, being 
 pleasant to take and more stimulating than such as contain the chloride of 
 ammonium : 
 
 1^. Ammonii carbonatis gr. xlviij. 
 
 Pulv. acaciae et sacchari da q. s. 
 
 Spt. lavandulae comp feij. 
 
 Aquae q. s. ad f§iv. — M. 
 
 Sig. A teaspoonful in water every two or three hours, for a child five years old. 
 
 The general strength of the patient, and particularly the respiratory 
 function, require special attention. To this end quinine in small doses and 
 alcoholic stimulants are highly beneficial, but for respiratory and muscular 
 stimulation no drug compares with strychnine in efiiciency. E. g. — 
 
 Jfy. Quininae sulph gr. xxiv. 
 
 Strychninae sulph gr. \. 
 
 Acid, muriat. dil gtt. xvj vel gtt. xxxij. 
 
 Glycerini f3iij. 
 
 Liq. pepsini" . . . . . . q. s. ad f^iv. — M. 
 
 Sig. A teaspoonful in water every three or four hours, alternating with the 
 expectorant remedies, for a child of five years. 
 
 In cases where the stomach is non-retentive quinine may be given in sup- 
 positories of two or three grains each. The use of such expectorant and tonic 
 treatment usually suffices to keep the bronchi free and to prevent the occurrence 
 of atelectasis ; but when these unwelcome accidents make their appearance and 
 suffocating paroxysms occur, active treatment must be instituted. The admin- 
 istration of emetic doses of ipecacuanha, five grains of the powder in a little 
 syrup, is an old method of treatment which serves admirably to clear the 
 respiratory passages. In some cases it may be well to combine alum or sul- 
 phate of zinc, with the ipecacuanha, but the preparations of antimony formerly 
 so commonly used are depressing agents which had better be avoided. "\A hen 
 vigorous emesis fails of the desired purpose, a warm bath or alternate hot and 
 cold douches may be resorted to, and stimulants given by the mouth and 
 
912 AMERICAN TEXT- BO OK OF DISEASES OF CHILD BEX. 
 
 hypoclerinatically. In all cases in which the strength of the child is greatly 
 affected it is necessary to change the position from time to time, so that hypo- 
 static congestion may be avoided. 
 
 Fever in catarrhal pneumonia does not usually call for active treatment, 
 from the fact that the pyrexia is not constantly maintained at a high point, 
 but such is not always the case. In the very early stages a few doses of the 
 tincture of aconite, a half or one drop repeated every hour or two, are of dis- 
 tinct value ; and in the later stages small doses of antipyrin or phenacetin 
 exert a powerful influence on pyrexia. The use of either aconite or more 
 active antipyretics must always be most cautious, and the first indication of 
 general depression would call for the immediate withdrawal of the medicines. 
 Unquestionably the use of hydro therapic measures is most valuable in controlling 
 fever, in stimulating the general and respiratory tone, and in quieting the 
 nervous system. The patient may be carefully sponged with lukewarm or 
 cold water or wrapped in sheets wrung out in water, or he may be placed in a 
 bath of temperature varying according to the age. With very young children 
 the temperature of the water should be near that of the body, and gradually 
 cooled after the patient has been placed in it ; in older children the initial tem- 
 perature may be 85° or 80°. After removal from the bath the skin should be 
 lightly dried with a towel or woollen cloth and the patient wrapped in a blanket. 
 
 Excessive nervous symptoms are to a large extent controlled by sponging 
 or bathing, but in cases where this is inadequate small doses of chloral may 
 be given in enemata, or asafoetida in 5 grain doses, may be added to the quinine 
 suppositories. 
 
 In more chronic cases the general health and the respiratory action should 
 be maintained by the closest attention to daily life and by administration of 
 suitable tonics. 
 
 During convalescence of acute cases renewed exposure must be avoided, 
 and the child should receive cod-liver oil, arsenic, iodide of iron, or other 
 tonics ; and, if possible, a change of climate is of material advantage. 
 
CROUPOUS PNEUMONIA 
 
 By WILLIAM PEPPER, M. D., 
 
 Philadelphia. 
 
 Croupous Pneumonia — designated also lobar pneumonia and fibrinous 
 pneumonia — is a specific inflammatory disease of the lungs, characterized by 
 fibrinous exudation into the vesicular structure and consolidation of the lung, 
 presenting a characteristic clinical course and terminating by self-limitation in 
 seven to ten days. The croupous pneumonia of children diners from that of 
 adults only in some of the less important manifestations, in the situation of the 
 lesion, and in the smaller mortality. 
 
 Etiology. — One of the most important causes of croupous pneumonia is 
 exposure to cold. The history of a large majority of the cases will disclose 
 the fact that the child has suffered chill from exposure, and the study of 
 mortality statistics shows that two-thirds of all cases occur during the winter 
 and spring. Cold cannot, however, in the light of recent knowledge, be looked 
 upon as the exciting cause of the disease, though there are still some who 
 maintain that a small number of idiopathic cases from exposure do exist. 
 
 Age is an important factor in determining the form of pneumonia. The 
 croupous variety, though it does sometimes occur in infants at the breast, is 
 rare before the age of three, and in children is most common between five and 
 ten. On the other hand, broncho-pneumonia is a prevalent disease in chil- 
 dren under three or two, its frequency being explained by the great tendency 
 to catarrhal processes manifested in young children. 
 
 The previous health of the child is another point in which the croupous 
 form differs from broncho-pneumonia. Unlike the latter, it affects children 
 who are robust and in good health. Rilliet and Barthez said that in only 
 one-quarter of the cases was the child in good health before, but this may 
 have arisen from confusion with broncho-pneumonia, and in the statistics of 
 private practice of Dr. J. F. Meigs and myself there were but 7 of 52 cases 
 secondary to previous diseases. Of the diseases upon which croupous pneu- 
 monia may be consequent, pulmonary tuberculosis, measles, whooping-cough, 
 influenza, and typhoid fever may be named ; but in all of these in children 
 under three years of age broncho-pneumonia is more apt to occur as the com- 
 plication. 
 
 Malhygienic influences may induce pneumonia, either by causing exposure 
 or by reducing the power of resistance in some other manner. 
 
 The exciting cause in a great majority of all cases is the pneumococcus of 
 Frankel. This lance-shaped coccus usually occurs in pairs as a diplococcus, 
 and is surrounded by a transparent capsule. It has been found in a very large 
 percentage of cases of croupous pneumonia, but also in the catarrhal form, and 
 it seems to bear close etiological relations also to cerebro-spinal fever, to 
 middle-ear disease, and to endocarditis. The pneumococcus is a normal con- 
 stituent of the saliva ; and it is held that after exposure to cold or similar 
 
 58 913 
 
914 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 predisposition the micro-organism gains greater virulence or the lungs become 
 less resisting. There are, however, other micro-organisms which occasionally 
 seem the causative agents. Among these the bacillus of Friedlander, the 
 bacillus of influenza, the streptococcus pyogenes, and staphylococci are promi- 
 nent. 
 
 The evidence in favor of contagiousness of pneumonia of both forms is 
 fairly convincing, though the contagiousness is slight. I have seen a local 
 epidemic in a children's hospital in which the disease crept from bed to bed 
 around the ward, and similar instances are common in the recent literature of 
 the disease. 
 
 Morbid Anatomy. — The stages in the morbid anatomy are exactly the 
 same as in the adult, but more frequently there is a coexistence of the several 
 stages in the child, so that when one part of the lung is newly congested 
 another may show the most advanced consolidation or beginning resolution. 
 The stages are those of congestion, consolidation, red and gray, and resolution. 
 During the first stage the lung is swollen and red, and the surface of a section 
 is smooth and moist. The fluid which flows from the cut surface contains air 
 and is bloody. In the stage of consolidation the lung becomes solid or hepa- 
 tized ; it is friable, so that the finger easily tears through it, and the surface 
 is granular and dry. The granular appearance is due to the fibrinous exudate 
 which fills up the air- vesicles and smaller bronchioles. Microscopically, the 
 vesicles are seen to contain a fibrin network enclosing leucocytes, red corpuscles, 
 and a few desquamated cells of the lining membrane of the vesicle ; and the 
 blood-vessels of the intervesicular septa are over-full. In the first stage of 
 consolidation, that of red hepatization, the number of red corpuscles is very 
 great, but in the stage of gray hepatization they have largely been removed. 
 During resolution the exudate rapidly undergoes softening and is expectorated 
 or absorbed. 
 
 More rarely, termination in abscess-formation or gangrene results, or 
 chronic pneumonia may follow as a sequel. 
 
 As in adults, croupous pneumonia of children is a lobar process, but it is 
 far more frequently a bilateral disease in children. The lobe most frequently 
 affected is the lower lobe of the right lung, as in adults. Apex pneumonia, 
 however, is as common a disease in children as it is uncommon in adults, and 
 some writers claim the right apex as the more frequent seat. 
 
 In every case in which the pneumonic consolidation reaches the pleural 
 surface of the lung there is a certain amount of plastic pleurisy. More rarely 
 effusion of liquid occurs, and I have seen extensive empyema result. In some 
 cases there is also a concomitant bronchitis. This condition is occasionally 
 found in croupous pneumonia of adults, but with not nearly so great frequency 
 as in children. 
 
 Symptoms. — The onset of croupous pneumonia in children, as in adults, 
 is usually abrupt, but there may be a short prodromal period during which 
 the child is drowsy or restless and chilly, or coughs slightly and complains 
 of pain in the side. As a rule, however, the onset is decided, a paroxysm of 
 vomiting or convulsions, with rapid rise of temperature, at once calling attention 
 to the seriousness of the malady. Rigor may be present, but distinct chill, such 
 as is so constantly noted in adults, is rarely met with. Instead of this, con- 
 vulsions and vomiting, especially when indiscretions in diet have preceded the 
 onset, are very common in young children. The temperature rises rapidly, 
 and in a few hours may reach 104° F. It continues during the course of the 
 disease with moderate daily remissions, and declines at its termination by 
 rapid crisis. More rarely decided remissions and gradual decline may mark 
 
CP O UPO US PXE UMONIA . 
 
 915 
 
 the case. With the rise of temperature great rapidity of pulse is noted, but 
 even greater relative rapidity of the respirations, and in bad cases dyspnoea 
 is a most urgent symptom. The child lies on the affected side, and from time 
 to time is seized with paroxysms of sharp, short cough. In young children 
 the grimaces and cry give evidence of the pain experienced during coughing, 
 and older children complain of pain in the side or abdomen. Expectoration 
 is rarely seen excepting in children over seven years, when it may occur, and 
 presents the characteristic hemorrhagic or rusty character so commonly seen 
 
 Fig. 1. 
 
 DAY OF DISEASE 1 
 
 6 7 
 
 10 11 IS 13 
 
 14 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 M E M E M £ 
 
 M E 
 
 M E 
 
 M E 
 
 *f"^ 
 
 U& 
 
 iW 
 
 m- 
 
 We- 
 
 Mfe 
 
 
 1 
 
 14» 
 
 I 
 
 — 
 
 If 
 
 ±9& 
 
 1 
 
 -93- 
 
 
 mr 
 
 
 1 
 
 n 
 
 ■flfr 
 
 IW 
 
 ■«fr 
 
 w- 
 
 8RMAL 
 
 98- 
 
 -60-. 
 
 W- 
 
 — 
 
 
 Chart of Temperature (rectal), Pulse, 
 of the left lung in a 
 
 and Respiration in Croupous Pneumonia of the apex 
 patient three years old; recovery. 
 
 in the pneumonia of adults. The child may be restless and irritable, and 
 insist upon being constantly changed from the nurse's arms to the bed ; but 
 when the disease is most severe and dyspnoea is marked, complete apathy is apt 
 to be developed. The face is flushed, and particularly a bright red spot may 
 be seen on the cheek or region of the zygoma of one or both sides ; the aire 
 of the nose dilate with each inspiratory eifort ; herpes is often seen upon the 
 lips. The tongue is coated, the appetite is lost, and in certain cases vomiting 
 and diarrhoea may persist throughout the disease. Ordinarily in mild cases, 
 when convulsions or delirium have been present at the onset, they rapidly dis- 
 
916 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 appear with full development of the disease, but in severe cases nervous symp- 
 toms may take a prominent place throughout the case, and in some malignant 
 forms death may occur in convulsion before the appearance of the ordinary 
 symptoms of the disease. 
 
 In bad cases as the disease nears a fatal termination the respiratory efforts 
 become more and more rapid and irregular ; the pulse becomes more rapid 
 and weak ; duskiness or cyanosis may develop, with increasing drowsiness and 
 stupor, and the child may die convulsed or comatose. In favorable cases the 
 temperature rapidly declines about the seventh to the tenth day, and during 
 the early days of convalescence remains subnormal. Coincidently with the 
 decline of temperature the dyspnoea becomes less urgent, the pulse gains in 
 force, the nervous symptoms, if marked, soon disappear, and convalescence pro- 
 ceeds. Sometimes, however, convalescence is rendered tedious by diarrhoea or 
 stomatitis or by tendency to slight recrudescences of the fever. 
 
 Varieties. — Though, as a rule, the symptoms in croupous pneumonia have 
 a typical and regular course, there are occasional cases in which the manifes- 
 tations are so irregular as to warrant the description of certain clinical varie- 
 ties : (1) Cerebral pneumonia is a type in which from the onset excessive 
 pyrexia and nervous symptoms, such as delirium, convulsions, or coma, so 
 dominate the case that the underlying disease might readily be overlooked, and 
 the existence of meningitis be suspected, especially as cough and other pul- 
 monary indications may be wholly absent. Such cases are most frequently 
 observed in children debilitated by previous disease, and very often the pneu- 
 monic changes affect the apex of the lung. The relation of apical involve- 
 ment to severity of nervous symptoms has, however, been greatly exaggerated. 
 (2) Abdominal pneumonia is a less common variety, in which vomiting and 
 diarrhoea, with marked abdominal pain, are prominent symptoms. In some 
 cases these may be so decided as to indicate the existence of gastro-enteritis, 
 or, when pain and abdominal distention are excessive, of acute peritonitis. 
 In a small number of cases, especially of basal pneumonia of the right side, 
 jaundice is noted, and to such the term "bilious pneumonia" has been 
 applied. (3) Wandering pneumonia, or pneumonia migrans, bears so close 
 a similarity to broncho-pneumonia that the distinction requires the greatest 
 care. The disease affects one portion of the lung after another, and gives to 
 the case an irregular and lingering nature quite unusual in the croupous form 
 of pneumonia. By the completion of the disease consolidation may have been 
 present in every part of the lung, but the consolidation is usually not well 
 marked. 
 
 Physical Signs. — The physical signs are often less distinctive than in 
 adults, and it is especially to be remembered that the apex is almost as fre- 
 quently the seat of the disease as the base, and that bilateral pneumonia is 
 a much commoner condition in young children than in adults. In a typical 
 case, however, the signs are quite decided. The respiratory expansion is often 
 seen to be lessened on the affected side ; percussion and auscultation give evi- 
 dence of the consolidation of the lung. Dulness on percussion is never so 
 decided as in older persons, and sometimes the emphysematous condition of 
 the lung surrounding a centrally located pneumonia may cause the percussion 
 note to be hyper-resonant or tympanitic. In these cases deep percussion may 
 reveal the true condition of things, or the consolidation may subsequently 
 extend to the surface of the lung. On auscultation the typical crepitant rale 
 of pneumonia may be heard in a minority of the cases, either with ordinary 
 breathing or during the deep inspiratory efforts after coughing. In 31 cases 
 of the late Dr. Meigs and myself, the crepitant rale was heard in but 10. 
 
CROUPOUS PNEUMONIA. 917 
 
 Subsequently, when consolidation is complete, the breath-sounds become 
 decidedly bronchial, as we found in 46 of 57 cases ; and the vocal resonance 
 and fremitus may be found increased over the affected areas. The latter, how- 
 ever, are untrustworthy signs and difficult to determine. In children under 
 five or six it is not unusual to find evidences of bronchitis in addition to the 
 signs of consolidation, and coarse moist rales may persist throughout the case. 
 In any case moist rales become prominent during resolution and give evidence 
 of the softening of the exudate. 
 
 The physical signs are subject to wide variations in certain atypical cases. 
 Thus the existence of a large pleuritic exudate of plastic nature would render 
 the dulness decided, without altering the breath-sounds otherwise than by 
 muffling them to a greater or less extent. In the rare cases in which liquid 
 effusion occurs this condition becomes still more marked, and the auscultatory 
 signs may be completely obscured. Wandering pneumonia is apt to be pecu- 
 liar, not only in its migratory character, but also in the incompleteness of the 
 consolidation, so that but a small area of dulness may be detected. 
 
 Complications and Sequels. — Pleurisy is a constant accompaniment of 
 pneumonia which reaches the surface of the lung, but is usually of no great 
 severity. Effusion may, however, supervene, and in the pneumonias of measles, 
 scarlet fever, and typhoid fever, purulent effusion is occasionally met with. 
 Pericarditis may also occur, either alone or following the pleuritic complication. 
 The excessive nervous symptoms of cerebral pneumonia frequently create the 
 suspicion of meningitis, but this does not actually occur so frequently as the 
 symptoms would indicate. In such cases also hyperpyrexia becomes so decided 
 as to amount to a complication. The occurrence of jaundice has been alluded 
 to in the reference to abdominal pneumonia. Nephritis is a complication met 
 with in a certain proportion of cases, and one which materially increases the 
 gravity of the disease. It is much commoner in the pneumonia of children 
 than in that of adults. Abscess and gangrene of the lung are rare sequels, 
 as is also chronic indurative pneumonia. 
 
 Diagnosis. — The sudden onset of pneumonia with vomiting and convulsion 
 and high fever simulates very closely the onset of scarlatina. The distinction 
 is, however, rarely difficult if the excessive rapidity of the pulse, the soreness 
 of the throat, and the early appearance of a rash in scarlet fever be kept in 
 mind, and the physical examination for the signs of pneumonia be carefully 
 applied. 
 
 When the disease is fully developed it may be extremely difficult to dis- 
 tinguish it from broncho-pneumonia, especially from cases of the latter which 
 become lobar by confluence. On the other hand, a wandering type of croup- 
 ous pneumonia with imperfectly developed consolidation may simulate an ordi- 
 nary form of broncho-pneumonia, but the diagnosis is sufficiently detailed in 
 the description of that disease. Acute meningitis is often suspected when 
 profound nervous symptoms make their appearance, and indeed the latter may 
 obscure the underlying pneumonia. In such cases only a careful physical 
 examination will reveal the existence of pneumonia ; and, as for a complicat- 
 ing meningitis, it must be remembered that such is far less common than 
 we might suppose from the symptoms. The abdominal type of pneumonia is 
 sometimes mistaken for gastro-enteritis, peritonitis, or even acute ileus, and is 
 only recognized by careful study of the breathing of the patient and by the 
 physical signs. 
 
 Pleurisy with effusion is distinguished by the decidedly dull or flat percus- 
 sion note and the movable character of this dulness ; by the absence of breath- 
 sounds, rales, and vocal fremitus ; and by the milder character of the symp- 
 
918 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 toms. At its onset pain is more severe than in pneumonia, but fever and the 
 general depression of the child are decidedly less marked. 
 
 Prognosis. — Primary croupous pneumonia of young children is a disease 
 of little gravity compared with the same disease in adults or with broncho- 
 pneumonia of children. Of 60 cases, nearly one-half of them under two 
 years, Baginski lost but 4. In secondary cases, however, the prognosis is 
 much more grave, and in those -dependent upon primary septic diseases the 
 mortality is very high. As a rule, marked dyspnoea, high fever, and pro- 
 nounced nervous symptoms are indications of evil omen ; but common experience 
 has shown that in this disease, of all others, a favorable termination may fol- 
 low the most desperate case. Complications, such as pleurisy or pericarditis 
 and extensive involvement of one or both lungs, naturally make prognosis 
 more unfavorable. 
 
 It is to be remembered also that croupous pneumonia tends to relapse, and 
 that second attacks at remote periods are not unusual. 
 
 Treatment. — The seriousness of the disease requires that the patient be 
 at once placed at rest in bed. The room should be kept at an even tempera- 
 ture of about 68° to 70°, and drafts must be carefully avoided. It is always 
 well to protect the chest by a jacket made of cotton batting lightly quilted. 
 The food must be light, but nutritious ; broths, junket, and milk, as a rule, 
 prove most acceptable. Sufficient water should be permitted to relieve thirst. 
 The medicinal treatment need not generally be a vigorous one, care being taken, 
 however, that the strength of the patient be properly maintained. In the early 
 stages small doses of tincture of aconite in combination with the solution of 
 ammonium acetate or with sweet spirits of nitre serve to control the tempera- 
 ture and to quiet excessive action of the heart. If, however, fever becomes 
 more decided, aconite will prove inadequate, and recourse to stronger antipyretics 
 may be necessary ; but hydrotherapic measures are more efficient. Sponging 
 with cool water and the cold pack or bath are the safest and surest means of 
 controlling temperature, and when carefully used give rise to no unpleasant 
 consequences. The prejudices on the part of parents may, however, prevent 
 their use, in which case small doses of antipyrin or phenacetin become neces- 
 sary. When cough and pain in the side are troublesome symptoms, opium may 
 be given in quantity sufficient to allay the irritation, guarding carefully, how- 
 ever, against excessive opiate effect. In severe cases, where general depres- 
 sion and cardiac weakness are marked, recourse must be had to stimulating 
 remedies. Brandy or whiskey may be used in liberal quantity, and carbonate 
 of ammonium is useful in cases in which the cough is tight and irritating. 
 For the support of the heart digitalis is unquestionably the most reliable 
 remedy, though care must be taken lest it prove disturbing to the stomach. 
 In cases of extensive or double pneumonia, in which the strength of the child 
 is profoundly affected and the heart and respiration losing force, stimulation 
 must be pushed to the utmost. In such cases the hypodermatic administration 
 of strychnine and of such diffusible stimulants as ether and aromatic spirits 
 of ammonium may help to carry the child over the crisis, and the inhalation 
 of compressed air or oxygen may prove of signal service. Throughout the 
 disease the general systemic tone is well maintained by the use of quinine in 
 suppositories, to which asafcetida may be added in case nervous symptoms 
 become pronounced. If asafcetida does not suffice, chloral by enema may be 
 tried, and usually exercises the happiest control. 
 
 Of late the use of serum from the blood of convalescent patients has been 
 advocated, and has seemed to effect a crisis in some cases, but the time is not 
 yet ripe for a definite expression on the value of such treatment. 
 
GANGRENE AND ABSCESS OF THE LUNG. 
 
 By HENRY JACKSON, M. D., 
 
 Boston. 
 
 I. Gangrene of the Lung. 
 
 Gangrene of the Lung is a necrosis of the pulmonary tissue, with 
 decomposition of the affected portion, due to the invasion of the tissue by the 
 bacteria of putrefaction. 
 
 It is important to remember that gangrene may be closely simulated by a 
 post-mortem putrefactive softening of the lung, due to the action of the con- 
 tents of the stomach. These spots may be multiple, are dark-greenish or 
 black in color, and have a sour smell. This process is identical with the post- 
 mortem softening so often found in the stomach and oesophagus. There is 
 rarely found a necrosis of the lung-tissue without putrefaction ; this form 
 usually occurs in small patches. The tissue is reddish-brown in color and easily 
 torn, but there is no odor, as in true gangrene of the lung. It is usually found 
 in patients suffering from diabetes, and, so far as I know, it has not been met 
 with in children. 
 
 Etiology. — Gangrene of the lung is not met with as a primary disease, 
 but is always secondary to some other pathological condition. It is found in 
 two classes of cases essentially different : First, gangrene may result from a 
 lobar pneumonia ; this occurs only in individuals whose general health has 
 been seriously affected, and is especially common in drunkards. On account 
 of the impairment of the circulation, either from local disease of the arteries 
 or from extreme weakness of the heart, the inflammatory exudation is not 
 absorbed ; it becomes foul from the entrance of the bacteria of putrefaction, 
 and gangrene ensues. This form of gangrene is rare in children. On the 
 other hand, gangrene may be the result of wounds of the lung or may follow 
 severe contusion of the chest ; in the latter instance, as Orth says, the process 
 probably results from the decomposition of unabsorbed blood. Another class 
 of cases is found where the gangrene is the direct result of inoculation from 
 putrefactive processes situated at a distance from the lung, which is infected by 
 septic emboli through the blood-current, or from the aspiration of foul secre- 
 tions from bronchiectatic cavities or gangrenous ulceration in the mouth and 
 naso-pharynx. 
 
 Gangrene of the lung in children is usually met with in those of a weak 
 constitution, with poor circulation, where some local cause can be found as the 
 origin of the septic process. It is rarely met with except as an intercurrent 
 disease. In 16 cases treated by Barthez and Rilliet the gangrene was asso- 
 ciated as a complication with the following diseases : Measles, 3 cases : small- 
 pox, scarlet fever, intestinal catarrh, tuberculosis, each 1 case ; pulmonary and 
 general tuberculosis, 3 cases ; intestinal catarrh, with collapse, 2 cases : menin- 
 gitis, typhoid fever, bronchitis, and pleuro-pneumonia, each 1 case. 
 
 919 
 
920 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 A very considerable number of the cases of gangrene in children are asso- 
 ciated with acute septic processes in the middle ear or foul ulcerations in the 
 mouth or naso-pbarynx. Several cases have been reported where gangrene of 
 the lung has followed the inspiration of some foreign body. It is especially 
 noteworthy that recovery appears to be the rule in such cases even after 
 extensive destruction of the lung-tissue has occurred, as evidenced by the 
 expectoration of large masses of foul pus and the demonstration of cavities 
 by physical examination. Small patches of gangrene are not infrequently 
 found in lungs which contain tuberculous cavities, the gangrene being de- 
 pendent upon the aspiration of bits of putrid material from these cavities. 
 Again, it is not an unusual accompaniment of chronic bronchitis with cavity- 
 formation. The only case of gangrene in a young individual which has come 
 under my observation was of this character. A young girl of eighteen pre- 
 sented herself at my clinic with the history of cough for several years ; she 
 was never strong. For many months the cough had been paroxysmal in 
 character, and accompanied by the expectoration of large masses of fetid 
 sputum. After moderate cough she raised at once several ounces of greenish 
 fetid pus ; the sputum contained many bacteria, but no bacilli of tuberculosis. 
 Physical examination showed a pale, thin girl ; chest long and narrow, shoulders 
 rounded. No dulness on percussion ; throughout both lungs numerous coarse, 
 moist rales. The breath was fetid. This case was apparently one of chronic 
 bronchitis with large bronchiectatic cavities, as shown by the sudden expecto- 
 ration of large masses of sputum. 
 
 In the autopsy records of the Boston City Hospital I do not find a case of 
 gangrene of the lung in a child, though the hospital receives quite a large num- 
 ber of children among its patients. I find thirteen cases of gangrene of the 
 lung, and the list fairly covers the varying conditions in which gangrene may 
 occur : Four cases of acute fibrinous pneumonia with gangrene : 1st. A drunkard 
 aged fifty-four, with delirium tremens and pneumonia of both upper lobes ; 
 2d. A woman aged thirty-five, acute abscess in peritoneal cavity and acute 
 suppurative perihepatitis ; 3d. A woman aged twenty-eight, much reduced by 
 chronic empyema of eight months' duration ; 4th. A man of thirty-six, habits 
 not given, etiology obscure. Three cases of tuberculosis with gangrene : 1st. 
 A man of thirty-eight, chronic nephritis, chronic endarteritis ; 2d. A woman 
 aged seventy, acute broncho-pneumonia, bed-sores, and fracture of the thigh ; 
 3d. A man aged fifty, putrid bronchitis, cough for many years, emaciated, 
 recent abscess in the throat. Two cases associated with surgical operations : 
 1st. A man aged forty-five, drunkard, syphilis, stricture of long standing, with 
 urethral tears ; 2d. Old man, operated upon for cancer of the tongue, inha- 
 lation pneumonia, and gangrene of the lung, with gangrenous pyo-pneumothorax. 
 Two cases of injury to the head, with inhalation pneumonia, both old. One 
 case of typhoid fever in a drunkard, with broncho-pneumonia. One case, a man 
 aged twenty-seven, who had a gangrenous abscess of the lung and gangrenous 
 pleurisy. These cases are collected from a large number of autopsies which 
 include many cases of tuberculosis of the lungs and pneumonia. The only 
 case in which there was not some previous local or constitutional disease ex- 
 planatory of the gangrene is the last one mentioned. 
 
 Gangrene of the lung is, at any age, a rare disease, and, except in a few 
 cases where it follows acute pneumonia, is usually met with in individuals of 
 weak constitution in whom some septic process offers a point of origin for septic 
 emboli which may be carried to the lung. It is interesting to study the autop- 
 sies made on cases of diphtheria at the Boston City Hospital as bearing upon 
 the etiology of gangrene. In 26 cases in a continuous series, 19, or 73 per 
 
GANGRENE AXD ABSCESS OF THE LUNG. 921 
 
 cent., had some affection of the lungs : of these cases, 14, or 50 per cent., had 
 acute catarrhal pneumonia ; 5 had atelectasis. One of the cases of atelectasis 
 had also a small abscess. None of these 19 cases presented evidence of gan- 
 grene of the lungs. As all these cases of pneumonia occurred in individuals 
 with a serious local septic condition, it is evident that gangrene of the lung is 
 rare, even in septic cases, unless the resistant power of the pulmonary tissue is 
 impaired by a previously-existent general feebleness of the individual. In other 
 words, the pulmonary circulation is so favorable that an acute inflammatory 
 process does not tend to become gangrenous simply because the immediately 
 exciting cause of the inflammation is a septic material. 
 
 A few cases of gangrene of the lung have been observed in which careful 
 examination failed to elicit any reasonable explanation of the etiology. Such 
 a case is reported by Holt. A child three years of age, who had not been 
 sick except for an attack of bronchitis two years before, was suddenly taken 
 ill ; the disease ran its course with signs of acute pneumonia and bronchitis ; 
 death in two weeks. Autopsy showed right-sided pleurisy with gangrene of 
 two-thirds of the right lower lobe. 
 
 Pathology. — Gangrene of the lung may be met with as a diffused or a 
 circumscribed process. The circumscribed form occurs more frequently in 
 children ; small patches are found scattered through the lungs ; they are 
 greenish or black in color, the tissue is softened, easily broken down, and has 
 a most intensely fetid odor. Surrounding the patches of gangrene there is 
 usually an area of acute inflammation, comparable to the line of demarcation 
 which surrounds a slough. It is usual to find, in one or more of these areas 
 of gangrene, cavities which contain a foul, dirty material composed of broken- 
 down lung-tissue, while the walls of the cavities themselves are shreddy. 
 When the primary lesion is in the upper part of the lung, numerous areas 
 of gangrene are found in the lower lobes, due to the inspiration of small 
 bits of necrotic tissue. Microscopical examination of the contents of such 
 gangrenous areas shows the presence of bits of elastic tissue of the lung, 
 numerous cells exhibiting fatty degeneration, and immense numbers of bac- 
 teria of many kinds ; fat-crystals and globules of free fat are also met with in 
 abundance. No specific bacteria have been found in cases of gangrene of the 
 lung ; the bacteria belong to the various species which are the etiological 
 factors in ordinary putrefactive processes. Streng describes two cases of 
 gangrene of the lung in which he found infusoria. The infusoria were cells 
 about the size of a white blood-globule : they had cilia and were capable of 
 active motion. 
 
 When the gangrenous area, in its extension, reaches the pleural surface, 
 there results a gangrenous pleurisy, which may become encapsulated by the 
 formation of adhesions. This formation of an encapsulated pleurisy gives at 
 times an important hint for treatment, making it possible in suitable cases to 
 open the lung by free incision and drain a gangrenous cavity without causing 
 a general pleurisy. It is not unusual that during the progress of the disease 
 small blood-vessels are eroded, thus giving rise to haemorrhage of greater or 
 less severity. 
 
 Symptoms. — In many cases the symptoms of the gangrene are masked by 
 the more prominent symptoms of the primary disease, and the gangrene is only 
 discovered at autopsy : this is especially true of children, in whom expecto- 
 ration is rare. Loss of flesh and strength is rapid ; the complexion is pale, 
 gray ; sweating is a prominent sign. The temperature is irregular, much more 
 intermittent than in pneumonia: the course of the temperature may be an im- 
 portant guide in the differential diagnosis between an acute pneumonia and a 
 
922 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 diffused gangrenous affection of a large part of the lung, where the physical 
 signs point to consolidation of a large area of lung-tissue. The pulse is rapid 
 and feeble. Physical examination yields varying results according to the area 
 of the diseased tissue : we may find only the evidence of a bronchitis, but if 
 
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 the area of gangrene is large we find dulness due to consolidation. Where large 
 areas have been destroyed by the gangrenous process we may find, after cough 
 with expectoration, amphoric respiration and a high-pitched tvmpanitic note, 
 indicating the presence of a cavity. The breath is exceedingly foul and has a 
 peculiar fetid, sickening odor : it is important to bear in mind that a local 
 gangrenous process in the mouth may give rise to an odor almost as disagreeable 
 as that of gangrene of the lung. Caries of the nasal bones with retained secre- 
 tion, ozsena, gives an odor even more similar to that of gangrene of the lung. If 
 there be expectoration, the sputum is dark greenish-yellow and very fetid : it 
 may be large in amount, even in quite young children, as the gangrene causes 
 the formation of large cavities, which are usually emptied at irregular intervals. 
 An important diagnostic sign is haemoptysis, which is of especial value in chil- 
 dren, since with them, in other diseases, this symptom is rare. Kohts records 
 the case of a child of three years who, after an excision of the hip-joint, spat 
 up tour or five tablespoonfuls of blood, and soon became very weak, had exceed- 
 ingly foul breath, and died in a few weeks after the onset of the unfavorable 
 symptoms. 
 
 Prognosis.— The prognosis in gangrene due to septic emboli or inhalation 
 pneumonia is almost necessarily fatal. It is about equally bad in gangrene 
 following pneumonia, as it is only met with in children previously much re- 
 duced. Several cases have been reported of recovery from gangrene which 
 
GANGRENE AND ABSCESS OF THE LUNG. 923 
 
 had followed the swallowing of a foreign body. Kohts describes such a case 
 which occurred in his own practice. A girl of six years swallowed a bit of 
 bone : eight weeks later she had excessive cough with foul expectoration and 
 fever. Ten months later she coughed up the foreign body, and finally, after a 
 year, was completely restored to health. 
 
 Treatment. — The first indication is to sustain the strength by giving the 
 greatest possible amount of food ; stimulants may be pushed to an extreme 
 degree. Small doses of strychnia are at times useful in asthenic forms of 
 pneumonia as seen in diphtheria, and may be tried in gangrene. This drug 
 acts as a stimulant to both the circulation and respiration. Direct cardiac stim- 
 ulants, like tincture of strophanthus or of digitalis, are indicated if the pulse 
 be weak and rapid. Where there is fair reason to suppose that the gangrene is 
 circumscribed and not of very large extent, incision of the lung is admissible : 
 this surgical procedure is, however, limited to cases that are free from general 
 septicaemia ; that is, practically, to cases of gangrene dependent upon the 
 swallowing of a foreign body. If there be a pyo-pneumothorax, free incision 
 of the pleural cavity is always indicated. If the child is old enough to inhale, 
 sprays of creasote or turpentine should be used, as these modify the odor of the 
 breath, and may aid in hastening a curative process. 
 
 II. Abscess of the Lung. 
 
 Abscess of the lung, like gangrene, may be an occasional sequel of acute lobar 
 pneumonia in children. In such cases physical examination shows an absence 
 of the usual signs of resolution after the subsidence of the fever. There ensues 
 an irregular rise and fall of the temperature, the pulse becomes rapid, and there 
 is a progressive loss of flesh and strength. It is not unusual that a large 
 amount of pus may be raised when the abscess breaks into a bronchus ; after 
 the expectoration of such a quantity of pus there is often found amphoric respi- 
 ration. The abscess often extends to the pleural surface, and finally breaks 
 through into the pleural cavity. As the process is more chronic, pleural adhe- 
 sions are more likely to occur than in gangrene of the lung ; so that when the 
 abscess breaks we have an encapsulated pleural abscess. Rarely, a neglected 
 empyema may break into the lung and give rise to a pulmonary abscess instead 
 of forcing its way outward through the skin. 
 
 The prognosis, in abscess of the lung, though serious, is not so absolutely 
 unfavorable as in gangrene. 
 
 As to the general treatment, the same course may be followed as outlined in 
 gangrene. This condition offers a better opportunity for surgical interference 
 than does gangrene : we do not have the general septic condition to contend with. 
 Before making a free incision into the lung the diagnosis should be confirmed 
 by an aspirating needle, and incision should be made at the point where the pus 
 is withdrawn. 
 
BRONCHITIS. 
 
 By WALTER S. CHRISTOPHER, M. D., 
 
 Chicago. 
 
 Bronchitis is an inflammation of the bronchial mucous membrane. On 
 account of the great number of independent causes capable of producing 
 this condition, it should be regarded as a symptom rather than a disease. 
 
 Bronchitis may be classified from several standpoints. With reference to 
 the parts of the bronchial tree affected, it may be classified as large tube, small 
 tube, and capillary bronchitis. Under the first category tracheitis should be 
 included. Capillary bronchitis, referring to the inflammatory condition of the 
 smallest bronchioles, is probably always associated with broncho-pneumonia and 
 does not exist as a distinct entity. The term, therefore, is an unfortunate one, 
 and should not be used; indeed, any general classification of bronchitis with 
 reference to the anatomical distribution of the bronchial tubes is misleading 
 and often erroneous. 
 
 As to duration, bronchitis is classified as acute, chronic, and recurrent. 
 From the standpoint of origin it is denominated primary or idiopathic, and 
 secondary or symptomatic. It is doubtful if bronchitis ever occurs as a 
 primary disorder, an opinion which Sutton has also expressed, although it must 
 be admitted that it is not always possible to clinically determine the antece- 
 dent conditions. As to intensity, it is convenient to adopt the division into 
 mild and severe cases. 
 
 Etiology. — The etiological factors which lead to the production of bron- 
 chitis are exceedingly varied, and the consideration of them is one of the most 
 important factors in the study of this subject. Much light is thrown upon the 
 nature of bronchitis by grouping together the various elements which go to 
 produce the disease in its different forms. Bronchitis is a constant symptom 
 in most of the exanthemata and in some other of the acute infectious diseases, 
 produced no doubt by a direct action of the particular poisons present. Prom- 
 inent among diseases of this type are pertussis and measles. Typhoid fever is 
 invariably accompanied by some bronchial catarrh, and, while in the adult this 
 symptom is frequently so slight as to be practically unnoticed, it is by no means 
 so in children, and the younger the child the more important does the symptom 
 become. As seen in the West, a disease which seems to be typhoid fever, and is 
 so admitted by many practitioners, is characterized by the great predominance 
 of the bronchial symptoms ; and there can be but little doubt that some cases of 
 so-called idiopathic bronchitis in infants, some of which have advanced even to 
 the stage of broncho-pneumonia, are manifestations of typhoid fever. While 
 bronchitis is one of the usual symptoms of influenza, not infrequently it is the 
 most important and most striking ; particularly is this true of infants. During 
 the prevalence of influenza, cases of bronchitis' are seen that cannot be referred 
 positively to this infection, but which probably are manifestations of it. Rubella, 
 rather less frequently than measles, has bronchial catarrh as a symptom. In 
 
 924 
 
BRONCHITIS. 925 
 
 scarlet fever bronchial catarrh rarely occurs, but the possibility of its occurrence 
 in this disease should not be overlooked. Pulmonary tuberculosis is a common 
 cause of bronchitis in infants. Septicaemia, or wound infection, occasionally has 
 bronchitis as one of its numerous symptoms. Another toxic influence of great 
 practical importance is to be found in infection from the intestine. Several years 
 ago Sevestre called attention to cases of broncho-pneumonia accompanied by 
 putrid diarrhoea, from which he inferred that the cause of the pneumonia was to 
 be found in the infection from the putrid contents of the bowel. Later, his pupil, 
 Le Sage, determined in the lungs of such cases the presence of the bacillus coli 
 communis. More recently, similar cases have been investigated by his pupils, 
 Gastou and Renard, who did not find the coli bacillus uniformly, but occa- 
 sionally the pneumococcus, a staphylococcus, and an encapsulated bacillus. 
 While there is no positive research going to show that a similar condition 
 obtains in the case of bronchitis, there is clinical evidence which confirms the 
 idea that some cases of bronchitis are due to infection or poisoning from the 
 intestine. That poisoning by a chemical agent alone is capable of inducing 
 the anatomical conditions of acute bronchitis has been shown very conclusively 
 by Hamilton, who describes the appearances found in the bronchial tubes of a 
 healthy man dead of opium-poisoning, and proves quite conclusively that the 
 appearances found were due to the opium-poisoning exclusively. The condi- 
 tions were exactly those produced at the beginning of acute bronchitis. In 
 Bright's disease the bronchitis which occasionally occurs is no doubt a toxic 
 symptom, although in some instances, particularly in the acute Bright's disease 
 of children, it is an evidence of pulmonary oedema. 
 
 In infants and young children innutrition plays a most important role in 
 the production of bronchitis. It is frequently asserted that dentition is a cause 
 of bronchitis. The coexistence of dentition and bronchitis is no doubt true ; 
 the recurrence of bronchitis in certain children with the proruption of each 
 tooth likewise is to be admitted ; but in the cases which have fallen under my 
 own observation there has invariably been a demonstrable degree of innutrition, 
 and to this factor, rather than to the dentition, should be ascribed the occurrence 
 of the disease. In the presence of some nutritional deficiencies, other physio- 
 logical conditions, no less trifling than dentition, may be capable of exciting a 
 bronchitis. The particular form of innutrition present is usually shown to be 
 rickets — that is to say, a fat-starvation, characterized by profuse sweating about 
 the head, by delayed dentition, by restlessness at night, and later by the bony 
 changes. No doubt exposure to cold becomes active as an etiological factor in 
 those whose nutrition is below par, but it is more than doubtful that exposure 
 to cold alone is capable of inducing the condition of bronchitis. Nevertheless, 
 it must be admitted that bronchitis occurs much more frequently during the 
 cold and damp periods of the year than during the dry and warm seasons. 
 
 Inhalations of irritating gases and the accidental introduction of foreign 
 bodies into the bronchi are capable of producing acute bronchitis in a purely 
 mechanical way. • Obstructive heart lesions, by interfering with the pulmonary 
 circulation, may likewise lead to oedema and some of the changes of the milder 
 form of bronchitis. Chronic bronchitis, once established, is capable by its 
 mere presence of being the starting-point of subsequent acute attacks ; indeed, 
 any form of lung degeneration, as has been pointed out by Sutton, is capable 
 of inducing attacks of bronchitis. 
 
 Probably the most important cause of recurrent bronchitis is the presence 
 of enlarged bronchial glands. And when it is remembered that any acute 
 bronchitis, no matter how trifling, may lead to the enlargement of these glands, 
 and that acute bronchitis, in one form or another, is probably in children the 
 
926 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 commonest of all pathological manifestations, the importance of broncho-adenitis 
 as a cause of recurrent bronchial catarrh, and, indeed, as an independent affec- 
 tion, is at once apparent. It is not at all uncommon to find children suffering 
 through several winters with attacks of bronchitis recurring at short intervals, 
 and in almost every instance it can be found upon investigation that enlarge- 
 ment of the bronchial glands is at the root of the trouble. Many cases classed 
 as phthisis pulmonalis in younger children are instances of broncho-adenitis. 
 It must also be noted that bronchitis may be secondary to a local extension 
 downward of any form of laryngeal inflammation. 
 
 From the wide variety of factors concerned in the production of bronchitis 
 it is hardly to be expected that a micro-organism should be found as a specific 
 cause of this condition ; nevertheless, E. F. Grtin has noted in cases of bron- 
 chitis produced by various causes, measles, whooping-cough, etc., a bacillus 
 which he regards as the specific cause of the catarrh. 
 
 Morbid Anatomy. — A very careful study of the anatomical changes occur- 
 ring in bronchitis has been made by Hamilton, 1 whose work has been referred 
 to freely in the preparation of the following outline. The anatomical changes 
 in acute bronchitis have been found to be identical, irrespective of the cause. 
 The bronchial mucous membrane throughout is not uniformly affected, but the 
 inflammation is found distributed either generally, in patches of greater or less 
 extent, or limited principally to one lung or even a part of one lung. The 
 trouble may be limited to the tubes of large calibre or may extend into the 
 smaller tubes. The tendency to extend into the smaller tubes is more marked 
 in children than in adults, and particularly is this true of infants. Inasmuch as 
 the accumulation of the catarrhal products in the smaller tubes adds a gravity 
 of its own to the situation, it is well to emphasize this peculiar tendency of the 
 trouble in those of tender age. 
 
 On section of the lung a muco-purulent discharge is seen to ooze from the 
 bronchi, and by squeezing the lung the same material is forced out of the 
 smaller tubes. To the eye the surface of the mucous membrane appears con- 
 gested and vessels are seen ramifying on the surface. According to Hamilton, 
 the first microscopic change consists in the " relaxation and distention of the 
 abundant plexus of blood-vessels ramifying in the inner fibrous coat imme- 
 diately beneath the basement membrane — that is to say, of the branches of the 
 bronchial artery." Immediately following this the basement membrane becomes 
 thickened and oedematous and is thrown into folds. By the end of twenty or 
 thirty hours the columnar epithelium becomes loosened and desquamates in 
 patches. The cast-off epithelium becomes one of the elements of the catarrhal 
 secretion, but as these cells are not reproduced until after the process ceases, 
 they are. only found in the expectoration during the early stages. During this 
 period the bronchial secretion is diminished and the accompanying cough is 
 spoken of as " tight." The cells of the deeper layers of the epithelium nearly 
 all remain attached to the basement membrane, and when freed from the over- 
 lying columnar epithelium proliferate actively, and give off into the bronchial 
 secretion an abundant mass of small round cells. The secretion is further made 
 up of the material poured out by the mucous glands. These elements partake 
 of the general activity. Their secreting cells become greatly distended with 
 mucus, and, breaking down, pour out an abundance of this material into the 
 bronchial tubes. 
 
 Throughout the whole process, according to Hamilton, the basement mem- 
 brane remains intact, except in so far as it becomes thickened, and forms a 
 barrier between the inner epithelial elements and the outer fibrous, muscular, 
 1 The Pathology of Bronchitis, etc. London, 1883. 
 
BRONCHITIS. 927 
 
 and lymphatic elements. Beneath the basement membrane the inner fibrous 
 coat of the bronchus becomes thoroughly infiltrated with small cells, and, as 
 these cells cannot pass inwardly because of the basement membrane, they 
 make their way outwardly and infiltrate the muscularis and the outer fibrous 
 coat. Beyond this infiltration the muscularis and the outer fibrous coat are 
 not involved if the process ceases in the acute stage. The cellular infiltration 
 continues outwardly, involving the interlobular septa and even reaching the 
 pleura. Hamilton notes that the lymphatic glands at the root of the lung, the 
 bronchial glands, are invariably involved in the process and become enlarged. 
 This harmonizes with clinical experience. Particularly in infants and young 
 children does this change take place. There is no one item in the morbid 
 anatomy of bronchitis which is of greater consequence than this. It is im- 
 portant to note that enlargement of the bronchial glands occurs in every case 
 of bronchitis ; that in sharp attacks or after repeated attacks the enlargement 
 becomes considerable ; and that the enlargement is not always tuberculous, but 
 may become so. A considerable enlargement of the bronchial glands is not 
 infrequently mistaken for pulmonary phthisis. As has already been noted, 
 broncho-adenitis is a potent factor in the further production of bronchitis, and 
 should always be suspected in the presence of recurrent or chronic bronchitis. 
 It is furthermore important in that it leads to the establishment of anaemia and 
 to delayed convalescence, for, as Rachford has shown, disease of the lymphatic 
 system is a potent factor in the production of chronic anaemia in children, with 
 resulting malnutrition. 
 
 When an acute bronchitis has run its course and is about to terminate in 
 resolution, the vascular congestion and the epithelial activity ceases, the muco- 
 purulent secretion grows less, and finally the columnar epithelium is redeveloped 
 over the denuded spots from the now less active epithelium beneath. 
 
 During the course of bronchitis it sometimes happens that atelectasis or 
 collapse of lobules occurs. The amount and distribution of collapse varies 
 very greatly. It is usually associated with emphysema and with broncho-pneu- 
 monia, which supervene under the same conditions as favor the occurrence of 
 atelectasis. Broncho- pneumonia is the most serious termination of bronchitis. 
 
 Chronic bronchitis may result from the acute form or follow obstructive 
 heart lesions, or it may be produced by the inhalation of foreign matter. When 
 the acute form fails to undergo resolution, the small cell infiltration of the 
 fibrous coats continues, and results in an enormous thickening of the whole 
 bronchus. This thickening causes a diminution in the calibre of the tube, and 
 further leads to atrophy and absorption of the muscularis and cartilages. The 
 diminished elasticity of the bronchia then favors the formation of fusiform 
 dilatations. If the infiltration goes on, the formation of fibrous tissue, so-called 
 interstitial pneumonia, ensues. The subsequent contraction of this tissue, par- 
 ticularly that which has been formed in the interlobular septa, draws out the 
 bronchial walls in places, leaving irregular dilatations of the tubes. This con- 
 dition, known as bronchiectasis, is a potent factor in the causation of subsequent 
 acute attacks. Among the lesions of chronic bronchitis atelectasis and emphy- 
 sema are always found. 
 
 Symptoms. — Acute bronchitis varies in its severity from an exceedingly 
 mild to an exceedingly severe type. The character of its onset is largely deter- 
 mined by the causes which lead to it. In the milder forms the onset may be 
 rather insidious, but sometimes it commences sharply with feelings of malaise, 
 some elevation of temperature, cough, soreness of the chest, and at times with 
 catarrh of other mucous surfaces, as those of the larynx, the throat, and the 
 nose. In this form none of the symptoms become severe, although the cough 
 
928 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 may be somewhat distressing. The fever does not reach a point to attract 
 attention, and, if the child be young, expectoration does not occur. Such an 
 attack usually lasts three or four days, but may be prolonged, according to 
 the cause which has produced it, for several weeks. 
 
 In the earliest stages of bronchitis the cough is dry and rasping, and indi- 
 vidual paroxysms are apt to be prolonged. The secretion at first is scanty, but 
 after twenty-four to thirty-six hours becomes freer. It is removed from the 
 bronchial tubes by the act of coughing, but in the case of infants and young 
 children it is not expectorated ; indeed, it is with great difficulty that infants 
 can remove the secretion from the bronchial tubes into the mouth, and when 
 once in the mouth it is swallowed and not expectorated. Expectoration is an 
 art which has to be acquired, and usually is not learned until the sixth or 
 seventh year of life. A cough which is sufficiently severe to cause expulsion 
 of bronchial secretion from the mouth in children who have not yet acquired 
 the art of expectorating is usually whooping-cough. The swallowed secretion 
 occasionally produces some disturbance of the large bowel, and may be associ- 
 ated with mucous diarrhoea, but the mucus in the movements, while in part 
 originally secreted in the bronchial tubes, is also in part formed in the intestine 
 itself. It is to be noted in this connection that a mucous diarrhoea may be 
 induced on the one hand by a bronchitis, and on tlr other hand a bronchitis 
 may be produced as the result of a diarrhoea, or at least as the result of a putrid 
 condition of the intestinal contents. In milder cases of bronchitis the respira- 
 tion is not particularly hurried ; in young infants, however, it becomes quite 
 rapid even in mild cases. In the severer forms of bronchitis, where there is 
 much thickening of the bronchial mucous membrane and great difficulty in 
 the removal of the bronchial secretion, and a corresponding interference with 
 aeration, the respirations become correspondingly rapid. But the difficult 
 respiration of acute bronchitis cannot always be attributed to mechanical occlu- 
 sion of the bronchial tubes, for not infrequently great dyspnoea will be present 
 and disappear suddenly without a corresponding removal of mucus from the 
 bronchi. Difficulty of respiration is manifested in several ways : First, by an 
 increase in the rate of respiration ; second, by dyspnoea ; third, by special forms 
 of dyspnoea, particularly the grunting expiration. When dyspnoea is present 
 the alae of the nose dilate on inspiration, and if the dyspnoea be due to mechan- 
 ical causes, the tissues above the sternum and the soft parts along the insertion 
 of the diaphragm sink in during inspiration. These symptoms, which usually 
 are diagnostic of broncho-pneumonia, may be occasionally found in cases in 
 which the evidences of pneumonia are not altogether clear and in which only 
 bronchitis can be made out. But, inasmuch as they not infrequently disappear 
 quite suddenly in a manner that seems impossible in broncho-pneumonia, it is 
 justifiable to assume that they are indeed the result of a bronchitis pure and 
 simple. Even in broncho-pneumonia the dyspnoea is at times entirely out of 
 proportion to the amount of lung-tissue invaded, and cannot be explained 
 entirely by the mechanical obstruction to the aeration of the blood. It is 
 simpler to suppose that such are cases of toxaemia, in which the dyspnoea is 
 itself a toxic manifestation, in part at least. 
 
 In severe forms of bronchitis the respiration may become exceedingly rapid, 
 but the pulse, while frequent, may not be increased in proportion to the respira- 
 tion. The temperature varies greatly in different cases, but usually there is 
 some elevation. It is hard to believe, however, that bronchitis, of itself, neces- 
 sarily causes an elevation of temperature, and it is more than likely that the 
 associated pyrexia is a distinct and co-ordinate symptom produced by the same 
 factors which cause the bronchial catarrh. No definite temperature curve can 
 
BRONCHITIS. 929 
 
 be ascribed to bronchitis; it follows the other conditions present, and in the 
 severer forms runs high. 
 
 The facies of severe bronchitis resembles that of broncho-pneumonia ; that 
 is to say, the countenance is anxious, the abe of the nose dilate, the lips may 
 become cyanotic, and in general the countenance indicates distress. Under 
 such conditions it is perhaps true that broncho-pneumonia is usually present to 
 a greater or less degree, but this is certainly not always the case, as this facies 
 is sometimes found in bronchitis which has invaded only the larger tubes. 
 Nevertheless, the prognosis, whether broncho-pneumonia be found upon physical 
 examination or not, is grave in accordance with the facies just described. 
 
 Nervous symptoms are often very marked in the severer forms. Great rest- 
 lessness occurs not only as a result of the difficulty of respiration, but also as a 
 toxic symptom. Ataxic features are occasionally noticeable, and drowsiness 
 deepening into coma is at times seen. A toxic or so-called febrile dyspnoea 
 is often met with ; that is to say, a dyspnoea which is out of proportion to the 
 mechanical conditions present, and apparently due to the same or a coincident 
 cause as that producing the fever. The grunting expiration, noted above, is 
 often of this type ; it usually occurs when the rate of respiration is not greatly 
 increased, and, while present during the waking hours, disappears during sleep. 
 The bronchitis which is caused by the putrefaction of bowel-contents is essen- 
 tially toxic. Often mild, it may be very severe and accompanied by great 
 acceleration of respiration, by dyspnoea, and by marked head symptoms. An 
 uncomplicated case of this kind is relieved by the action of a suitable purga- 
 tive, the most marked symptoms disappearing at once, leaving no doubt of the 
 toxic origin. 
 
 The cough which accompanies enlargement of the bronchial glands is 
 usually dry and harassing, and often assumes a croupy character. Not infre- 
 quently, however, the accompanying bronchitis is severe, and may continue for 
 weeks or even months with a profuse bronchial secretion, showing little or no 
 tendency to recovery. This is but one phase of the condition which Dr. B. K. 
 Rachford 1 designates by the term "scrofulous bronchitis." He describes it as 
 follows : " It is, as a rule, recurrent, coming on during the cold and disagreeable 
 winter months and disappearing during the summer months. It is characterized 
 by marked anaemia, and as a rule by other well-known signs of scrofula, such 
 as enlarged external lymphatics, chronic coryza, etc. In these cases of scrof- 
 ulous bronchitis there may be extensive tubercular disease of the deep-seated 
 lymphatics of the abdomen or chest, without any evidence whatever of external 
 scrofulosis. In such cases the Avell-marked anaemia and the possible family 
 history of tuberculosis will be of material aid in diagnosis." 
 
 This form is very often mistaken for pulmonary tuberculosis, but it may 
 extend over a very prolonged period without the production of pulmonary 
 phthisis, although it tends to that termination. The prognosis is about the 
 same as in other forms of glandular tuberculosis. 
 
 Bronchitis is accompanied by a great variety of symptoms referable to other 
 organs and variable, inasmuch as the associated features are determined by the 
 particular causes which produce the bronchitis, and necessarily must vary with 
 them. 
 
 Chronic bronchitis in children does not differ sufficiently from the same 
 condition in adults, either in its symptoms or treatment, to require separate 
 consideration. 
 
 Prognosis. — Prognosis as to duration should be guarded, as it depends 
 upon the cause which has produced the disease. Those cases which we are com- 
 
 1 Personal communication. 
 59 
 
930 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 pelled to recognize clinically as idiopathic bronchitis usually, when mild, termi- 
 nate in three or four days, and even when severe rarely last more than a week 
 or ten days. A bronchitis which is caused by typhoid fever will last from ten 
 days to three weeks, and disappear with the disease which it accompanies. In 
 the case of pertussis the bronchitis may be prolonged quite indefinitely. In 
 measles, while it may disappear in four or five days, it not infrequently lasts 
 several weeks. Bronchitis of purely intestinal origin, usually disappears imme- 
 diately upon the removal of the bowel-contents. 
 
 Prognosis as to severity is determined by a number of factors, but ordinarily 
 it is good. It is customary to say that the prognosis in bronchitis of the larger 
 tubes is more favorable than in bronchitis of the smaller tubes, and in general 
 this is true, but by no means is it always so, as some of the most severe attacks, 
 so far as fever, depression, and other nervous symptoms go, are those in which 
 the large tubes only are affected. The age of the patient is always an important 
 element in the prognosis. The infant with bronchitis is to be regarded as always 
 in danger, as broncho-pneumonia may readily supervene. The exciting causes 
 of the attack must also be taken into consideration. Bronchitis symptomatic 
 of a general infection, such as measles, is very likely to be commensurate with 
 the other symptoms so far as severity is concerned. The presence of enlarged 
 bronchial glands is to be taken as indicating a prolongation or recurrence of the 
 trouble, and as paving the way for a possible termination in pulmonary phthisis. 
 The condition of the child's nutrition determines to a very considerable degree 
 the severity of an attack. Where the nutrition is below par, particularly 
 where rickets is well marked, the disease is apt to prove very severe, and to 
 take upon itself suddenly severe nervous symptoms or to lead to the develop- 
 ment of broncho-pneumonia. Marasmus and great weakness from any cause, 
 interfering with the prompt expulsion from the tubes of the accumulating 
 secretions, are conditions unfavorable to the satisfactory progress of the case. 
 The cough per se is of but little aid in prognosis. It may be very severe in 
 children who are evidently but slightly ill, and, again, may be nearly absent 
 in children who are in great danger. The character of the respiration is of 
 more importance from a prognostic standpoint. Whenever it becomes rapid, 
 or its rhythm is interfered with, or the grunting expiration appears, or dyspnoea 
 manifests itself, the prognosis should be guarded. With improvement of the 
 respiration in rate and rhythm a more favorable prognosis may be made. The 
 temperature is often an important guide : the higher the temperature, other 
 things being equal, the graver the prognosis ; the lower the temperature, the 
 better the outlook. With a pulse that tends to irregularity irrespective of the 
 temperature and respiration-rate, the prognosis is not favorable. But more 
 important than all these symptoms is the condition of the brain, delirium in 
 any of its forms having its usual grave significance. Intense cardiac depres- 
 sion, and sleeplessness, or, on the other hand, somnolence, all are indicative of 
 severe and threatening conditions. 
 
 Diagnosis. — The diagnosis involves the recognition of the existence of 
 the bronchial catarrh itself, and the determination, so far as possible, of the 
 etiological factors. The existence of bronchitis is ordinarily recognized with- 
 out any difficulty. The history of cough, with bronchial secretion of recent 
 origin, is usually enough to establish the diagnosis. An examination of the 
 chest, which should always be made, will decide. In the earlier stages, before 
 the secretion has become established, sibilant and sonorous rales are heard. Not 
 infrequently, however, these rales are very scanty, and not always heard on 
 both sides of the chest. Later the rales become moist and more numerous. 
 When the smaller tubes are invaded, small and even sub crepitant rales are 
 
BRONCHITIS. 931 
 
 heard. At no time in an uncomplicated bronchitis is there any modification 
 of the percussion note. 
 
 The severer forms are to be differentiated from pneumonia. This can only 
 be done by the detection of the consolidated pneumonic area by percussion and 
 auscultation. The consolidated area is expected to show dulness on percussion, 
 and bronchophony and bronchial breathing on auscultation. But when the 
 area is small and centrally located, these signs cannot always be made out. 
 Fortunately, it is not of the highest importance to determine these conditions 
 exactly, because the prognosis and treatment will not be essentially modified by 
 the presence of a small area of pneumonic consolidation. 
 
 Pleural effusion, whether serous or purulent, does not always present 
 specific symptoms indicating its nature, but is often shown only by a cough 
 which may readily be mistaken for that of bronchitis. The physical exami- 
 nation will always differentiate these conditions. 
 
 The presence of bronchitis being once established, the search for the 
 etiological factors begins. The existence of one of the exanthemata as a 
 causative factor is usually readily made out by the history and appearance 
 of the child. Pertussis, however, is difficult to determine before the occur- 
 rence of the convulsive stage. It may be suspected, however, if the cough be 
 very severe and the disease be prevalent. Influenza usually presents its neural- 
 gic and other nervous features. The character of the stools should always be 
 carefully inquired into, and if there be any suspicion of putridity of the 
 bowel-contents, the fact should be noted as a possible factor in the case. The 
 condition of the nutrition should be carefully studied, particularly in infants, 
 and if the history shows the occurrence of profuse sweating, especially about 
 the head at night, with great restlessness and a tendency to lie uncovered, 
 if there be beading of the ribs, recurrent bronchial attacks during dentition, 
 and occasional laryngismus stridulus, rickets is to be diagnosticated. 
 
 Treatment. — The treatment of bronchitis includes attention to the local 
 conditions in the chest, to the general constitutional disturbance, and to the 
 removal, as far as possible, of the causative factors. It is not convenient, 
 however, to divide the description of the treatment with strict reference to 
 these three factors, but rather to consider the matter somewhat in the order in 
 which the various steps are undertaken in actual practice. 
 
 The very mildest cases require no treatment whatever, but they should 
 always be watched, particularly in infants, so that interference may be made 
 as soon as necessary. 
 
 It is good practice to commence the treatment of every case of bronchitis 
 in infants and young children with the use of a laxative, the reason for this 
 being that the intestinal tract of the infant so commonly contains putrid fieces 
 which do not always manifest themselves by special signs. In older children 
 some signs of bowel disturbance may be waited for, but in severe cases the 
 character of the bowel-contents should always be investigated by the aid of 
 purgatives. Besides their action on the bowels, purgatives deplete the liver and 
 prepare that organ to receive some of the blood which has been determined to 
 the bronchi. The most available laxatives are castor oil and calomel. 
 
 Calomel, which is preferable in the infant, should be administered in three 
 doses, of one grain each, at intervals of four or five hours. When putrid fteces 
 are found, all animal food should be prohibited for one or two days, and such 
 intestinal antiseptics as naphthaline and salol administered. 
 
 Expectorants are often of great service in the earlier stages of bronchitis, 
 but, as a rule, they are abused. Their sole use is to cause an increase in the 
 bronchial secretion. When the secretion is scanty, and the rales few and dry, 
 
932 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and the cough, in consequence, frequent and harassing, expectorants afford 
 relief. But when the secretion has become thoroughly established, and auscul- 
 tation shows the rales to be abundant nnd moist, then expectorants are of 
 no further use, and it is better to withhold them. The best expectorants 
 are ammonium chloride and potassium iodide. The following formula may be 
 employed for an infant from three to six months of age : 
 
 ^. Ammon. chlorid gr. xvj. 
 
 Syr. tolutan 
 
 Aq. destillat ad f gj- — M. 
 
 Sig. One teaspoonful in a little water every two or three hours. 
 
 Ipecacuanha is widely used. It is of peculiar value because, besides increas- 
 ing secretion, it tends to dilate the cutaneous capillaries. When the secre- 
 tion is excessive and the efforts at coughing inadequate to remove the ac- 
 cumulation, emesis affords much relief. For this purpose ipecacuanha is 
 valuable. 
 
 The modern coal-tar antipyretics have a marked effect in bronchitis. They 
 appear to act almost as specifics, diminishing the amount of secretion, lessening 
 the severity and frequency of the cough, and relieving pain, without acting 
 like opium in simply covering up symptoms. Of these, the safest probably is 
 phenacetin. For an infant from six months to two years of age the follow- 
 ing formula will be found useful : 
 
 ty. Phenacetin gr. xii-xxiv. 
 
 Caffeine gr. j-ij. — M. 
 
 Div. in chart. No. xii. 
 Sig. Give one powder every four hours. 
 
 The smaller dose may be used at six months and the larger at two years. 
 For younger infants the dose should be reduced, and for older children slightly 
 increased. These powders are advantageously alternated with the calomel 
 powders given at first. Here, as elsewhere, phenacetin should be used cau- 
 tiously, withheld entirely from weakly children, and never continued over a 
 long period. 
 
 In severer cases the inhalation of antiseptic vapors seems at times to be 
 useful. For this purpose it is convenient to evaporate turpentine or oil of 
 eucalyptus from a water-bath in the patient's room. 
 
 Particularly in the bronchitis of infants and young children is the cough 
 salutary, and it should be laid down as a cardinal rule that no effort should be 
 made to smother it. Narcotics and antispasmodics distinctly increase the tend- 
 ency to pneumonia. But it is not always possible to dispense entirely with 
 the use of opium. In some very severe cases, where there is great restlessness, 
 a single full dose of opium to produce sleep is occasionally necessary. Used 
 in this way, the best results to the patient are obtained with a minimum of 
 danger. 
 
 Certain means very commonly employed in the treatment of bronchitis and 
 pneumonia have for their object the relief of internal congestion by the pro- 
 duction of a dilatation of the cutaneous capillaries. These are the poultice 
 jacket, the cotton and oiled silk jacket, local couuter-irritation, and the inter- 
 nal use of sweet spirits of nitre, alcohol, and aconite. Redness of the chest- 
 wall is readily obtained by thorough friction with camphorated oil or an oint- 
 ment of turpentine and lard. It is rarely necessary to use mustard. The 
 
BRONCHITIS. 933 
 
 agent selected should be well rubbed on twice each day, and the redness main- 
 tained by the use of the poultice jacket or the jacket of cotton batting and oiled 
 silk. When poultices are used, two should be made — a smaller one to lie upon the 
 front of the chest, and a larger and heavier one to cover the back and sides of 
 the chest and lap over the front poultice. As their object is to keep the 
 skin red, they must be as warm as can be borne, and changed often enough to 
 prevent cooling. The advantage of two poultices is to be found in the chang- 
 ing. The one at the back does not cool as rapidly as the front, which must be 
 the thinner, so as to embarrass the respiration as little as possible. Hence the 
 front poultice requires changing oftener than the back. Poultices wh'ich are 
 allowed to become cold constitute an element of danger, and therefore should 
 not be used on patients when the nursing is inferior. They are disadvantageous 
 also to very weak children, to whom their weight is a burden. When properly 
 employed their action is of the greatest service, and they should always be 
 used in properly selected severe cases. As a substitute for the poultice the 
 chest may be enveloped in a thick layer of cotton batting, and this covered 
 with oiled silk. This dressing, while inferior to poultices, is yet so convenient 
 and so serviceable that it should always be employed, in conjunction with 
 camphorated oil, even in quite mild cases. 
 
 The principal utility of alcohol in bronchitis has seemed to the writer to be 
 due to its power of relaxing the cutaneous capillaries. For this purpose it is 
 best administered in rather small doses at frequent intervals, and in the shape 
 of whiskey or some light, non-astringent wine. Sweet spirits of nitre, so 
 commonly employed in febrile conditions, is often of great service in bronchitis, 
 particularly when there is fever. It dilates the cutaneous capillaries, acts as a 
 diaphoretic, and by its diuretic action no doubt assists in the elimination of 
 toxic principles. 
 
 When bronchitis is produced by any of the specific fevers the cause cannot 
 be directly removed, but treatment directed to the amelioration of the com- 
 plexus of febrile conditions relieves the bronchitis, as it does the other mani- 
 festations of the poison. In those specific fevers which are best treated by 
 the application of cold the presence of bronchitis is not to be regarded as a 
 contraindication of the means. 
 
 Convalescence from bronchitis is always worthy of attention, and after 
 severe cases, where the bronchial glands are considerably enlarged, treatment 
 of this stage is highly important. Fortunately, proper medical attention at 
 this period produces excellent results and prevents much subsequent trouble. 
 
 In the treatment of broncho-adenitis cod-liver oil is a most important agent. 
 It is usually desirable to administer it plain, and by most infants it is well 
 borne. Its use should be continued for three or four weeks, and even longer 
 if the trouble does not yield readily. 
 
 When the bronchial glands are enlarged a coexisting anaemia will usually 
 require the use of iron. This agent is best administered as the reduced iron 
 or the freshly-prepared saccharated carbonate of iron. In either case the dose 
 should be large. Reduced iron in 5-grain doses three times a day to a child 
 two years old will give better results than smaller doses. For very young 
 infants iron is best administered in the shape of freshly-expressed beef-juice, 
 which may be given in teaspoonful doses three times a day. 
 
 The iodides may at times be used advantageously, and of these the best are 
 the syrup of hydriodic acid and potassium iodide. The latter should be given 
 in small doses, J grain to 1 grain, three times a day, and well diluted. The 
 ?yrup of the iodide of iron is rather disappointing in its action. 
 
 It is often desirable to use creasote or guaiacol, particularly where the 
 
934 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 glandular enlargement is very pronounced and general tuberculous infection is 
 feared. The following is a convenient formula for a creasote emulsion : 
 
 1^. Creasoti (beechwood) f^j- 
 
 Pulv. acacise gr. xv. 
 
 Aq. dest TTLxlv. 
 
 Glycerini q. s. ad f §ss. — M. 
 
 Sig. Four to eight drops in port wine three times a day. 
 
 Ordinarily it is not desirable to commence treatment of the broncho-adeni- 
 tis along these lines until after the subsidence of the acute attack of 
 bronchitis. Cases presenting nutritional deficiencies call for treatment both 
 during and after the attack. In most instances the innutrition in infants is 
 due to rickets, and cod-liver oil and iron act almost as specifics. Salt baths 
 and out-door exercise are also valuable, and should never be omitted. 
 
 In older children, the subjects of scrofulous bronchitis, the underlying 
 nutritional deficiencies particularly call for treatment. In these cases cod-liver 
 oil, iron, and iodine, while of service, are often disappointing, and do not 
 yield the satisfactory results obtained by their use in less severe cases, where 
 enlargement of the bronchial glands constitutes the principal departure from 
 the normal. In the severer cases of this type relief can only be obtained by 
 removal to a warm climate or to the sea-shore. In the experience of the 
 writer the Florida coast has afforded great relief to such patients. 
 
PLEURISY AND EMPYEMA. 
 
 By HENRY KOPLIK, M. D., 
 
 New York. 
 
 Pleurisy, or pleuritis, occurs in infancy and childhood usually as a second* 
 ary, and rarely as a primary, disease. There are certain forms in which the 
 pleura is inflamed without any appreciable exudate ; such are called dry or 
 fibrinous pleurisies. Other forms combine the above with an exudate of 
 fluid — serous, sero-purulent, or purulent — into the pleural cavity. These forms 
 are called pleurisy with effusion, or sometimes, less accurately, subacute 
 pleurisy. When the exudate has a sero-purulent character or is visibly puru- 
 lent, the pleurisies have been called empyema. Empyema in this article will, 
 for the sake of uniformity, be called purulent or suppurative pleurisy, while 
 those pleurisies which have a protracted course and are due to neoplasms will 
 be referred to only. 
 
 Frequency. — Pleurisy is a common disease of infancy and childhood. 
 The greatest number of cases occur before the fifth year of life (Simmonds). 
 The succeeding five years (five to ten years) show the next greatest frequency. 
 Our statistics upon pleurisy in childhood are incomplete, for the reason that 
 authors have not unreservedly exposed their material for criticism. Only 
 favorite methods have been published, to the exclusion of unfavorable results. 
 This has caused much confusion. Israel has tabulated 206 cases, of which 59 
 were purulent (29 per cent.). Mackey gives purulent cases in children 40 per 
 cent, as against 5 per cent, of the whole number in adults. In 240 cases 140 
 were boys (Simmonds). On the other hand, Hofmokl, who has a great pedia- 
 tric surgical practice in Vienna, tabulates 60 cases, of which 42 were females. 
 Thus, combining both statistics, the boys would still show the greater 
 frequency. 
 
 The left side is more frequently the seat of disease. Of 175 cases collected 
 by Simmonds, 103 were on the left side, whereas of the 60 tabulated by 
 Hofmokl, 33 were on the left side. 
 
 Pleurisy is generally a unilateral disease. Of 175 cases, only 7 were bi- 
 lateral (Simmonds). This is fortunate in infancy and childhood, where exudates 
 reach a large amount in a very short time. With these youthful patients 
 the natural resiliency of the chest combines with others factors to make even 
 enormous exudates comparatively well borne, as contrasted with a similar con- 
 dition in later life. In the adult the resistant chest-wall tends to cause greater 
 pressure-effects and displacements of important viscera. 
 
 Pathology. — The pleura is a connective-tissue structure, made up of elastic 
 fibres in a fibrillar membrane, containing branched connective-tissue cells and 
 covered with a layer of flat epithelium, called, in this membrane, endothelium. 
 In inflammations of the pleura which are not dependent upon and accompanied 
 by a neoplastic growth (tubercle or carcinoma), the changes take place at the 
 surface. The most frequent pleurisies are those acute processes which invari- 
 
 935 
 
936 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ably accompany the several forms of acute pulmonitis. They occasion but few 
 symptoms per se, and only in the event of a fatal termination of the primary 
 pulmonary disease do they come to the autopsy table. In these forms of 
 pleurisy the changes may be so trifling as to be indicated only by a slight 
 injection of the surface of the pulmonary pleura and a loss of its characteristic 
 lustre. Here and there a few fibrinous threads or adhesions may be found 
 coursing over the surface of the membrane or running from the costal to 
 the pufmonary pleura. This is the so-called dry pleurisy, pleuritis sicca. 
 In other cases there is a more extensive formation of fibrin, which becomes dif- 
 fused over the whole surface of both the pulmonary and costal pleura ; and 
 this formation may become so marked as to cause a distinct thickening of both 
 these surfaces. In some forms in children the amount of fluid is small com- 
 pared with the immense thickening of the pleurae. Some writers have main- 
 tained that in these fibrinous exudates the primitive endothelium may be found 
 upon the original pleural surface, beneath the exudative product ; others, that 
 the fibrinous exudation is coated with the original endothelium (Delafield). 
 The pleura itself may be but little altered, the only change being that its 
 lymph-spaces and blood-vessels are dilated, and there may be a diapedesis of 
 leucocytes. 
 
 In other forms of pleurisy the fibrinous exudation at the surface is also 
 combined with a serous exudate into the cavity of the pleura. This serum is 
 variable in amount : it usually contains leucocytes, in many cases bacteria, as 
 will be shown later. It may be quite clear, turbid, or opaque, yellow or 
 greenish in color and creamy or thin in consistency. In acute processes in 
 children large masses of fibrin may be found floating free in the cavity of the 
 pleura (metapneumonic cases). In many instances the adhesions are so great 
 as to bind down the lung at various places, thus enclosing the exudate in 
 quasi-capsular formations. Even in acute cases the fibrinous coating on the 
 surface of the pulmonary and costal pleura contains newly-formed blood-ves- 
 sels. Haemorrhages into the pleural cavity may rarely occur as a part of 
 such conditions as scurvy and true morbus Werlhofii, and then the serous or 
 purulent exudate becomes a so-called haemorrhagic one. 
 
 In some cases the fibrinous coating on the pulmonary pleura may be so 
 thick as to seriously impair the function of the lung. In children, however, 
 this is not common, except as a sequence of tubercular processes ; so that 
 a marked pleurisy, suppurative or fibro-serous, may be followed by a complete 
 restitutio ad integrum. It is rare that in acute processes the lung is in any 
 way compromised. It is only in prolonged, unrelieved pleurisy that this occurs, 
 and thus there may be perforation of the exudate with erosion of the pulmon- 
 ary or costal pleura [pleuritis necessitatis). Small purulent exudates, unrecog- 
 nized during the illness, may thus perforate after all fever has ceased and the 
 patient is apparently well. 
 
 In tubercular inflammation of the pleura, besides the production of fibrin, 
 serum, clear or haemorrhagic, and pus, there may be considerable thickening 
 of the costal and pulmonary pleura, caused by the inflammatory exudate, 
 which, as well as the pleura, is infiltrated with tubercle. In these cases the 
 serous or purulent effusion may be encapsuled by adhesions, while the lung is 
 crippled and bound down by layers of inflammatory tissue. In these forms 
 of pleurisy the anatomical changes are progressive. In acute fibrinous pleurisy 
 the exudative products on the surface of the pleura are organized into new con- 
 nective tissue or partly disappear, but the pleura is restored to its original 
 condition. Again, absorption takes place in those cases where the exudate does 
 not demand artificial relief. In children the adhesions form an important part 
 
PLEURISY AND EMPYEMA. 937 
 
 of the process in acute pleuritis, while in other forms the pleura may remain 
 permanently thickened by the formation of a surface layer of new connective 
 tissue, which may persist through life. There are non-tubercular forms of 
 pleurisy where, after the acute process has run its course, the pleura remains 
 thickened by newly-formed connective tissue ; and this not only involves the 
 pleural tissue proper, but also continues to extend and involve, through the 
 lymph-vessels, the interlobular tissue of the lung itself, causing a species of 
 cirrhotic changes. In these cases, which are prolonged, the lung-tissue is 
 seriously compromised. 
 
 In the exudates of the pleura there is a constant interchange of fluids 
 through the vessels of this membrane (Gerhardt). Drugs may find their way 
 from the general circulation into the pleuritic fluid. Iodine and salicylic acid 
 have thus been found. Moreover, the amount of leucocytes, red blood-cells, 
 and endothelial cells in the exudate is constantly varying, so that a serous 
 effusion may result from a hemorrhagic one, and an opaque purulent from a 
 serous. 
 
 The amount of fluid effused in children is usually considerable, and may 
 reach 1000 or 2000 c.cm. (Simmonds). Hofmokl in several cases evacuated 
 as much as 2000 to 5000 c.cm. 
 
 The chemical composition of pleural exudates may be of clinical interest. 
 The specific gravity varies from 1028 to 1032 (Bartels, quoted by Gerhardt). 
 Some authors have attempted to formulate prognostic signs from the specific 
 gravity of the pleural exudate, but few would accept such a line of thought to- 
 day. 
 
 The amount of albumin varies from 0.06-2.68 per cent, in non-inflam- 
 matory to 2.40-6.90 per cent, in inflammatory exudates ; extractives and 
 salts in non-inflammatory exudates, 1.08 percent., in inflammatory, 1.18 per 
 cent. ; the chlorides average 0.67 per cent, in both. Among the foreign sub- 
 stances, urea, uric acid, leucin, tyrosin, glucose, glycogen, cholesterin, xanthin, 
 and medicinal agents have, at various times, been found, proving that the fluid 
 in the pleural cavity is in direct touch with the general circulation and lymph- 
 atic system. 
 
 Etiology. — Primary pleurisy, occurring without any exciting cause in the 
 chest or elsewhere, is rare in children. There are numbers of cases in which 
 an acute effusion of inflammatory character takes place without any previous 
 symptoms of illness or external exciting causes. Our data upon this very 
 interesting and important question are still incomplete. Such a case came 
 under the notice of the author in a boy aged six years, in whom a pleural effu- 
 sion was present for a week without any previous symptoms. The liquid was 
 serous in character, and did not contain any micro-organisms. There was no 
 tubercular lung disease and no history of other illness. In these clinical cases 
 the etiology is very obscure. The author has elsewhere published cases of 
 infants where illness began acutely, nothing having been found except a ton- 
 sillitis follicularis. The chest showed no pneumonia or pleurisy at first. 
 Within a week, however, a purulent effusion was found in the chest. In these 
 cases it is impossible, inasmuch as recovery takes place, to establish the 
 primary cause. In those cases which come to the autopsy table after the 
 disease has existed a long time the pulmonary changes are no more conclusive. 
 
 Primary pleuritis, if it does occur in children, must be rare. There are so 
 many avenues of infection that to satisfactorily exclude all these has as yet not 
 been possible. Pleuritis in infancy and childhood is therefore mostly second- 
 ary to diseases of the lungs. All acute forms of pneumonitis — lobar pneu- 
 monia and broncho-pneumonia — may give rise to pleuritis. The greatest num- 
 
938 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 ber of cases has been traced to this cause. Of 84 cases of pleuritis tabulated 
 by Simmonds as occurring in children, 31 were caused primarily by pneumonia 
 (meta-pneumonic pleurisy). 
 
 The infectious diseases, measles, scarlet fever, pertussis, typhus, typhoid, 
 diphtheria, forms of tonsillitis, retro-pharyngeal or mediastinal abscess, may 
 precede and directly cause an attack of pleurisy. In these cases a pneumonitis 
 generally precedes the pleurisy or is present at the same time. Such a pleurisy 
 is to be classed under the heading of complications. It may be serous or 
 purulent, but is generally microbic in origin, as will be shown later. In the 
 new-born the class of cases included under the heading of septico-pyaemia are 
 sometimes complicated by a pleuritis, usually suppurative and of a progressive, 
 fatal type. In these instances the pleuritis is simply caused by the same 
 microbic agent, which enters at the umbilicus or elsewhere. Such cases have 
 been published by the author. The acute bone diseases, such as osteomyelitis, 
 may be complicated by purulent pleurisy ; so also may septic wounds in any 
 distant portion of the body, as the foot (Koplik). 
 
 Tubercular disease of the lung or tuberculosis elsewhere ; echinococcus 
 (Simmonds) or abscess of the liver ; any abscesses in the mediastinum ; forms of 
 endocarditis ; and abscesses in the abdominal cavity or involving any of the 
 viscera, — may cause pleuritis. A case of perityphlitis in the author's practice, 
 in a girl eight years old, after running an acute course was followed by chronic 
 peritonitis with multiple abscess-formations in the abdominal cavity, and was 
 later complicated by pleuritis on the right side. As no autopsy was allowed, it 
 was impossible here to trace a direct connection, but such has been done by 
 other authors. 
 
 In many cases of pleuritis, as in other diseases, it is possible to find as the 
 only exciting cause an exposure to cold or dampness. This has occurred so 
 often, and with such apparent connection, that most authors look upon cold 
 and dampness as undoubtedly exciting toward any pulmonary or pleural 
 inflammation. At least they are not without influence. A reduction of con- 
 stitutional resistance by these agents opens the avenues for the activity of well- 
 known exciting agents (microbic). 
 
 Traumatism of all kinds, even without a lesion of the external surface, may 
 act like cold in exciting pleurisy. Compression of the chest-wall or a blow 
 may not directly cause it, but certainly many cases follow so closely upon such 
 accidents that an intimate connection seems to be the inevitable deduction. 
 
 It is conceded upon all sides that there are evanescent forms of pneumonia 
 in children lasting only a few days. It is easy to conceive that a pleuritis 
 may have been preceded by such a pneumonia, the symptoms of the primary 
 disease being masked by those of the main condition, the effusion in the chest. 
 
 The etiology of pleurisy has been greatly elucidated, in recent years, by 
 the bacteriological studies of Weichselbaum, Fraenkel, Ehrlich, and Thue. 
 These authors have busied themselves with the study of pleuritic exudates and 
 their relationship to processes which affect the lung. They directed their atten- 
 tion to the adult cases. In 1891 the author made a series of bacterioscopic 
 studies in children, which, with certain peculiar exceptions, bring the pleurisies 
 of children much into the line of those of the adult as to causation. We know 
 that when the lungs are the seat of bronchitis, broncho-pneumonia, or lobar 
 pneumonia, a number of micro-organisms play an important role during the 
 course of the inflammatory processes. Thue, in a series of studies, established 
 beyond question that these micro-organisms (notably the diplococcus pneu- 
 moniae) can be found not only in the lung-structures, but especially in the 
 lymph-spaces of the tissue of the pleura and on the surface of the pleura itself, 
 
PLEURISY AND EMPYEMA. 939 
 
 even in most evanescent inflammatory reactions of that structure. This once 
 accepted, it is easy to explain how micro-organisms, which are per se capable 
 of exciting suppuration, when they once gain the surface of the pleura will 
 cause inflammatory response of that structure. Such is, in fact, the case. If 
 we examine the acute pleuritic exudates in children, we find they resolve them- 
 selves into groups. The most interesting group is that in which the effusion, 
 whether serous (clear) or purulent and full of fibrin clots and flocculi (sup- 
 purative), shows the presence of the diplococcus pneumoniae of Fraenkel or 
 the streptococcus lanceolatus. This micro-organism is the accepted exciting 
 factor of both lobar (Fraenkel) and lobular pneumonia (Weichselbaum). It is 
 found in both serous and purulent exudates (meta-pneumonic pleurisies), and 
 this in pure culture. So constant is this that we can group such pleurisies by 
 themselves, and both clinically and bacteriologically accept the diplococcus as 
 the connecting link between the process in the lung and the pleuritic inflam- 
 mation. It is not always possible to trace clinically the pneumonia and pleurisy 
 in sequence, for in many of these cases the pneumonia is so slight as to play 
 but a secondary clinical r61e. In other cases the direct clinical sequence of 
 pneumonia followed by pleurisy can be satisfactorily established. 
 
 In another group of cases the pleuritic effusion, if examined bacterioscop- 
 ically, is found to contain staphylococcus pyogenes aureus, and in other cases 
 the streptococcus pyogenes. The exact etiological r<3ie played by these micro- 
 organisms is not very apparent. It is true we can justly conclude that by 
 their presence in the pleural cavity they have been direct excitants of the 
 pleuritic inflammatory reaction. It is not clear, however, how they gain 
 access to the pleural cavity, and whether the pleuritis was preceded by, or was 
 concomitant with, some form of pneumonitis. These organisms are found in 
 the lungs during a lobar or broncho-pneumonia. In certain forms of broncho- 
 pneumonia following or complicating the infectious diseases, the streptococcus 
 pyogenes is found as a chief exciting factor of the pneumonitis. This has 
 been well established by Babes, Prudden, and Northrup. But there is a class 
 of pleurisies in children which are not secondary to the acute infectious diseases, 
 and in these the staphylococcus .and streptococcus have been found (Koplik). 
 The most probable conclusion in such cases is that there may have been some 
 element, such as an exposure or traumatism, which favored the invasion of 
 the pleura through the lungs. In many cases we could assume, in spite of 
 the absence of the streptococcus lanceolatus or Fraenkel's diplococcus, that ? 
 broncho-pneumonia might have existed, and the staphylococcus or ordinary 
 streptococcus, which always exists in these cases in the lung as a mixed infec- 
 tion, may have gained access to the pleural cavity to the exclusion of the 
 primary excitant, the diplococcus pneumoniae. 
 
 In many pleuritic effusions, both serous and purulent, the most careful 
 examination of the exudate fails to give any microbic elements, and in these 
 we are left to surmise the etiology. The serum and pus of such cases have 
 been injected into animals without arriving at any satisfactory conclusion. It 
 is possible that a proportion of these cases are tubercular, but it would be a 
 very extreme view to assume that all those cases of pleuritic effusion in which 
 no micro-organisms are found are tubercular. For this is at variance with 
 clinical experience. Many of these negative exudates have been assumed to 
 be due to acute primary pleurisies brought about by cold, exposure, or trauma. 
 The clinical regularity with which an exposure or traumatism can be shown to 
 have been followed by pleurisy leads us to assume that, though of itself it may 
 not be able to produce inflammation of a structure, it can so devitalize a 
 part or organ as to make the latter a ready prey to the action of microbic 
 
940 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 agents. On the other hand, we know that in the healthy individual the upper 
 air-passages are the seat of micro-organisms which, isolated from their habitat, 
 are pathogenic (the streptococcus of sputum). Yet in the healthy unexposed 
 individual these micro-organisms are harmless. We thus have that class of 
 pleurisies in which the staphylococcus of various kinds and the chain coccus 
 have been found, as well as part of the class in which no micro-organisms have 
 been established, as still to be more satisfactorily elucidated. 
 
 The question of primary pleurisy in children is also very difficult to ap- 
 proach. We know of pleurisies which, clinically, are very acute in onset, and 
 in which the effusion within twenty-four hours reaches such an extreme gross 
 quantity as to cause by its presence alone quite serious symptoms. In these 
 cases the effusion may be serous, or it may from the outset be purulent. In 
 many of them no previous history of lung trouble or any traumatism or 
 exposure has preceded. These are the cases which have been described as 
 acute primary pleurisy. While allowing the former classification to stand,' the 
 writer must express his conviction that future work will reveal some primary 
 etiological factor outside the pleura itself. The pleural cavity is such an 
 isolated space, much like the joints, that it is difficult, in the light of our 
 present knowledge, to conceive of its primary inflammatory reaction similar 
 to that taking place in the lung in pneumonitis. 
 
 In the septic pleurisies the micro-organism which has been found in children 
 is the streptococcus, probably the streptococcus pyogenes (Koplik). In the 
 tubercular pleurisies, whether the effusion be serous or purulent, the tubercle 
 bacillus can be found, but only with great difficulty. In many cases, as has 
 been shown by Ehrlich, it is absent. In the purulent exudates the staphy- 
 lococcus and streptococcus may be found as mixed infections, or they may be 
 absent. 
 
 Symptoms. — There are two distinct sets of cases in children : those with 
 an acute and those with an insidious onset. If the invasion be acute, we have a 
 picture which differs but little from the onset of a pneumonia, and as in the 
 majority of cases such a pulmonary process is coexistent, it is easily seen how 
 the symptoms of one condition may be masked by the other. A chill is 
 the rule only in older children, while in infants cerebral symptoms, convul- 
 sions, or stupor may usher in the disease. The fever is quite high — 103° to 
 105° F. ; and the pulse very much increased — to 140, sometimes 180 beats. 
 There is marked dyspnoea, and even in infants the face has an anxious expres- 
 sion. The urine is diminished, and in the course of a few days we have all 
 the symptoms — dryness of tongue, loss of appetite, and prostration — which 
 accompany any acute disease with fever. The cough, which may be present 
 from the beginning, is distressing, for the infant cries whenever it coughs; 
 but, as is the rule in infants and children of all ages, there is no expecto- 
 ration. After the acute symptoms have subsided a slight elevation of temper- 
 ature may persist, with a remittent curve, sometimes only about one-half 
 degree above the normal, with an evening rise of one or two degrees, but never 
 quite reaching the normal. This, with dyspnoea and pain, though less than at 
 first, and more infrequent cough, continues the clinical picture during the sub- 
 acute stage. The effects of the illness are shown by pallor instead of the 
 febrile flush of the onset, and, if the case continue without relief, even for two 
 or three weeks, by marked emaciation, especially in those patients suffering 
 from a purulent exudate. 
 
 In the other class of cases the onset is more insidious. The child may have 
 at first a marked febrile movement for a few hours, and as this passes away it 
 is apt to disarm suspicion. The child is not quite well ; it has a remittent 
 
PLEUBISY AND EMPYEMA. 941 
 
 curve of febrile movement, and, if older, will complain of occasional pain in 
 the side. The cough may be so slight as to be unnoticed. Yet the increasing 
 pallor, languor, and evident illness will bring the patient to the physician, who 
 will not suspect a pleurisy unless a systematic physical examination reveal fluid 
 in the chest. 
 
 The fever is. in most acute cases, high in the beginning, and, though it is 
 not uniformly so from day to day, it still reaches in some cases a maximum of 
 105°, and then may remit a degree or two. When pleurisy is accompanied by 
 pneumonia, the temperature, as in this disease, continues uniformly high, 103° 
 -105° F., until the eighth, ninth, tenth, or thirteenth day, when a fall will 
 occur with an attempt at crisis. At this period the axillary temperature 
 may reach 99°-99.5°, but it will not fall to the normal level. In the 
 following days, should the pleurisy continue, as in most of these cases it does, 
 the curve begins to rise gradually to 101° or 102°, and will remit in the morn- 
 ing. These cases are quite characteristic. In dry pleurisy without effusion 
 there is scarcely any fever. 
 
 The pulse is accelerated, being sometimes as high as 180, and especially 
 so in paroxysms of coughing. The tension varies, but in children the heart, 
 though pressed upon by effusion, generally is equal to the new condition in the 
 chest. It is only in fat, flabby children and those suffering from dyscrasise 
 that, with a rapidity and threadiness of pulse, even from the outset, we notice 
 instead of the usual flushed appearance a pallor of the skin and a cyanosis of 
 the mucous surfaces, as of the lips. 
 
 Dyspnoea is generally the most apparent symptom in children. The dilated 
 nostrils and the drawing inward of the infrasternal region both indicate a disturb- 
 ance of* the respiratory function. When the chest is touched, pain is evinced 
 by uneasiness and greater dyspnoea. The mother will say that the child cries 
 when taken hold of under the arms in the usual way. The babe will favor the 
 side affected by lying upon it, and suckling the left breast, if the right side be 
 the seat of trouble (Henoch). Older children will sometimes indicate the 
 portion of the chest in which the pain is located ; in other cases they will 
 mislead by indicating the epigastrium or abdomen as the seat of pain (diaphrag- 
 matic pleurisy). 
 
 The cerebral symptoms not only mislead, but may puzzle the physician for 
 days, until the effusion becomes large enough to detect. These symptoms 
 resemble those in pneumonia — convulsions, somnolence, vomiting, in older 
 children cephalalgia and epileptiform seizures. 
 
 Physical Signs. — Inspection of the chest in children who suffer from any 
 form of pleurisy, whether effusion be present or not, reveals a lack of movement 
 on the affected side. This is quite apparent in even very young infants, and 
 is in striking contrast to the motion of the opposite side in all the various 
 grades of dyspnoea which may be present in individual cases. If there be a 
 quantity of exudation or fluid in the chest, there is, in addition to lack of 
 motion, a very marked bulging of the affected side. By this is meant bulging 
 as a whole. The individual intercostal spaces do not always bulge in infants. 
 On the contrary, the chest may be full of fluid, and a retraction of the spaces, 
 increasing on inspiration, may exist. It is of little practical value to calcu- 
 late the amount of increase in circumference of the affected side. This will 
 vary with the amount of fluid present. 
 
 Palpation reveals but little if the form of pleurisy be dry and the effusion 
 slight. On the other hand, if the effusion be considerable, a most valuable 
 sign is furnished by the complete absence of vocal fremitus in older children. 
 In infants the absence of the cry-fremitus gives evidence of the same con- 
 
942 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dition. This is one of the most constant signs of pleurisy with effusion in 
 children, where, above all other things, the physical signs to be detailed are 
 constantly varying. It has been the practice of the author to rely largely upon 
 fremitus and a certain resistance to percussion, which will be noted later, in 
 deciding upon the presence of an effusion. If the healthy side be the seat of 
 bronchitis, a peculiar rale-fremitus may be felt on this side, but this is only 
 of negative interest. 
 
 Percussion. — The percussion-note over thickened pleura is dull ; over fluid, 
 flat. But, as has been hinted, in children these signs show the most marked 
 variation. There is nothing characteristic in the signs obtained by percussion. 
 The chest in an infant is so resilient that much depends upon the force used and 
 the skill of the examiner to bring out the requisite note. A layer of fluid may 
 exist between the lung and the chest-wall, and skilful percussion will reveal 
 dulness, while more forcible percussion brings out the pulmonary note of the 
 underlying lung. If the chest be filled with fluid, the note will be flat ; and 
 this is another reliable sign. In chests where the fluid fills out the lower por- 
 tion of the pleural cavity the pulmonary resonance will be obtained above, 
 while below there will be noted dulness varying to flatness, depending upon the 
 thickness of the layer of fluid between the lung and the percussing finger. 
 The resistance to the percussing finger is peculiarly wooden in character, 
 especially in children. The resonance upon the unaffected side of the chest 
 is increased, and sometimes tympanitic. 
 
 Auscultation may reveal rales or friction-sounds, bronchial voice, and bron- 
 chial breathing, or all these may be absent, the breathing being simply puerile 
 and the voice but little changed. Nothing is so deceptive as the auscultatory 
 signs in pleurisy. If no effusion be present, we hear friction-sounds in children 
 resembling for the most part the fine crepitations of pneumonia, and even when 
 the chest is full of fluid these crepitations may be quite loud. These may 
 be confined to small areas in dry pleurisy, or in pleurisy with effusion may 
 be diffused over the whole chest. This is what tends to confuse the examiner. 
 The voice in dry pleurisy is not changed. In pleurisy with all varieties of effu- 
 sion the voice may be normal, even when the chest is full of fluid. Again, as 
 stated, it may be bronchophonic. The breathing may be heard above the 
 level of fluid, and be diminished, absent, or bronchial, below. Again, breath- 
 ing may be heard with equal distinctness over a side which is full of fluid, 
 as over the unaffected side. In most cases we must rely mainly upon fremitus 
 and percussion. 
 
 In children sometimes, though rarely, the fluid will not appear in front of 
 the chest, though it exists over the whole side posteriorly. The lung seems to 
 have been pushed up and forward, instead of against the spinal column. In 
 such cases increased respiratory murmur and tympanitic resonance will be 
 obtained over the apex of the lung in front. 
 
 It is quite common to see the routine remark that displacements of 
 viscera, notably of the liver and heart, are common in children suffering 
 from pleurisy with effusion. This is not strictly true. In young children, 
 where the chest is very easily expanded by the accumulated fluid, the effu- 
 sion must be exceedingly large before downward displacement of the liver 
 will be appreciated. Older children also may carry large amounts of fluid 
 without marked displacement of the liver, though it can, in some cases, be 
 distinctly noted. In younger children effusion upon the left side may displace 
 the apex of the heart toward the sternum, but this is not apt to occur, except 
 as the result of very large effusion. In the adult the displacement of the liver 
 in right pleurisy, and of the heart in left, is quite a constant sign. 
 
PLEUBISY AXD EMPYEMA. 943 
 
 In conclusion, the author would lay stress upon the immobility, bulging of 
 the affected side as a whole, lack of fremitus, and flatness, combined with a pecu- 
 liar resistance to the percussing finger, as the leading reliable signs of acute 
 chest effusion, which may be corroborated by change in the voice and breath- 
 sounds. In children, as in adults, the effusion of pleurisy accumulates in the 
 most dependent part of the thorax, behind, adjacent to the vertebral column. 
 In children 100 grammes of effusion can be thus discovered by percussion at 
 the lower and inner portion of the chest-wall, adjacent to the spine (Gerhardt ; 
 Piorry). Accumulation of the fluid takes place thus in an oblique area, 
 growing deepest toward the median and tapering at the axillary line. Small 
 effusions in meta-pneumonic pleurisies may be encapsuled and give a localized 
 area of dulness or flatness. In tubercular pleurisies this is also very often 
 the case. In infants and young children the fine distinctions of change of 
 position of small exudates can hardly be made out, as in the adult, on account 
 of the restlessness of the patient. 
 
 Diagnosis. — The diagnosis of pleuritis in children is not difficult in the 
 majority of cases, but there is a percentage in which care must be exercised 
 before diagnosis can be positive. Dry pleurisy is diagnosed by the presence 
 of pain and the physical signs of local dulness and friction-rales. Localized 
 encapsulated pleurisies must be diagnosed by the circumscribed dulness or 
 flatness and the change of fremitus over a circumscribed area, with perhaps a 
 change in the voice and respiratory sounds. 
 
 If an effusion be of considerable size, the diagnosis is difficult when the 
 layer of fluid is so thin as not to mask the pulmonary resonance and give only 
 dulness ; but even here the fremitus will be absent. In marked effusion the 
 complete loss of fremitus, immobility of the affected side, and flatness, with a 
 certain wooden resistance to the percussing finger, are quite characteristic. It 
 is well not to rely too much upon vocal resonance or respiratory murmur. In 
 order that an effusion may not be overlooked, it is important to think of the pos- 
 sibility of its existence in every case, and to exclude it only after careful exami- 
 nation. It is of little moment if a delay of twenty-four or forty-eight hours 
 occur when the symptoms are not of a pressing character. But every practi- 
 tioner sees cases in which fluid must have been present for weeks without being 
 recognized. In children the exudate at a very early period, even from the 
 onset, is likely to be purulent, and it can be easily seen how important it is to 
 discover the character of an exudate as soon as possible. Aside from pressure 
 effects, the presence of a purulent exudate is dangerous on account of its 
 tendency to burrow inward toward the lung, eroding the pleura, or to rupture 
 externally. 
 
 If there be doubt as to the presence of fluid or as to its nature, these 
 facts should be determined as soon as possible. For this purpose a hypo- 
 dermic exploring needle should be used in the following manner : The mother 
 holds the babe in her arms in the usual way, the posterior part of the chest 
 is bared, and the area of most complete dulness or flatness is determined. This 
 part is first washed carefully with alcohol, and then with corrosive sublimate 
 (1 : 5000). A long exploring needle, a little larger than the ordinary hypoder- 
 mic needle, but stronger and stouter, having been attached to a well-cleansed 
 hypodermic syringe, is rapidly driven into one of the intercostal spaces, the 
 higher the better. On the right side, where the liver will present itself to the 
 entering point of the needle if too low, the puncture should not be lower than 
 the eighth space, in line with the angle of the scapula. The chief point, how- 
 ever, is to enter at the area of greatest dulness or flatness. Having pushed in 
 the needle about one-half an inch, the piston of the syringe should be drawn. 
 
944 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 The whole operation should be rapidly done, and the mother should be warned 
 to hold the child firmly, for any sudden movement might cause the needle to 
 impinge against the rib and break off — an accident which has occurred. This 
 little operation should be over before the child has ceased to experience the 
 pain of the entry of the needle. If no fluid be found the needle is rapidly 
 withdrawn and a piece of rubber plaster placed over the point of puncture. 
 The author has never had an accident in many such operations, and it requires 
 but ordinary cleanliness and care. It secures to the patient the benefit of an 
 absolute diagnosis. 
 
 Sometimes we may be absolutely certain of fluid, and yet be unable to 
 prove it with the needle. In such cases the needle has entered an adhesion of 
 the pleura, and at the next sitting, if still in doubt of the diagnosis, the needle 
 should be entered at another point. It is unwise after inserting the needle to 
 thrust it up and down the chest-wall or pleural space. In this way the lung 
 may be wounded, and emphysema, haemorrhage, or irreparable injury be caused. 
 While the needle is in the chest it should be held so lightly that any sudden 
 unexpected movement on the part of the child will not afford leverage to the 
 needle against the rib, for if this occur the needle is apt to break. When fluid 
 is obtained its character should be carefully determined, and the presence and 
 significance of contained bacteria should be investigated. The busy practi- 
 tioner may not have time to do this, but the author has devised a very simple 
 bulb l for the withdrawal and transportation of such fluids. 
 
 As far as prognosis and even treatment are concerned, it is of self-evident 
 importance to determine as early as possible whether an exudate is pneumonic, 
 tubercular, or doubtful. The presence of chain cocci, staphylococci, or the 
 diplococcus pneumoniae in a serous exudate will prepare the physician for the 
 advent of a purulent effusion, and the practical knowledge thus gained may be 
 of vital importance to the patient's future happiness. 
 
 In the presence of a suspected effusion it was previously, and still is among 
 some, the custom to temporize. It was argued that an exploring needle was 
 likely to cause a serous fluid to become purulent through the entrance of air 
 or some few micro-organisms. But the most ordinary cleanliness will render 
 this almost impossible. The author doubts very much if an effusion was ever 
 changed in character by careful hypodermic exploration. A slight amount of 
 air, or a few staphylococci, if through some carelessness introduced into a 
 serous exudate on the point of a needle, can scarcely change the character 
 of fluid filling the chest. The serous portion of exudates, like those in joints, 
 hydroceles, etc., is actually capable of annihilating the life of micro-organisms 
 in fixed ratio (Buchner ; Prudden). Moreover, serous effusions, formerly 
 thought to turn purulent through some accident, are really purulent and con- 
 tain the microbic element of pus from the outset, although they appear serous 
 to the eye. While advocating caution, the author recommends a fearless 
 resort to so valuable a guide as the hypodermic exploring syringe. 
 
 The tubercular cases alone offer the greatest difficulties of diagnosis, for, 
 as has already been shown, some serous and purulent exudates which contain 
 no micro-organisms may be tubercular, as may even those that contain 
 staphylococci or streptococci. But, fortunately, in children tubercular pleurisies 
 are not the most common forms. Hemorrhagic pleuritic exudates are very 
 rare in children. They are generally caused by grave disease — tuberculosis, 
 sarcoma, carcinoma, or morbus Werlhofii. 
 
 The cases of pneumonia which are complicated with pleurisy are the most 
 trying to the practitioner. Here on the eighth, ninth, tenth, or thirteenth day 
 1 American Journal of the Medical Sciences, 1892. 
 
PLEUBISY AXB EMPYEMA. 945 
 
 no complete crisis takes place. The temperature falls to within even one-half 
 of a degree of the normal in the axilla, but dulness persists in the lower part 
 of the chest or flatness appears over its w T hole extent. This condition is fre- 
 quently mistaken for so-called unresolved pneumonia. 
 
 Prognosis. — In children the prognosis in pleuritis is good. In the form 
 occurring after pneumonia or that caused by the staphylococcus or streptococ- 
 cus (non-septic), with effusion into the chest, recovery is rapid as soon as the 
 fluid is evacuated, and much depends upon early diagnosis. In suppurative 
 pleurisy, if allowed to remain unrelieved the pus will burrow, usually exter- 
 nally. The effusion then may infiltrate the soft tissues of the thorax, after 
 eroding the pleura, and point as an abscess at the side anteriorly or posteriorly. 
 Sometimes such an exudate, when on the left side, may receive an impulse 
 from the heart, and thus is occasioned the so-called pulsating pleurisy. Such 
 effusions have been mistaken for aneurisms, but lack of expansile pulsation 
 and the history of the case will guide in the diagnosis. The tumor disappears 
 when the chest is aspirated. If the pulmonary pleura becomes eroded by a pur- 
 ulent exudate, the perforation takes place into the lung, and the pus is more or 
 less quickly expectorated. Even in such cases, though unrelieved by any 
 additional measure, recovery has taken place, as in a case elsewhere recorded 
 by the author. Tubercular pleurisies do not recover completely in children; 
 fistulous suppurating cavities with retraction of the chest result. In some 
 cases the pleurisy has been so extensive as to cause retraction of the lung, its 
 utility being impaired by the binding of thick pleural plates, which leave 
 behind a large suppurating pleural sac. The septic cases are, as a rule, fatal, 
 though in fortunate instances recovery takes place. 
 
 Hofmokl treated by resection 60 cases, in which recovery was complete 
 in 26. Twenty-eight cases were fatal ; 13 of these were tubercular, 6 were 
 complicated with pneumonia, 3 died through pericarditis, 3 with peritonitis, 1 
 with amyloid degeneration of the organs, 1 with heart failure, and 1 with neo- 
 plasm. These cases were evidently more unfavorable, as to general character 
 of the pleuritis, than is common. 
 
 Complications. — The most dangerous complication of pleuritis is peri- 
 carditis, which in most cases is fatal. The occurrence of lobar or lobular 
 pneumonia as a complication has been dilated upon elsewhere. The septic cases 
 may be complicated by endocarditis or suppuration of other serous surfaces, 
 such as the peritoneum or that of the joints. Gangrene of the lung may cause 
 severe putrid inflammatory reaction of the pleura, and thus the pleural cavity 
 may contain gases with purulent exudation (pyopneumothorax). In these cases 
 a peculiar physical sign, known as the succussion sound, may be elicited by 
 shaking the patient. 
 
 Sudden death from heart failure may occur, but this must be rare. The 
 right heart, however, may become weakened to such an extent as to allow 
 the formation of thrombi, and their entry into the circulation may cause sudden 
 death. 
 
 Contraction and retraction of the chest-wall always follow, to a certain 
 extent, in those forms of pleuritis which have been left to nature. Many of 
 the deformities of the chest observed later in life are due to pleuritis in child- 
 hood. 
 
 The perforation of an empyema into the lung, with its evacuation through 
 a bronchus, has already been referred to as having rather a favorable prog- 
 nosis, even when not relieved by operation. As a rule, however, such cases 
 are best treated by external incision, although evacuation may be expected 
 by the bronchus. Again, perforation may take place through the chest-wall ; 
 
 60 
 
946 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 here a large boggy infiltration of the tissues of the chest or adjacent abdominal 
 wall takes place, constituting the condition known as empyema necessitatis. 
 
 Treatment. — It is difficult to formulate methods of treatment of pleuritis, 
 a disease in which the successful issue depends greatly upon judgment founded 
 upon experience. Those cases of pleuritis in which the process is circumscribed, 
 and in which the effusion in the pleural cavity is but slight, have pain as the 
 main symptom. The fever is generally marked, and requires, as a rule, but ordi- 
 nary methods. In children the pain is best relieved by some mild opiate, like 
 Dover's powder in proportionate dosage, or in combination with phenacetin and 
 salol. The latter has the advantage of controlling to a degree the febrile move- 
 ment. The author has seen but little advantage from the time-honored appli- 
 cation of iodine to the chest, nor has he seen much result from the internal 
 administration of the iodide of potassium. The latter is apt to disturb the 
 stomach, which at this time has largely to be depended upon to maintain 
 nutrition. The author would also advise against the use of external blisters of 
 all kinds, if for no other reason than the unnecessary pain which these agents 
 cause, and from the danger of infection in a weakened constitution if the skin 
 be broken. 
 
 When there is a moderate effusion of a serous character, even though this 
 effusion contain micro-organisms, yet if there is still no tendency to turbidity, 
 it is quite proper to make an attempt to favor absorption. Therefore, without 
 weakening the patient, care should be taken that the bowels are freely opened 
 from day to day, while the strength of the heart must be maintained. The 
 most useful combination of drugs in these cases is one of digitalis and calomel. 
 There is undoubtedly a very firm foundation for the belief that activity of the 
 kidneys will diminish a pleural effusion which is not due to renal or cardiac 
 disease. The fluid extract of digitalis should be used, in proportionate dosage, 
 in a separate mixture, whereas the calomel may be used in powder form. The 
 author generally gives both together. The supporting effect of digitalis upon 
 the circulation is aided by the diuretic effect of the calomel. Large doses of the 
 latter drug are unnecessary; small doses should be used at first and increased, 
 given at three-hour intervals. Salivation, or even dosage to its limit, is 
 injurious. 
 
 Where the chest is full of an exudate which is quite clear, but which causes 
 few symptoms of pressure, absorption may be hastened by aspiration of a 
 small quantity to begin with, trusting to drugs and nature for the rest. In 
 children this is rarely necessary, so quickly does the circulation, if supported, 
 respond to the demands made upon it. There are cases of pleurisy in which 
 a clear serous exudate of a pneumonic character may increase so rapidly and 
 cause such dangerous dyspnoea and pressure effects, that within a short space 
 of time it may be necessary to relieve the patient by aspiration. Even when 
 aspiration is effectually carried out, in some cases reaccumulation at once 
 occurs. Such exudates are not turbid, but clear, and may contain micro- 
 organisms. If reaccumulation occur in spite of diuretics, the question of a 
 radical procedure always presents itself. The author must support the view 
 founded upon experience, that such cases can be most effectually treated by 
 permanent drainage. The operations which are at our disposal for this end will 
 be taken up later. 
 
 From this it will be seen that the author regards aspiration as a palliative 
 measure, after the performance of which the little patient must be watched as 
 closely as before the operation. In children aspiration does not bear the same 
 relative therapeutic value in pleuritis that it does in the adult. Its immediate 
 performance entails as much care, causes as much anxiety, as a more radical 
 
PLEURISY AND EMPYEMA. 947 
 
 procedure, and with less satisfactory results. In most cases not only does 
 reaccumulation occur, but the effusion, at first serous, becomes purulent — 
 not because it has been infected by aspiration, but rather through the progress 
 of the pleuritis, as previously explained. Radical procedure may therefore be 
 required in rapidly reaccumulating serous exudates, causing pressure effects, 
 whether these contain micro-organisms or are free from such. 
 
 In small and large purulent exudates absorption rarely occurs spontaneously. 
 To temporize with a purulent exudate is to harm the patient. With purulent 
 exudates we include also those serous exudates which were formerly treated 
 expectantly : they are slightly turbid, and contain, to the eye, a few flocculi, 
 but, if examined bacteriologically and microscopically, will be found to contain 
 leucocytes and micro-organisms. To temporize with such so-called serous exu- 
 dates is to be finally disappointed in finding them more distinctly purulent 
 after a short period. In formulating diagnoses we must remember also that 
 exudates which are in part purulent tend to separate into a serous layer above 
 and a thick purulent layer below. Our needle may withdraw serum from a 
 chest which contains a fully-developed purulent exudate. 
 
 In the simple aspiration of the chest we should be guided by the case, 
 and with our needle avoid the proximity of vital organs. The sixth space 
 in front, the seventh in the axillary line, and the eighth behind are those 
 generally selected. Yet sometimes, fluid being low in level, a change may be 
 demanded. The point of the needle should enter near the upper border of 
 the rib, and should not be passed too deeply into the chest for fear of wound- 
 ing the lung. 
 
 The operative procedures which may be considered to be radical in their 
 nature, and which now have the confidence of clinicians are — incision, with 
 insertion of drainage-tubes ; siphonage of the pleural sac ; excision of the 
 ribs with insertion of drains. 
 
 Incision. — This operation is practised in the fifth space if in front, in the 
 sixth in the axillary line, and if behind, the ninth space is chosen. Konig 
 advises the higher point. Behind and on the right side we consider the pres- 
 ence of the arch of the liver. The incision is made near the upper border of 
 the rib, 5 to 8 cm. long. 
 
 This operation is popular with the practitioner, because it involves but 
 little technical skill, and once the incision is made, a drainage-tube is easily 
 inserted. In children, however, where the intercostal spaces are narrow, sur- 
 geons do not look with great favor upon simple incision, for the reason that it 
 is difficult to retain a tube of any great size in the wound. The opposing ribs 
 are constantly pressing the sides of the tube together, and in this respect the 
 drainage is imperfect. Moreover, the constant movements of the patient and 
 the chest are apt to dislodge the tube completely, and in the intervals of dress- 
 ing the wound the opening into the pleural cavity becomes distorted, so that 
 attempts to replace the tube give much pain or even fail completely. Many 
 cases will, however, do well with simple incision ; yet the fact remains that in 
 other cases a secondary operation, which has for its object the removal of a 
 piece of rib, has to be performed in order to obtain drainage. The author has 
 seen cases treated by incision, and thought to have recovered, in which reac- 
 cumulation occurred after removal of the tube, and necessitated a secondary 
 resection of the rib. 
 
 Resection. — In all cases of purulent exudation it saves much of the strength 
 of the patient if efficient drainage be obtained from the outset. This is secured 
 by the operation of resection of one of the ribs of the affected side. In this way 
 sufficient space is obtained for the insertion of a drain of considerable size, but 
 
948 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 this drain is not pressed upon by the adjacent ribs, and is not generally dis- 
 placed, or, if displaced, is easily readjusted. 
 
 The seventh, eighth, ninth, or tenth rib is chosen, as demanded by the indi- 
 vidual peculiarities of each case. The skin incision is made about 10 cm. 
 long, and 4 to 6 cm. of the rib is taken away with the bone forceps, after care- 
 fully reflecting the periosteum. The opening is then made into the pleural 
 S p ace — through the periosteum, or by a separate incision which passes through 
 the intercostal space below. The latter saves the whole periosteum intact, and 
 ensures reproduction of the bone without the least deformity. As in simple 
 incision, the opening may be made in the axillary or post-axillary line, or 
 behind in line with the angle of the scapula. On the right side the incision for 
 resection should not be made too low, as the arch of the liver will eventually 
 interfere with the retention of the drainage-tube. After the rib has been 
 resected and an opening made, some operators introduce the finger and break 
 up adhesions between the lung and chest-wall to free any encapsuled collections 
 of pus which may be present. This is to be deprecated, because in unskilful 
 hands the lung itself is apt to suffer injury. 
 
 Irrigation of the cavity is not necessary either at or after the operation. 
 Such a procedure may cause fatal syncope, or, if not attended with accident, 
 certainly does tend to prolong inflammatory processes going on in the chest. 
 Moreover, on account of the retention of some of the irrigating fluid, an 
 exudate at first of good character may become putrid. 
 
 In those suppurating pleurisies which, from various causes, such as the 
 perforation of a gangrenous or tubercular pulmonary focus, become putrid, 
 or have from the first been putrid, irrigation at long intervals with 
 Thiersch's solution or simple boric-acid solution or permanganate of potash is 
 admissible. 
 
 Resection of the rib has of late been confounded with Estlander's operation. 
 The latter operation is one undertaken to secure retraction of the chest-wall 
 against a crippled lung, and should not in any way be associated with the 
 comparatively simple procedure of removing an inch or so of one rib to give 
 space for the insertion of a drain in ordinary acute purulent pleurisies. 
 
 Though much has been said on the subject of valvular drains (Phelps), 
 which prevent the entrance of air into the pleural cavity, and are sup- 
 posed to favor expansion of the lung while securing complete drainage, there 
 seems to be little gained by their use. In the ordinary suppurating pleurisies 
 the customary surgical dressings seem to answer very well in taking up and 
 keeping aseptic any purulent discharge from the pleural cavity. The free 
 filtration of air into the pleural sac is not attended with any ill effects. It is 
 difficult to conceive how a discharge can become putrid from the admission of 
 air alone into the pleura. There must be other elements present to cause such 
 a bad result ; and these will be found in ineffectual drainage with retention of 
 old discharges in the pleural sac, or in some necrotic focus adjacent to the 
 pleura and opening into it. 
 
 It was formerly customary to make counter-openings in the chest to favor 
 drainage, but this has been found to be undesirable. 
 
 Siphonage. — To some the operation of resection will always be a grave 
 procedure, and there has been a constant effort to find some substitute which 
 would be more satisfactory than simple incision, yet not so complicated as 
 resection. This has resulted in perfecting an operation which depends on 
 the principle of siphonage, through negative pressure, to drain the pleural 
 cavity. The Buelau operation, to which reference is made, consists of the 
 introduction of a drain through an opening in the intercostal space ; this 
 
PLEURISY AND EMPYEMA. 949 
 
 drain is connected with tubing which empties into a siphon-bottle, under the 
 surface of an antiseptic fluid. 
 
 The operation requires (a) a trocar exactly 6 mm. in calibre, fitted with a 
 cannula : (b) a new disinfected Jacque catheter, fitted accurately to the cannula 
 and passing through its lumen with ease, yet not loosely ; (c) attached to this 
 catheter, by means of glass tubing, a rubber tubing 75 cm. long. 
 
 A small incision is made in the skin of the intercostal space, where the 
 Trocar is to enter. The trocar and cannula are then inserted, the trocar with- 
 drawn, and the Jacque catheter, with its blunt extremity cut squarely off, is 
 introduced for about 15 centimetres into the chest. The cannula is now with- 
 drawn over the Jacque catheter, escape of chest-contents being for the time 
 prevented by pinching the catheter. The catheter is now connected with 
 the tubing, which is led into a bottle filled one-third with an antiseptic fluid. 
 The pleural exudate thus escapes into the bottle beneath the layer of anti- 
 septic fluid, and air is prevented from entering the chest. Among the 
 advantages claimed for this operation by its advocates are its simplicity and 
 the prevention of entrance of air into the pleural sac. The negative pressure 
 in the pleural sac is also maintained, and the siphonage favors expansion of 
 the lung. The siphoning exudate is under constant observation through the 
 glass tubing and bottle, and when recovery sets in its advent can be noted by 
 the cessation of the discharge. There are no dressings except the adhesive 
 plaster, which retains the catheter in the chest. The results of this operation, 
 especially with children, in the hospitals of Hamburg have been so gratifying 
 as to make certain surgeons there its enthusiastic advocates. Scheede, on the 
 other hand, fears that unruly children will displace the tube in the chest. The 
 advocates of the siphon method maintain that this is not likely to happen. 
 Their results are certainly equal to those of surgeons using other methods, and 
 should bring the operation into favorable notice. 
 
PULMONARY EMPHYSEMA. 
 
 By JOHN DORNING, M. D., 
 
 New York. 
 
 Pulmonary Emphysema is an abnormal accumulation of air within the 
 vesicles or in the extravesicular connective tissue of the lungs. 
 
 The varieties of this malady are — I. Interstitial, interlobular, or extraves- 
 icular emphysema. II. Vesicular or alveolar emphysema, subdivided into a, 
 compensatory or vicarious emphysema; 6, substantive, idiopathic, or hyper- 
 trophic emphysema. III. Atrophic emphysema. As this last form occurs only 
 in advanced life, no further allusion will be made to it here. 
 
 I. Interstitial Emphysema. — In this condition there is an accumulation 
 of air in the connective tissue of the lung. It is usually the result of some 
 violent expiratory effort, such as would occur in a severe case of pertussis. 
 When the escaped air extends beneath the pleura, small air-bubbles appear on 
 the surface of the lung, showing the outlines of one or more lobules. Some- 
 times large bullae are seen. In unusual cases the air may burrow along the 
 larger bronchi into the mediastinum and up into the subcutaneous tissue of the 
 neck. Interstitial emphysema, as a rule, gives rise to no symptoms, and unless 
 it extend to the neck is not a serious malady. 
 
 II. Vesicular or Alveolar Emphysema. — a. Compensatory Emphy- 
 sema. — As the term would imply, this is a condition in which the vesicles 
 of one portion of the lung are abnormally distended in consequence of the 
 crippling or non-expansion of some other part of the organ. 
 
 Etiology. — It is this form of emphysema rather than the substantive form 
 that is to be observed in young children. Indeed, cases of typical substantive 
 emphysema are extremely rare in early childhood. In the genesis of compen- 
 satory emphysema there probably exists in most of the cases as a predisposing 
 factor a defect in the nutrition of the pulmonary tissue. Thus with the same 
 exciting causes in operation it is much more likely to occur in rachitic subjects 
 than in children whose nutrition is perfect. The immediate causes include any 
 mechanical obstruction to free respiration that would give rise to increased 
 pressure within the vesicles. In protracted bronchitis, particularly when the 
 finer bronchial tubes are affected, the swollen mucous membrane and the accu- 
 mulation of viscid mucus interfere with the entrance of air into the correspond- 
 ing lobules, causing a partial or complete atelectasis of the parts involved. 
 This will leave an unoccupied space in the chest-cavity which becomes filled 
 by the hyperdistention of adjacent lobules. This is the inspiratory theory. 
 Again, as is so often observed in pertussis, in consequence of obstruction to 
 the free egress of air through the glottis with extra-violent expiratory efforts, 
 the retained air is forced in the direction of the least resistance, the apices and 
 anterior borders, causing an over-distention of the vesicles in these regions 
 — the expiratory theory. 
 
 In the vicinity of solidified areas of lung-tissue, as in pneumonia or tuber- 
 
 950 
 
PULMOXABY EMPHYSEMA. 951 
 
 culosis, emphysema is usually discernible. When one lung is compressed by 
 fluid in the pleural cavity, the other lung by reason of its increased function 
 becomes over-expanded. Pleuritic adhesions that prevent the normal expan- 
 sion of the apex and posterior border of the lung necessitate over-distention 
 of other parts of the organ, especially the anterior and inferior borders. 
 
 In addition to other complications, emphysematous distention of parts of 
 the lungs is to be found in membranous croup. In advanced rachitis the plia- 
 bility of the ribs and costal cartilages favors the development of emphysema in 
 the anterior margins of the lungs. 
 
 Inflation of the lungs in the asphyxiated new-born child by blowing into 
 its mouth has been said to give rise to emphysema. Such a cause must be quite 
 exceptional, judging from the manner in which lungs that have been removed 
 from the body collapse after forcible inflation. 
 
 Pathology. — In the majority of cases of compensatory emphysema com- 
 plicating acute bronchitis and pertussis recovery evidently takes place. In 
 these cases there has undoubtedly been simply a hyperdistention of the pul- 
 monary air-vesicles without any structural changes in their walls. The same 
 may be said of the inordinate inflation of the lung of the non-affected side in 
 acute pleurisy with effusion, where there has been a rapid absorption of the 
 accumulated fluid. Where the affection is associated with tuberculous infiltra- 
 tion or old pleuritic adhesions, dilatation of the air-vesicles, with thinning of 
 their walls and other structural changes characteristic of substantive emphysema, 
 may be found to exist. From this we may conclude that the longer the dura- 
 tion of the immediate causes of compensatory emphysema, the more likely is a 
 true emphysema to develop. 
 
 Symptoms. — A diagnosis of compensatory emphysema cannot, in most 
 instances, be made either from the symptoms or by physical exploration of the 
 chest. In fact, there are no distinctive signs of the affection unless consider- 
 able of the lung be involved, and its existence is generally assumed. Bulging 
 of the supraclavicular space during the severe expiratory efforts of coughing, 
 and a falling-in during inspiration, have been regarded as indicative of an 
 involvement of the apices. Where one side of the chest is filled with fluid the 
 hyper-resonance of the opposite side with the exaggerated vesicular murmur 
 would suggest the belief that the one lung is performing the work of the two, 
 and that the vesicles are abnormally distended. If extensive pleuritic adhe- 
 sions exist, a prolonged low-pitched expiratory murmur may be heard over 
 certain portions of the lung, but especially at the anterior border. In this 
 latter situation the same character of respiration may be detected in rachitic 
 subjects with marked chest-deformity. 
 
 Treatment will be considered under Substantive Emphysema. 
 
 b. Substantive Emphysema. — This is a chronic and generally incurable 
 malady, characterized by an abnormal distention of the pulmonary vesicles, 
 with structural changes in their walls. 
 
 Etiology. — Well-marked substantive emphysema in young children — that 
 is, under the age of ten years — is extremely rare. After this age it is occa- 
 sionally observed, but not until adolescence is it encountered with any fre- 
 quency. Authorities differ materially in their views regarding the causation 
 and nature of this disease. From the frequency with which it is found to run 
 in families it would, in a measure, appear to be of an hereditary nature. Jack- 
 son investigated 28 cases, and found that 18 were born of parents one or the 
 other of whom had suffered from emphysema. Greenhow collected 42 cases, 
 23 of which appeared to be of an hereditary tendency. The histories of many 
 cases of emphysema in the adult show that there have been frequent respiratory 
 
952 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 affections from early life ; still, in other instances where the disease has been 
 extensive, no account of previous attacks of bronchitis can be elicited. 
 
 Increased air-pressure within the pulmonary vesicles, due to forced and 
 long-continued inspiration or expiration, is by some investigators considered at 
 least the exciting, if not the primary, cause of emphysema. 
 
 According to the inspiratory theory of Laennec as modified by Hutchin- 
 son, Traube, and Grairdner, emphysema is a result of bronchial catarrh. The 
 presence of a tumefied mucous membrane and viscid mucus in the bronchioles 
 prevents the entrance of air into the corresponding lobules, giving rise to areas 
 of collapse, and to fill up the deficiency so caused the neighboring lobules 
 become hyperdistended. 
 
 The theory of expiration as maintained by Jenner and Mendelsohn would 
 seem to afford a more adequate explanation, than does the inspiratory theory, 
 of the part mechanical distention of the air-cells plays in the production of 
 substantive emphysema. During forced expiratory efforts with a closed glot- 
 tis, as occurs in violent attacks of coughing or severe straining, the air is 
 driven in the direction of the least resistance — namely, the apices and anterior 
 borders of the lungs. It is in these situations that the greatest degree of dila- 
 tation is usually found. There are cases, however, where the disease is diffused 
 throughout the lung, without a history of previous cough or increased 
 expiratory pressure. 
 
 C. J. B. Williams claimed there was a fatty degeneration of the lung-tissue 
 that aided in bringing about the pathological changes observed in emphysema. 
 Fatty matter has been found in only a small number of cases. Jenner taught 
 that the most frequent anatomical change in the lung was fibrous degeneration 
 resulting from slight but long-continued congestion. 
 
 Delafield believes substantive emphysema to be a chronic inflammation of 
 the lungs, a pneumonia, and the dilatation of the air-vesicles a mere result of 
 this inflammation, and not the essential lesion : the inflammation, he states, is 
 of the same type as that which so often attacks the endocardium, the inner 
 coat of the arteries, the liver, and the kidneys — a chronic inflammation attended 
 with the production of new fibrous tissue, and at the same time with atrophy 
 and disappearance of normal tissue. It is quite evident that increased air- 
 pressure within the vesicles does not exclusively account for the presence of 
 substantive emphysema. Indeed, it seems doubtful if it can be considered as 
 anything more than an exciting cause or as aggravating the disease when it has 
 already been established. We think it may reasonably be inferred that chil- 
 dren who suffer with frequent prolonged attacks of bronchitis are likely to 
 become the subjects of emphysema later in life, not only because of the pul- 
 monary disturbance induced by the increased intralobular pressure, but on 
 account of the existing condition which predisposes the child to the repeated 
 bronchial catarrhs ; for in such children there is unquestionably a vulnerability 
 of the tissues the outcome of some defect in the nutrition. 
 
 Pathology. — In the rare cases of substantive emphysema that occur in 
 early life most of the changes that are to be observed in the adult are present, 
 only in a less degree. On opening the thorax the lungs do not collapse. They 
 have a peculiar cushiony feel and pit on pressure. The color is pale grayish or 
 yellowish gray. The air-vesicles present varying degrees of dilatation. " Their 
 walls are in some parts of the lung thinned, in others thickened. Coalescence 
 of neighboring vesicles and obliteration of the capillaries occur in some in- 
 stances. The epithelium of the air-cells presents degenerative changes. In 
 the bronchial tubes may be seen evidence of chronic bronchitis, with dilata- 
 tion of the bronchioles in some advanced cases. There may be some hyper- 
 
PULMONARY EMPHYSEMA. 953 
 
 trophy of the right ventricle, and less frequently a secondary dilatation. The 
 secondary lesions of emphysema do not usually occur until long after childhood. 
 
 Symptoms.— Substantive emphysema not infrequently is present in the 
 adult without giving rise to any subjective symptoms. This being the case, the 
 more abundant reason there is why, with its less extensive development, it may 
 exist in the young subject without thus manifesting its presence. When rational 
 symptoms are present, they resemble, in a milder form, with the exception of 
 those dependent upon secondary lesions, which are absent, those observed later 
 in life. 
 
 Dyspnoea is probably the most marked symptom. At first it may be expe- 
 rienced only during unusual exercise ; later, it becomes more constant, and is 
 aggravated by even slight exertion, attacks of bronchial catarrh, and by dis- 
 tention of the stomach by a hearty meal or by the accumulation of gas from 
 indigestion. Asthmatic attacks are of not infrequent occurrence. Off and on 
 during the winter there is more or less cough. 
 
 Physical Signs. — Inspection. — The typical barrel-shaped chest of emphy- 
 sema is seldom observed in children. There may, however, be a slight increase 
 in the antero-posterior diameter. This will be more noticeable when associated 
 with rachitic deformity of the thorax. Posteriorly, the curve of the spine may 
 be increased, giving the back a rounded appearance. This must not be con- 
 founded with rachitic curvature of the spine. There is some increased exer- 
 tion in respiration, but the rigidity of the chest, due to ossification of the costal 
 cartilages, seen in advanced adult cases is absent. There may be some retrac- 
 tion of the upper abdominal region, owing to the powerful action of the dia- 
 phragm on the lower ribs. Jenner has observed falling in of the supraclavic- 
 ular region during inspiration in cases where the apices were affected. Furst 
 considered expansion of this region during severe cough as a characteristic sign. 
 
 Palpation is negative. 
 
 Percussion. — Pulmonary resonance may remain unaltered. In older child- 
 ren, when it is changed, it is of a vesiculotympanitic quality. In young child- 
 ren the great elasticity of the thoracic walls and the smallness of the organs 
 to be examined favor the transmission of resonance from the distended intes- 
 tines, so that, unless there be very marked distention of the thorax, sufficient 
 to displace the liver downward, percussion will be of little value. Thus it is 
 the extent, and not the intensity, of the pulmonary resonance that is to be 
 considered. 
 
 Auscultation. — The respiratory murmur is usually feeble and of a low pitch. 
 Expiration is prolonged. When bronchitis is present sonorous, sibilant, and 
 mucous rales are heard. The heart-sounds are generally clear; the second 
 sound may be accentuated in older cases. 
 
 Prognosis. — Recovery from compensatory emphysema, if the malady has 
 not existed for too long a time, may be expected. Perfect restoration of the 
 lungs, however, when substantive emphysema has once become established, is 
 not to be looked for. It never of itself proves fatal ; still, it may be a com- 
 plicating factor in bringing about a fatal issue. It is claimed by some that in 
 cases of short duration with but limited involvement of the lung, under favor- 
 able circumstances recovery ma} r take place. Not infrequently, improvement, 
 even to the extent of an apparent cure, may be observed, but later in life, in 
 most instances, it will be found to have been only temporary. At one time it 
 was erroneously believed that emphysema protected the subject against tuber- 
 culosis. 
 
 Treatment. — In children the treatment should be mainly prophylactic. 
 As malnutrition is evidently a predisposing factor, everything pertaining to the 
 
954 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 diet and hygiene, even from early infancy, should receive due consideration. 
 In this way the exciting causes of the disease may be prevented, or, should 
 they develop, the patient will be in a better condition to withstand them. 
 
 When the affection is present it is infinitely necessary that measures be 
 adopted toward the improvement of the general health. The whole body 
 should be protected by woollen underclothing. The cold sponge bath, used 
 only to an extent that will produce a proper reaction, is a general tonic of 
 unquestionable value. By maintaining a healthful condition of the skin it 
 lessens the liability to repeated bronchial catarrhs. An abundance of out-door 
 air, with exercise regulated to suit the physical endurance of the patient, is an 
 essential part of the treatment. An equably dry climate with an altitude of 
 not over a thousand feet is very desirable. The diet should be principally 
 nitrogenous. The value of milk is too well appreciated to need more than 
 mere mention. The quantity of food taken at one time should not be great 
 enough to cause any embarrassment of the respiration. Cod-liver oil, particu- 
 larly if rachitis be present, should be administered. When the pure oil is given, 
 begin with small doses, five to ten drops three times a day, and increase grad- 
 ually until a full teaspoonful is reached. The emulsion of cod-liver oil, either 
 simple or in combination with malt extract, is in some cases preferable to the 
 plain oil. 
 
 In the way of medicinal treatment iron in some form should be used when 
 there is any evidence of anaemia. Of the different preparations, the tincture 
 of the pomate is for children one of the most acceptable both to the palate and 
 the stomach. A child three years of age may be given from five to eight 
 drops in a little plain or sweetened water three times a day ; at ten years, ten 
 to twenty drops. The citrate or the tincture of the chloride may also be used. 
 In older children either Basham's mixture or the ethereal tincture of the acetate 
 of iron can be recommended. 
 
 Strychnine has been thought to possess some specific virtue in the treatment 
 of this disease. That its action is anything more than that of a general tonic 
 seems doubtful. Care should be taken in prescribing the drug for young chil- 
 dren. Tincture of nux vomica is a safer preparation, and may be administered 
 in from one-half to two-drop doses at six years of age. Arsenic in the form of 
 Fowler's solution, in from one-half to two-drop doses at eight years of age, is a 
 general tonic of some value. 
 
 The mechanical treatment by compressed air, while valuable in certain cases 
 in the adult, is less practicable, and may be positively harmful, in children. 
 
 All the exciting causes of compensatory emphysema or those that aggra- 
 vate the substantive form, if not preventible, should be mitigated as much as 
 possible. 
 
 For the chronic bronchitis that so often coexists with substantive emphy- 
 sema iodide of potassium is generally recognized as a drug of great worth. In 
 many cases favorable results may be obtained by combining it with linseed oil, 
 as follows: 
 
 Jfy. Potassii iodidi .... gij. 
 
 01. lini fjiij. 
 
 Pulv. acaciae giij. 
 
 01. gaultheriae ........... gtt. viij. 
 
 Syrupi . . J fgij. 
 
 Aq. dest q. s. adfgvj. — M. 
 
 Ft. emulsio. 
 Sig. Teaspoonful three or four times a day at ten years of age. 
 
PULMOXABY EMPHYSEMA. 955 
 
 Another drug of marked excellence where there is much bronchial secretion 
 is terebene. At eight or ten years of age it may be given thus : 
 
 1^5. Terebene f^ij. 
 
 Tinct. opii camph f^ss. 
 
 01. menth. pip gtt. vj. 
 
 Syr. acacise . . q. s. adf^iij. — M. 
 
 Sig. Teaspoonful every four hours. 
 
 The treatment of the complicating asthmatic attacks will be considered in 
 the article on Bronchial Asthma. 
 
BRONCHIAL ASTHMA 
 
 By JOHN DOBNING, M. D., 
 
 New York. 
 
 Asthma is a peculiarly distressing form of paroxysmal dyspnoea, accom- 
 panied by wheezing respiration and characterized by a freedom from all mani- 
 festations of the affection in the intervals of the attacks. 
 
 Etiology. — It seems to be generally conceded by writers on the subject 
 that those who suffer with asthma inherit a tendency to the disease. In many 
 cases there is an ancestral history of gout instead of asthma. According to 
 the statistics of Thery and Hyde Salter, asthma is more common among males 
 than females. It is of frequent occurrence during childhood. Of Hyde Salter's 
 225 cases, 71 developed the disease during the first decade. It is said to be 
 more common in the upper than in the lower walks of life. In a certain class 
 of cases the cold season seems to exert some predisposing influence on the 
 malady. 
 
 The exciting causes may be divided into those which act directly upon 
 the nervous mechanism of the lungs, and those which are reflected from 
 more remote parts or organs. 
 
 It is to be borne in mind that the exciting causes are only operative when 
 there is a predisposition to the disease. In some instances no definite ex- 
 citing cause can be discovered. Ursemic, cardiac, gouty, saturnine, and mer- 
 curial asthma are thought to be the result of an irritation of the respiratory 
 centre in the medulla oblongata by vitiated blood. Irritation of the pneumo- 
 gastric nerve along its course, as by the pressure of enlarged bronchial 
 glands, may give rise to paroxysms of asthma. Eustace Smith has rarely 
 failed to find evidence of swelling of the bronchial glands in the cases he has 
 seen of asthma in the child. The enlargement of these glands is a result of 
 bronchial catarrh. The asthma observed in the subjects of congenital syphilis, 
 the so-called syphilitic asthma, can very likely be explained by a syphilitic 
 enlargement of the bronchial glands. Bronchitis, either alone or associated 
 with emphysema, is generally recognized as an exciting cause of asthma. Such 
 cases may be accounted for either by a direct irritation of the terminal fila- 
 ments of the pneumogastric nerve or by the concomitant swelling of the bron- 
 chial glands. 
 
 The inhalation of various irritants, as dust, the pollen of plants, smoke, 
 gases, certain vapors, and the emanations from certain animals, are well known 
 to excite asthmatic attacks. In this connection idiosyncrasy plays a prom- 
 inent part. Some individuals are susceptible to only a few or perhaps but 
 one of such irritants, and what will excite a paroxysm in one patient will 
 have no influence on another. Thus, one patient cannot bear the perfume 
 of some particular flower, as the rose, Easter lily, or heliotrope ; another 
 cannot tolerate the presence of a cat, horse, or dog ; and a third dare not 
 
 956 
 
BBOXCHIAL ASTHMA. 957 
 
 encounter the air of certain localities. It is a well-known fact that a change 
 of residence may either bring on the attacks or entirely prevent them. Sudden 
 changes in the barometrical pressure, with strong easterly or northerly winds, 
 are particularly detrimental to some asthmatics. Indigestion, overloading the 
 stomach, or the ingestion of certain articles of diet not infrequently precipitates 
 a paroxysm. In some rare instances intestinal worms are said to be an exciting 
 factor. Asthmatic attacks may be induced by polypi in the nose. Volto- 
 lini of Breslau was the first to direct attention to this fact, and his observations 
 have been confirmed by later investigators. Hypertrophy of the mucous 
 membrane over the turbinated bones and nasal septum has been shown by 
 Daly, Harrison, Roe, Allen, Hack, and others, to be a source of reflex irrita- 
 tion in provoking paroxysms of asthma, more especially hay asthma. Skin 
 eruptions, notably eczema and urticaria, have been included in the category 
 of exciting causes. West has "never known eczema to be very extensive and 
 very long continued without a marked liability to asthma being associated with 
 it." Cases have been observed where asthma and eczema have coexisted or 
 alternated with each other, and the cure of one has been coincident with recov- 
 ery from the other. It would seem not unreasonable to assume that where 
 urticaria or eczema and asthma coexist or alternate with each other, instead of 
 there existing a reciprocally etiological relation between the two, both are 
 dependent upon some common cause. 
 
 Pathology. — Thus far, no well-defined post-mortem alterations have been 
 discovered that would place the pathology of bronchial asthma, if it really be 
 a distinct affection and not merely a symptom, without the domain of specu- 
 lation. There is a number of theories regarding the nature of this affection, 
 the most plausible of which are : 
 
 1st. That it is due to spasm of the bronchial muscles — the most popular 
 theory at the present time. This theory is based upon the experiments of 
 Williams and Longet, who, after the discovery of muscular tissue in the walls 
 of the finer bronchi by Reisseisen, found that electrical irritation of the lungs 
 and pneumogastric nerve produced contraction of the bronchial tubes. Among 
 the advocates of this theory are Romberg, Bergson, Trousseau, Hyde Salter, 
 Paul Bert, and Biermer. 
 
 2d. The next theory, and one having many supporters, is that the dyspnoea 
 is due to a sudden tumefaction of the bronchial mucous membrane with exuda- 
 tion, the result of turgescence of its blood-vessels caused by the action of the 
 vaso-motor nerves (Weber), fluctionary hyperemia (Traube). Stoerck adopted 
 this theory from having, during the paroxysm, observed with the laryngoscopic 
 mirror an acute hyperemia of the laryngeal and tracheal mucous membrane, 
 which disappeared after the attack had subsided, and he consequently inferred 
 that the same condition existed in the smaller bronchial tubes. 
 
 3d. Another view regarding the nature of this malady is that it is depend- 
 ent upon a catarrh of the bronchioles (bronchiolitis exudativa). This theory 
 is based on the presence in the sputum of certain peculiar spiral structures 
 described by Curschmann (Fig. 1). 
 
 Leyden discovered in the sputum of asthmatics certain elongated octahedral 
 crystals (Fig. 1), which he believed, by their irritation of the terminal nerve- 
 filaments in the bronchial mucous membrane, induced bronchial spasm. These 
 crystals have been found in pneumonic expectoration, and hence, while not 
 pathognomonic, they may be of some diagnostic value in differentiating 
 bronchial asthma from other forms of dyspnoea. 
 
 Symptoms. — In the majority of instances the asthmatic attack occurs 
 without any premonition whatever ; sometimes, however, certain sensations are 
 
958 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 experienced which to those who have previously suffered are pretty sure evi- 
 dence of an approaching paroxysm. The premonitory symptom may be a 
 depression or exaltation of spirits, a chilly feeling, a sense of constriction of 
 the chest or throat, flatulent distention of the abdomen, itching of the skin, 
 
 Fig. 1. 
 
 4 e ii / ' 
 
 Curschmann's Spirals and Leyden's Crystals (Strumpell). 
 
 the voiding of a large quantity of clear urine, or some other functional dis- 
 turbance peculiar to the individual. Not infrequently an acute catarrh of the 
 upper air-tract precedes the attack. 
 
 The paroxysm generally comes on after the patient has retired for the 
 night ; still, it may occur at any hour of the day. It commences with the 
 characteristic wheezing, and soon "the patient is awakened by a distressing sense 
 of lack of breath, which becomes more and more urgent until he is finally 
 compelled to assume a position that will facilitate an easier entrance of air into 
 his lungs. He may sit up in his bed or in his chair, with his hands grasping 
 his knees, his shoulders elevated, and his head thrown backward, so that all 
 the muscles of respiration and their auxiliaries may act to greatest advantage ; 
 or, he may find greatest relief by kneeling before his cot or chair with his head 
 resting on his hands or a pillow. Often the desire for breath is so pressing 
 that the sufferer will rush to an open window in the hope of obtaining relief. 
 The face assumes an anxious expression, pallid at first, and as the dyspnoea 
 increases changing to a dusky bluish hue. The eyes are prominent and have a 
 staring expression, the nostrils are widely dilated, and the mouth is partly open. 
 The skin becomes moistened with perspiration as the distress increases. The 
 respiration, particularly expiration, is noisy and wheezing, and may be 
 heard in the adjoining apartment. Inspiration is short and jerky, expiration 
 very much prolonged. The number of respirations is seldom much increased, 
 and may be even less than normal. Speech, beyond monosyllables, is impossi- 
 ble. Notwithstanding the laborious efforts in breathing there is merely an up- 
 and-down movement of the ribs, with but little or no expansion, the thorax 
 being fixed in the position of full inspiration. The pulse is small, rapid, and 
 thready in proportion to the intensity of the dyspnoea. There is no elevation 
 of the temperature. If the attack be prolonged, the surface temperature falls 
 below normal, the extremities become cold, clammy, and bluish, and death 
 seems imminent. 
 
 As the paroxysm subsides there is more or less cough and expectoration, 
 whether they have previously existed or not. In some cases the expectoration 
 consists of rounded masses of tenacious mucus ; in others it is profuse and 
 watery. Sometimes streaks of blood are found. In some rare and severe 
 cases haemoptysis has been known to occur. 
 
BBOXCHIAL ASTHMA. 959 
 
 After the paroxysm there is usually considerable exhaustion, and the patient 
 soon falls asleep. On awakening, with the exception of a little soreness of the 
 respiratory muscles, no discomfort is experienced, and the patient afterward 
 enjoys his usual health. 
 
 The duration of the attack may vary from a few hours to several days, with 
 remissions and exacerbations. The paroxysms vary in frequency. They may 
 recur as often as once a week or there may be an interval of months between 
 them. Ordinarily there is no regularity in the recurrence of the attacks. A 
 periodicity, however, is sometimes noticed, and is probably due to some con- 
 dition operative only at particular times. 
 
 Physical Signs. — During the paroxysm inspection shows an expanded and 
 barrel-shaped thorax, with but little respiratory motion. Inspiration is short 
 and quick, expiration prolonged and violent. On percussion more or less 
 hyper-resonance is obtained; in mild cases it is slight, but when the attack is 
 severe and of long duration it is usually quite marked. Auscultation reveals, 
 in severe cases, diminution or suppression of the vesicular murmur. 
 
 In mild attacks the respiratory murmur may be exaggerated and jerky. 
 All over the chest may be heard an ever-changing variety of sonorous and sib- 
 ilant rales. They are piping, cooing, wheezing, and often musical in their 
 nature. They are louder during expiration. Toward the close of the parox- 
 ysm moist rales are to be heard, or, if bronchial catarrh exists, they may be 
 detected from the beginning of the attack. 
 
 Prognosis. — Uncomplicated asthma is, per se, rarely if ever fatal. In 
 general the prognosis is better in young subjects than in adults. Hyde Salter 
 makes the statement that "in young asthmatics the tendency is almost invariably 
 toward recovery." The prognosis may be said to be favorable when the attacks 
 are dependent upon some removable cause, when mild and occurring at long 
 intervals, when there is no hereditary predisposition, and when there is freedom 
 from complications. 
 
 Diagnosis. — The rational and physical signs of an uncomplicated paroxysm 
 of asthma are so distinctive that, if properly appreciated, there should be little 
 or no difficulty in reaching a correct diagnosis. 
 
 The affections which it is thought may possibly be mistaken for bronchial 
 asthma are the various forms of obstruction in the upper air-passages, as for- 
 eign bodies in the throat; retro-pharyngeal abscess; diphtheritic and false 
 croup ; oedema of the glottis ; neoplasms of the larynx ; spasmodic contraction 
 of the adductors of the larynx or paralysis of the abductors; tracheal stenosis 
 or foreign body in one or the other of the main bronchi ; bronchitis, pneu- 
 monia; emphysema; pulmonary oedema; pleuritic effusion; cardiac disease; 
 uraemia, and spasm of the diaphragm. 
 
 In obstructive dyspnoea from any cause the difficulty in breathing is 
 during inspiration, while in asthma it is during expiration. There is also 
 inspiratory recession at the episternal notch and epigastrium not observed 
 in asthma. In the former there is the absence of wheezing in the chest, 
 and the dyspnoea is continuous instead of paroxysmal, as in asthma. Changes 
 in the quality of the voice will exclude the latter affection. Examination of 
 the throat with the finger or mirror will enable one to determine the exact 
 nature of the obstruction. Occlusion of a main bronchus will cause a 
 diminished intensity or absence of the respiratory murmur on the affected 
 side. The dyspnoea of bronchitis and pneumonia comes on gradually and 
 is attended with some degree of fever ; the respirations, particularly in 
 pneumonia, are rapid and often short and catching. In asthma the onset is 
 
960 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 more sudden, there is no elevation of temperature, and the respirations are 
 either but slightly or not at all increased in frequency. 
 
 Some difficulty may be experienced in distinguishing between emphysema 
 and asthma on account of their frequent coexistence. Each may induce the 
 other. Emphysema more often exists without asthma than does the latter 
 affection without some degree of the former. In emphysema the dyspnoea is 
 remittent rather than intermittent as in asthma. It is aggravated by physical 
 excitement, and hence is more likely to occur during the day than at night. In 
 pulmonary oedema the increased frequency of the respiration, with perhaps 
 some dulness on percussion, the presence of large and small moist rales all over 
 the chest, the profuse and watery expectoration, and the absence of wheezing 
 will ordinarily distinguish it from asthma. In pleuritic effusion the usual dul- 
 ness on percussion, the limitation of the diminished respiratory murmur to the 
 area occupied by the fluid, the detection of aegophony, and the absence of the 
 characteristic dry rales of asthma will suffice for a diagnosis. 
 
 Cardiac asthma is not very common in children. It, however, resembles 
 bronchial asthma in that it may be paroxysmal in nature, intense in degree, 
 and may come on at night. It generally follows cardiac excitement. The 
 absence of the varied musical sounds in the chest and of the prolonged expira- 
 tion, and the presence of a cardiac lesion capable of inducing dyspnoea, will 
 be of some assistance in distinguishing the one from the other. 
 
 Dyspnoea due to uraemia need never be confounded with bronchial asthma 
 if the precaution is taken to examine the urine of every case coming under 
 observation. 
 
 Spasm of the diaphragm may be distinguished from asthma by the sudden, 
 abrupt inspiration, the hiccough, and, after a few seconds, the quick, violent 
 expiratory effort. 
 
 Treatment. — The treatment of asthma comprises the management of the 
 paroxysm and the treatment of the patient in the intervals between the attacks. 
 If possible, the exciting cause should be discovered and removed. For instance, 
 if clearly dependent upon an overloaded stomach or the presence of some indi- 
 gestible substance in the alimentary canal, an emetic or an enema will afford 
 prompt relief. To relieve the patient during the attack, in the absence of any 
 apparent and removable cause, it generally becomes necessary to have recourse 
 to some sedative or depressant. The numerous drugs recommended vary so in 
 their action upon different subjects that not infrequently a number have to be 
 tried before the one is found that gives the greatest relief. The one drug that 
 is most frequently successful in cutting short the paroxysm is morphine admin- 
 istered subcutaneously. In young children, however, it is rarely necessary to 
 use it, as some one of the remedies to be mentioned will usually be found to 
 be sufficiently effective. In later childhood, if given, the greatest caution 
 should be observed, as children are markedly susceptible to the toxic influence 
 of morphine. To a child ten years of age from -fa to y 1 ^ of a grain of the sul- 
 phate, combined with -^-q of a grain of atropine sulphate, may be given hypo- 
 dermatically. Next to morphine in abating the asthmatic paroxysm comes 
 chloroform. The relief is speedy, but often only temporary, so that repeated 
 inhalations are usually required. In the writer's experience chloral hydrate is 
 superior to chloroform at any period of childhood, in that its effects, though 
 less prompt, are more lasting. At five years of age 5 grains dissolved in at 
 least 1 drachm of some simple menstruum, may be given, and repeated in forty 
 minutes if there be no abatement of the dyspnoea. If it cannot be taken by 
 the mouth, 10 to 15 grains dissolved in half an ounce of water may be injected 
 into the rectum. 
 
BRONCHIAL ASTHMA. 961 
 
 The fumes of nitre-paper (charta potassii nitratis), a very popular remedy, 
 Trill often cut short a mild attack and give considerable relief in a severe 
 one ; sometimes it has no effect at all. The remedy is prepared by dip- 
 ping a sheet of absorbent paper into a saturated solution of nitrate of potas- 
 sium and afterward drying it ; the dried paper is then cut into pieces of 
 the required size and is ready for burning. The patient should be placed in a 
 small room or in some kind of an extemporized tent, so that he can inhale the 
 fumes of the burning paper. It acts promptly if at all, at first exciting some 
 cough, but in a few minutes alleviating the distress. 
 
 Inhalation of the smoke of Datura stramonium and Datura tatula is often 
 serviceable. In young subjects it must be used with care, and the inha- 
 lation stopped as soon as the sight or intellect becomes confused. Lobelia and 
 belladonna, either separately or combined, are beneficial in some cases. 
 
 Tobacco, while an excellent remedy in adult cases, is too powerful a depress- 
 ant to be recommended in children. The nitrite of amyl and nitro-glycerin do 
 good, but they have not yielded such results as would be expected from our 
 knowledge of their physiological action. If used at all in children, they must 
 be given with due caution. Quebracho and Grindelia robusta have been advo- 
 cated, but their action is uncertain. 
 
 Iodide of ethyl is thought to be efficacious (Germain SeV). Eight to twelve 
 drops by inhalation is a fair dose at eight years. Pilocarpine, \ to -^ of a grain 
 hypodermatically at five years, has been advocated by Berkart. Coffee and 
 alcohol are useful in the adult ; but it is questionable if it would be wise to 
 have recourse to them, particularly the latter, in children. 
 
 Intense mental emotion, as a sudden alarm or a pleasurable surprise, will 
 frequently at once check an asthmatic paroxysm. 
 
 During the intervals of the attacks every effort should be made to discover 
 and remove the exciting cause. Hypertrophied turbinated bodies should be 
 reduced, nasal polypi extirpated, adenoid growths in the naso-pharynx removed, 
 and catarrh of any part of the respiratory tract relieved by appropriate meas- 
 ures. Particular attention should be given to the diet, especially when the 
 asthmatic attacks bear any relation to the state of the digestion. As a rule, 
 it is best to allow only a light and easily-digested supper, and that early enough 
 in the evening to be digested and passed from the stomach before retiring. 
 
 When there is no apparent exciting cause the general condition of the 
 patient requires attention. The value of an out-door life, in the open country 
 if possible, the daily cold sponge-bath, the protection of the body by suitable 
 clothing, and a nutritious diet in the asthmatic subject is too well appreciated 
 to require more than mere mention. All those affections that directly or 
 indirectly cause enlargement of the bronchial glands are to be most sedulously 
 guarded against. Cod-liver oil, beginning with small doses and gradually 
 increasing, should be administered in most cases. Iron is frequently indicated. 
 The tincture of the pomate of iron in from 5- to 10-drop doses at five years of 
 age is an acceptable and easily-digested preparation for children. The tincture 
 of the chloride or the syrup of the iodide may be given if the digestion be good. 
 In many cases arsenic renders good service. It is best administered in the 
 form of liquor potassii arsenitis (Fowler's solution), beginning at the age of 
 five years with 1 drop in water three times a day, and increasing gradually to 
 4 or 6 drops. On the supervention of toxic symptoms the drug should be dis- 
 continued for a time. 
 
 Iodide of potassium is lauded as possessing some special beneficial action in 
 asthma. If given to the point of tolerance and continued for a long period of 
 time, it often yields good results. In some cases, however, it utterly fails. 
 
 61 
 
962 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Quinine and strychnine have their respective advocates. The former will prove 
 valuable where there is a malarial complication. In small doses they are both 
 tonics. 
 
 Change of climate or locality will relieve some patients. Asthma is such a 
 capricious malady that it would be next to impossible to select any particular 
 locality and guarantee immunity from the attacks. Some city patients are 
 benefited by removal to the country, those living in the country by going to 
 the city, dwellers at the sea-coast by a change to the interior, and those living 
 inland by a residence at the sea-board. The fact of the matter is, each patient 
 must select his own climate. 
 
FIBROID PHTHISIS. 
 
 By FREDERICK C. SHATTUCK, M. D., 
 
 Boston. 
 
 This affection — otherwise known as chronic pneumonia, interstitial pneu- 
 monia, cirrhosis of the lung, or fibroid induration of the lung — is a process 
 not uniform in origin, generally unilateral, very chronic in course, resulting 
 in the substitution of connective for pulmonary tissue in a more or less con- 
 siderable area, usually associated with bronchial dilatation, and often, at some 
 period in the case, with tuberculosis. 
 
 Etiology. — This condition — for, in the great majority of cases at least, it 
 is a condition rather than a disease — is not very common at the best, and is, 
 in its fully-developed form, very rare in children, though its origin may date 
 back to childhood. Of 30 fatal cases with autopsy collected by Bastian in 
 Reynolds's System of Medicine, only 2 were under fifteen years of age, 3 from 
 fifteen to twenty, while more than one-half of the cases succumbed between 
 twenty and forty. The age of both children was seven years, and one of 
 them was reported by Sir D. Corrigan in his original paper on " Cirrhosis 
 of the Lung," published in 1838 in the Dublin Journal. In Wilson Fox's 
 great posthumous work on " Diseases of the Lung and Pleura " will be found 
 references to other cases in children. 
 
 That the affection should be rare in children is not surprising, inasmuch as 
 inflammation, like nutrition, in the young is a more active process than in 
 adults, and is less likely to lead to the formation of organizable products than 
 in later life. The power of complete repair is also greater in children, and in 
 them, if recovery takes place, it is less likely to leave permanent or progressive 
 changes behind. The literature of the subject would seem to show that in 
 children pneumonia and broncho-pneumonia are the affections which are most 
 apt to be followed by fibroid changes in the lung. Of the two, the latter is 
 probably the more frequent antecedent. That simple bronchitis may pave the 
 way to connective-tissue growth seems probable. It is certain that pleurisy 
 may do so, though this origin is probably more frequent in adults. The thick 
 false membranes may then serve as the starting-point for a growth of connective 
 tissue into the contracted lung itself, while bronchiectasis gradually comes 
 about as a result of frequent cough, and also as a means of equalization of the 
 atmospheric pressure within and without the chest. Other things being equal, 
 the older the person the more rigid the chest-wall and the less can it collapse. 
 The space which the firm adhesions prevent the lung from reoccupying must 
 thus be filled in a measure by dilatation of the bronchi, of some of the air- 
 vesicles, and even of the blood-vessels and lymphatics. 
 
 There is another sequence of events which is certainly more common in 
 adults, if indeed it ever occurs in children. The arrest of an ordinary ulcer- 
 ating pulmonary tuberculosis, with the formation of abundant connective-tissue 
 growth in which the bacilli are, as it were, bottled up, is here alluded to. The 
 writer has seen some conspicuous examples of this. The report of one of them, 
 
 963 
 
964 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 with autopsy, may be found in the Boston Medical and Surgical Journal, 
 1880. 
 
 The fibroid phthisis which results from irritation by particles of dust, as 
 in miners, grinders, painters, and the like, is not apt to be encountered in 
 children, and is a bilateral affection. 
 
 The view is expressed by Strimipell, Osier, and other recent writers that 
 most cases of fibroid phthisis either are or have been tuberculous. That this 
 is true of some cases there can be no question ; but further investigation is 
 needed to enable us to determine how large the proportion is, or whether, 
 indeed, such destructive processes ever go on without the aid of the tubercular 
 bacillus. That many of the inflammations of serous membranes, including 
 the pleura, formerly believed to be simple or due to exposure to cold, are really 
 tubercular, seems now to be well established. And the origin of some of these 
 cases of fibroid phthisis in pleurisy has been already alluded to. The dis- 
 covery of the true criterion of tuberculosis is still too recent to permit the 
 accumulation of sufficient positive evidence to establish the relation of fibroid 
 phthisis and pulmonary tuberculosis. In the older reports, if no miliary 
 tubercles or caseous masses were found after careful search, the case was classed as 
 non-tubercular. I have not met with any reports of thorough microscopic ex- 
 amination of these cases of late years. But we have learned since Koch's 
 great discovery more than we knew before as to the multiplicity of the lesions 
 following the local and general action of his bacillus, and also more as to their 
 frequent self-limitation, and, indeed, curability. 
 
 Pathological Anatomy. — The striking morbid feature of this affection 
 is the presence of connective tissue in the lung with corresponding destruction 
 of the true parenchyma. The changes are generally unilateral, and may be so 
 even when the primary process — broncho-pneumonia, for instance — is essen- 
 tially bilateral. The lower are more frequently affected than the upper lobes. 
 Bands of fibrous tissue may traverse the affected part, and these bands are, 
 for obvious reasons, less likely to be pigmented in the young than in adults. Or 
 the distribution of the connective tissue may be more uniform, producing an 
 appearance which has been compared to that of the uterus after delivery. Peri- 
 bronchitic thickening is practically always present to a greater or less degree, 
 as is also bronchial dilatation, resulting in the formation of cavities of greater 
 or less size. 
 
 Another mode in which cavities are formed or increased in size is through 
 ulceration, the accompaniment of the growth of tubercular bacilli or the 
 result of the irritation of retained and decomposing secretion, or both at once. 
 Miliary tubercles, caseous masses, or calcified deposits may be seen by the 
 naked eye. The microscope may reveal tubercular bacilli in active growth in 
 the secretion or the tissues, or safely imprisoned within the connective tissue. 
 Here and there within the diseased portions there may be macroscopic or mi- 
 croscopic islets of relatively normal or of emphysematous lung-tissue. The 
 microscope may also demonstrate within the indurated lung or the thickened 
 pleura dilated blood- and lymphatic- vessels. 
 
 The affected lung may be moderately or very greatly diminished in size, 
 with corresponding contraction of the chest, approximation of the ribs, droop 
 of the shoulder, and twist of the vertebral column. 
 
 The pleura is rarely if ever spared ; it may contain an encapsulated collection 
 of fluid, more probably sero-fibrinous. Adhesions vary considerably in thick- 
 ness and density ; they may be cartilaginous, and so firm that the lung must be 
 cut out of the chest at the autopsy. It seems reasonable to suppose that when 
 the process started in the pleura the thickening of that membrane is more con- 
 
FIBROID PHTHISIS. 965 
 
 spicuous than when it started in the lung itself and secondarily affected the 
 pleura, as does every inflammatory process of the lung or of the chest-wall 
 which approaches one or the other layer of the serous cavity. 
 
 The sound lung, or sound portions of both, is the seat of compensatory 
 hypertrophy ; perhaps of emphysema, either confined to the edge or more 
 widely distributed. Adhesive pericarditis is common as a result of extension 
 of inflammation from the pleura, especially when the left lower lobe is the seat 
 of the disease. The heart itself is often more or less drawn out of place, and 
 the right chambers are apt to be dilated and hypertrophied in extensive disease 
 of long standing, in consequence of the augmented internal pressure to which 
 the cavities are subjected by reason of the increased resistance in the pulmo- 
 nary circulation. If compensation has failed in the right ventricle, the common 
 secondary results of such failure are shown by general and visceral venous 
 stasis. 
 
 Symptoms and Course. — Cough and expectoration are practically con- 
 stant, though they vary widely in degree and severity in different cases or in 
 the same case at different times. The character of the expectoration is not 
 distinctive. If notable cavities of bronchiectatic or other origin are present, 
 their existence may be suggested by a more or less periodically profuse ex- 
 pectoration, by profuse expectoration in certain positions of the body, or by 
 the separation of the sputum on standing into an upper frothy, a middle 
 serous, and a lower layer of purulent masses. The presence of tubercle bacilli 
 is suggestive of a recent infection from without or of a fresh outbreak from 
 within. If ulceration is going on, elastic fibres may be found. Haemoptysis 
 is extremely common, is often repeated, and usually moderate in amount. It 
 may, however, as in ordinary phthisis, arise from a good-sized vessel travers- 
 ing the wall of a cavity, and then be so profuse as to be the immediate cause 
 of death. Dyspnoea may be absent while the patient is at rest, but very 
 marked after but slight exertion. 
 
 Constant fever, with its attendant emaciation and constitutional disturbance, 
 is absent. The process in itself is not a febrile one, and a rise of temperature 
 which may be found at any time is attributable to some secondary or compli- 
 cating affection. General nutrition may be excellent, and the fat layer notable. 
 Clubbing of the tips of the fingers and toes and incurvation of the nails may 
 be more marked in this than in any other condition, save, perhaps, congenital 
 heart defects; this is an infallible indication of chronicity. In a word, the 
 appearance of the patient may be, in the main, that of one in perfect health, 
 from which a wide deviation is found to exist when the clothing is removed 
 from the chest and a physical examination is made. 
 
 It does not seem advisable under the circumstances to enter here into a 
 detailed account of the physical signs, which are so similar to those of a case 
 of chronic tuberculosis. I shall therefore briefly touch only on those which are 
 most striking and distinctive. 
 
 Inspection is apt to show a disparity in size and mobility between the sides 
 of the chest ; unilateral shrinkage, the droop of a shoulder, and curvature 
 of the spine reaching their highest expression in those cases originating in or 
 complicated by extensive pleural changes. Palpation, auscultation, and per- 
 cussion reveal the presence of consolidated lung containing secretion, perhaps 
 of cavity formation. As contrasted with ordinary phthisis, these changes are 
 more apt to be found at the base than at the apex. Cardiac pulsation may be 
 visible over unusually large or in unwonted areas, according as retraction of 
 the lung away from the heart, or adhesions to the pericardium and retraction of 
 the heart itself, or both together, may happen to have operated in the case in 
 
966 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 hand. Sometimes, however, the heart is unduly overlapped by the hypertro- 
 phied healthy lung, and its pulsations may then be obscured. Although the 
 right heart is apt to be, often markedly, hypertrophied and dilated, the fact 
 that it is so must be often a matter rather of inference than of direct signs fur- 
 nished by the examination of the organ itself. The explanation of this fact 
 lies in the altered mutual relations of the lungs and heart under the influence 
 of the disturbing factors mentioned above. Cardiac murmurs bear no con- 
 stant relation to the condition. 
 
 If, for any cause, the compensatory hypertrophy of the right ventricle fails, 
 the characteristic evidences of stasis in the pulmonary and systemic veins are 
 superadded to those of the underlying condition — cyanosis, distention or pul- 
 sation of the jugulars, anasarca, ascites, enlarged or tender liver, the urine of 
 passive renal congestion, and the like. 
 
 The course of the affection is essentially chronic, and, on the whole, pro- 
 gressive, though apparently stationary periods, perhaps of considerable duration, 
 seem to occur. Intercurrent attacks of bronchitis are not rare, and certainly 
 do nothing to retard progress. Death may occur from failure of the cardiac 
 compensation, haemoptysis, exhaustion, or from intercurrent disease. 
 
 Diagnosis. — This can seldom present any great difficulties, provided that a 
 good history can be obtained and a careful physical examination be made. The 
 combination of a history of chronic cough and expectoration, with repeated 
 haemoptysis ; the physical signs of pronounced lung destruction, usually unila- 
 teral, often with cavity -formation ; and hypertrophied and dilated right ventricle, 
 with the maintenance of a surprisingly good condition of general nutrition, 
 presents a picture which is perfectly characteristic. The very small respiratory 
 margin is also noteworthy. Chronic pleurisy with great thickening of the mem- 
 brane and contraction of the side is perhaps more liable to give rise to error 
 than any other affection. The history of the case, but, above all, the signs of 
 pronounced pulmonary changes, and the occurrence of haemoptysis, are the 
 chief aids in the differentiation. The good general nutrition, the absence of 
 fever, and the duration and mode of onset of the trouble are sufficient to 
 exclude ordinary pulmonary tuberculosis. The thoracic physical signs of 
 cancer of the lung or pleura might be similar ; but the course and duration are 
 quite different. Congenital syphilis of the lung is of pathological rather than 
 clinical interest. Acquired syphilis of the lung is very rare in children : it 
 is also rare in adults, but resembles clinically ordinary phthisis more than the 
 fibroid variety, which, moreover, is not amenable to mercury and the iodides. 
 
 Prognosis. — There can be no question that the expectation of life is cur- 
 tailed by this condition. Probably Dr. Oliver Wendell Holmes did not have 
 it in mind when he said that the way to ensure length of days is to acquire an 
 incurable disease. And yet its owners may live many, many years. The 
 danger is rather from intercurrent disease than from the fibroid induration of the 
 lung itself. If the patient's circumstances permit, he will naturally lead a 
 more careful life than if he were sound in all parts. In a case of the writer's, 
 proving fatal at twenty-eight years of age, the onset dated back presumably 
 to measles at the age of seven, and yet the patient worked as a shoeblack in a 
 damp, narrow, and sunless alley in all sorts of weather until shortly before his 
 death from haemoptysis. Had he been able to take care of himself, it is proba- 
 ble that he might have lived many years longer. 
 
 Treatment. — It is obvious enough that little can be done to repair 
 damage already done. Therapeutic effects must, therefore, in the main, be 
 directed to staying the progress of the affection as far as possible, and to ward- 
 ing off intercurrent diseases, which may either promote the extension of the 
 
FIBROID PHTHISIS. 967 
 
 fibroid growth or carry off the patient. Hygienic measures are thus vastly 
 more important than medicinal agents. The limitation of the respiratory 
 capacity is such in most cases as to preclude residence in high altitudes. 
 Climatic change has for its object an abundant supply of fresh, pure air with 
 lessened risks of colds and bronchitis. The amount and character of exercise 
 are to be determined by the peculiarities of each case. Tonics and stimulants 
 are to be given if the appetite and digestion seem to require them. Expecto- 
 rants may be needed from time to time. Narcotics and hypnotics, except 
 occasionally and in the last stages, are to be avoided as far as is possible. 
 Iodide of potassium may render good service in promoting recovery from bron- 
 chitis, but cannot be expected to have much influence on the connective tissue 
 growth. Failure of compensatory hypertrophy of the right heart calls for 
 cardiac tonics, as when it occurs under other circumstances. 
 
 In a word, it should be our aim to keep our patient in the highest possible 
 condition of health, treating him rather than his disease. 
 
PART IX. 
 
 DISEASES OF THE HEART. 
 
 CONGENITAL AFFECTIONS OF THE HEART. 
 
 By BARTON COOKE HIRST, M. D., 
 
 Philadelphia. 
 
 Cardiac anomalies of pre-natal origin, like other developmental abnormal- 
 ities, cannot be easily classified in a thoroughly satisfactory manner. Osier 
 gives an etiological division into (1) those affections due to defective develop- 
 ment, (2) those resulting from intra-uterine endocarditis ; and (3) those that are 
 caused by a combination of both causes. The same author employs, however, 
 the following general classification : I. Conditions in which structures normal 
 to the foetus persist during extra-uterine life, such as open foramen ovale, per- 
 sistency of the Eustachian valve, and patency of the ductus arteriosus. II. 
 True anomalies of development, as absence or imperfection of the ventricular 
 septum, absence of the auricular septum, anomalous division of the truncus 
 arteriosus, transposition of the great vessels, and numerical variations in the 
 valve segments. III. Conditions caused wholly or in part by endocarditis, as 
 extreme stenosis of the cardiac orifices, puckering, thickening, and adhesion of 
 the valve segments. 
 
 The writer will employ Baginsky's classification, somewhat modified, as 
 follows : 
 
 1. Patency of the foramen ovale. 
 
 2. Defect of the ventricular septum. 
 
 3. Anomalies of the right and left auriculo-ventricular orifices. 
 
 4. Stenosis and atresia of the pulmonary artery. 
 
 5. Persistence of the ductus arteriosus. 
 
 6. Stenosis of the aorta. 
 
 7. Transposition of the arterial trunks. 
 
 8. Numerical anomalies of the valve segments. 
 
 9. Ectopia cordis. 
 
 1. Patency of the Foramen Ovale. — Much attention — more than it 
 deserves — has been bestowed upon this affection of the heart. Of itself, it does 
 not entail, as a rule, any disadvantage upon the individual. A patent foramen 
 ovale has been discovered in many persons dying of a variety of diseases, in 
 whom, during life, there was no evidence of heart embarrassment. Unless 
 there be associated anomalies, congenital or acquired, increasing the pressure 
 in the right auricle, the blood will not flow in any quantity from right to left 
 auricle, even though the foramen be open, and consequently the arterial blood 
 
 968 
 
VONGENITAL AFFECTIONS OF THE HEART. 969 
 
 will not be vitiated to any appreciable extent. If pressure be increased in the 
 ricrht auricle by a contracted auriculo-ventricular septum or by an obstacle to 
 the escape of blood from the right ventricle, then the stream may be deflected 
 into an abnormal course, the heart be embarrassed by extra work, and the 
 blood in the aorta become mixed. The child will be cyanotic, and its life will 
 very likely be cut short. 
 
 If the size of the patent foramen is increased by a defect in the anterior 
 muscular septum between the auricles, as well as in the membranous septum, the 
 anomaly is a very serious one. I have had an opportunity to make a post- 
 mortem examination in two such cases. In both the children lived but a few 
 hours after birth, and they were intensely blue. In one the cyanosis reached 
 a grade I hu,ve never witnessed before or since. 
 
 The cause of a patent foramen ovale is either an absence or defective 
 development of the membrana fossae ovalis or a defective institution of respira- 
 tion. Normally, the opening is closed by the increased blood-supply to the 
 auricles incident to the beginning of respiration. Should the latter act be 
 imperfectly performed, as in atelectasis, the mechanical force to close the fora- 
 men by pressure upon its valve — with the subsequent adhesion of its free edges 
 to the rim of the oval fossa — is lacking. More frequently, however, in infants 
 that survive birth the membrana fossae ovalis is lacking or ill developed, and 
 the foramen consequently cannot be closed. It is claimed by Sansom that 
 patency of the foramen can be diagnosticated during life by cyanosis without 
 heart murmur, or by cyanosis with systolic and presystolic murmurs over the 
 cartilages of the third and fourth ribs. But if one remembers that there are 
 many other causes of cyanosis in the new-born infant besides heart defects, and 
 that an open foramen uncomplicated by other anomalies may very likely present 
 no symptoms at all, the difficulty of making this diagnosis may be appreciated. 
 As interesting anatomical conditions under this head, but without clinical sig- 
 nificance, are to be noted perforations of the valve of the foramen ovale and 
 small slit-like openings under the valve where it has not adhered to the rim 
 of the opening. The last are very common. 
 
 2. Defect of the Ventricular Septum. — This anomaly is most fre- 
 quently associated with other abnormalities of the heart, as stenosed orifices 
 and vessels, or defect of the auricular septum. It is not at all uncommon in its 
 lesser degrees, but total defect is rare, and, when present, is associated almost 
 always with defect of the auricular septum, constituting the so-called reptilian 
 heart or cor biloculare. The defect is most frequently found in the anterior 
 muscular portion of the septum, as shown by Rokitansky, and not in the median 
 membranous portion, where it formerly was believed to be most frequently 
 situated, but is in reality very rarely found. The effect of an unnatural open- 
 ing between the ventricles is a propulsion of some of the blood from the left 
 ventricle into the right during the former's contraction. Should the latter suf- 
 ficiently hypertrophy to dispose of the extra amount of blood thrown into it, 
 there need not necessarily be striking symptoms of heart defect. But should 
 the hypertrophy not be sufficient, there results an embarrassed respiration and 
 an obstructed venous circulation, with cyanosis and transudation of serum into 
 connective tissue and body-cavities. As Baginsky points out, the cyanosis is 
 due to this cause, and not to the mixing of arterial and venous blood. 
 
 The diagnosis of defect in the ventricular septum can be made, it is asserted 
 by Roger and Sansom, by a loud systolic murmur over the precordial region 
 and between the shoulders, not transmitted to the vessels. The existence of a 
 ventricular septum defect is unfavorable to the life of the infant, mainly on 
 account of the associated anomalies. Sansom, however, records a case in a 
 
970 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 child that lived eight and a half years, and Johnstone another that lived seven 
 years. 
 
 3. Anomalies of the Right and Left Auriculo-ventricular Ori- 
 fices. — These consist in stenosis and valve defects, mainly, the result of an 
 intra-uterine endocarditis of the right and left heart-cavities. Osier claims 
 that the endocarditis is secondary to developmental anomalies and is almost 
 always of the chronic, sclerotic type, and very rarely of the verrucose or warty 
 variety. He describes a typical specimen as presenting thickened valve seg- 
 ments, which are shrunken and smooth. In the case of the auriculo-ventricular 
 valves the cusps become united and the attached chordae tendineae are thick- 
 ened and shortened. In the semilunar valves all trace of the segments usually 
 disappears, leaving a stiff, membranous diaphragm perforated by an oval or 
 rounded orifice. 
 
 Valve defects from endocarditis are more commonly found upon the right 
 than upon the left side. We shall first, therefore, glance at the anomalies of 
 the right auriculo-ventricular orifice. 
 
 There is usually a thickening of the tricuspid valve as well as of other 
 portions of the endocardium. The right ventricle is small. If the disease 
 leads, as is not very uncommon, to complete atresia of the orifice, the circula- 
 tion is only possible in a roundabout way, and then only when there is a defect 
 in the ventricular septum. The blood flows from the right to left auricle, and 
 from the left ventricle, in part, into the right, and so into the pulmonary artery. 
 The left ventricle, from the additional work thrown upon it, is dilated and 
 hypertrophied. In case of associated stenosis and insufficiency the right heart 
 is dilated and hypertrophied. Cardiac murmurs, systolic and diastolic, with a 
 thrill imparted to the thoracic wall, are loud and distinct, the heart's action is 
 labored, the cyanosis is marked, and passive congestion everywhere is pro- 
 nounced, leading on slight provocation to haemorrhages. 
 
 In addition to the abnormalities resulting from disease in the tricuspid 
 valves, developmental anomalies may be found, as an imperfect separation of 
 the cusps, so that there is a circular opening between auricle and ventricle, 
 with an annular diaphragm surrounding it. On the other hand, there may be 
 four cusps instead of three. 
 
 The most common cause of abnormality in the left auriculo-ventricular 
 orifice is a left-sided endocarditis. If stenosis of the orifice is well marked, 
 the blood in the distended left auricle flows back through the patent foramen 
 ovale into the right auricle, thence into the right ventricle, and so, by the 
 ductus arteriosus, into the aorta. The left ventricle, becoming functionally 
 more or less useless, undergoes atrophy, sometimes to a very marked degree. 
 When the child is born the determination of blood to the lungs, and the 
 increased amount flowing to the left auricle, embarrass the heart extremely. 
 Congestion of the lungs, extreme cyanosis, and an early death is the result. 
 As in the right orifice, there may be the developmental anomalies of imperfect 
 differentiation of the cusps or their division into three instead of two segments. 
 
 4. Stenosis and Atresia of the Pulmonary Artery. — Osier divides 
 the anomalies of the pulmonary orifice into stenosis, atresia of the orifice and 
 of the artery, and stenosis of the conus arteriosus. 
 
 Stenosis of the pulmonary artery is one of the commonest and most im- 
 portant congenital defects of the heart. A child may live some length of 
 time — may, in fact, reach adult life — with a serious narrowing of the pulmonary 
 orifice and with enormously dilated and hypertrophied heart-cavities and mus- 
 cles, without special symptoms until some extra strain is imposed upon the 
 heart, especially by congestion of the lungs, when sudden death is likely to 
 
CONGENITAL AFFECTIONS OF THE HEART. 971 
 
 occur. On the other hand, intense cyanosis and embarrassed respiration and 
 circulation may be manifested from the first, and the infant may live but a 
 few hours. The continued existence and development of the infant depend 
 upon the hypertrophy of the heart. If this be truly compensatory, the child 
 may thrive surprisingly well, even in grave cases. The prognosis as regards 
 duration of life is better than in any other form of congenital heart defect of 
 serious character. One individual reached the age of fifty-seven, and 16 per 
 cent., according to Assmus, survive the twentieth year. But the tenure of life 
 is always uncertain, for any sudden call upon the heart for extra work may 
 prove fatal. And these cases are particularly liable to have grafted on them, 
 at some time after birth, a fungous or infectious endocarditis that may be the 
 immediate cause of death. Moreover, individuals affected with a contracted 
 pulmonary orifice are peculiarly liable to tuberculous disease. 
 
 The cause of this anomaly is almost invariably an intra-uterine endocarditis, 
 but it may possibly be a developmental defect. The symptoms are cyanosis, 
 with signs of embarrassed circulation and respiration. The body warmth is 
 likely to be very imperfectly preserved. The slightest exposure of the 
 extremities leads to a remarkable frigidity, and the infant manifests signs 
 of discomfort or suffering in consequence, unless it is too apathetic to take note 
 of its surroundings. A mental and physical apathy very likely characterizes the 
 individual throughout life. 
 
 As already stated there may be no special symptoms, even in bad cases, or 
 at most, attacks of dyspnoea, lividity and heart palpitation from time to time. 
 
 On auscultation a loud systolic murmur is heard over the second and third 
 ribs to the left of the sternum, and at the apex, which is not transmitted to the 
 carotids. A thrill is imparted to the thoracic wall, the area of cardiac dulness 
 is much increased, and the anterior wall of the thorax is protruded in later life. 
 
 Complete atresia of the pulmonary orifice and of the artery, while rarer 
 than stenosis, is not very uncommon. The condition is due to defective 
 development, and not to disease. If the atresia is of early appearance in 
 embryonal life, there is a wide opening between the auricles and advanced 
 atrophy of the right ventricle. The blood flows from the right auricle to the 
 left auricle, and in part to the lungs by the medium of the ductus arteriosus. 
 If, as is likely, there is a defect in the ventricular septum, the aorta may arise 
 equally from both ventricles, or even belong more to the right ; in which case 
 the latter is much hypertrophied and dilated. The symptoms are more pro- 
 nounced and the prognosis much worse than in stenosis. There is intense 
 cyanosis, great dyspnoea, the child becomes very often convulsed, and dies 
 usually in a few hours. 
 
 Stenosis of the conus arteriosus forms, according to Assmus and Osier, a 
 considerable portion of the cases of obstruction at the pulmonary orifice. The 
 former collected 47 cases of the kind. The condition is due to faulty develop- 
 ment. By a constriction of the lower portion and dilatation above, a sort of 
 accessory auricle may be formed. There are almost always other defects of 
 development, as a defective ventricular septum. The symptoms are those of 
 stenosis of the pulmonary orifice. 
 
 5. Persistence of the Ductus Arteriosus. — By the fourteenth day, 
 or within the first four weeks at least, the ductus arteriosus is closed by an 
 overgrowth of the cells in its inner wall. Occasionally, in consequence of 
 puerperal infection of the new-born with infected thrombi, or on account of 
 defects in cardiac development, or as a result of the imperfect institution of 
 respiration and an anomalous pulmonary circulation, the duct remains patent. 
 It has been my experience, in making post-mortem investigations upon the 
 
972 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 bodies of young infants, that a slight degree of patency is by no means 
 uncommon during the first year of life. It is frequently easy to pass a small 
 probe through the duct or to squeeze a drop or two of blood through, but in 
 such cases the duct, of course, plays no part of practical importance in con- 
 veying the main-stream of the blood. The clinical symptoms of an efficient 
 patency of the ductus arteriosus are rapid hypertrophy and dilatation of the 
 right ventricle, dilatation of the pulmonary artery, increase in area of cardiac 
 dulness, long-continued systolic murmurs, thrill of the anterior chest-wall, 
 protrusion of the upper part of the sternum, attacks of dyspnoea, cyanosis or, 
 perhaps, an almost cadaveric hue, a disposition to bronchitis and congestion of 
 the lungs, and anasarca. Atheromatous processes in the pulmonary artery are 
 common in individuals 'who live some years. 
 
 The prognosis is not favorable. Of sixteen cases 7 died in childhood, 5 
 lived from nineteen to thirty-four years, and 4 to between forty and fifty. 
 
 6. Stenosis of the Aorta. — Obstruction at the aortic orifice is the result 
 of developmental defect or of endocarditis, as in the case of obstruction at the 
 pulmonary orifice. Stenosis is rarer, while atresia is relatively more common, at 
 the aortic than at the pulmonary orifice. As in the right side of the heart, 
 the conus arteriosus may be narrowed, but the condition is rare. Stenosis of 
 the aortic orifice is a much more serious condition than narrowing of the pul- 
 monary orifice. Of 33 cases, only 1 survived the first month. Stenosis of 
 the conus arteriosus, on the other hand, does not seem so serious, for the 
 majority of cases have been observed in adults. The aorta itself may be 
 narrowed at the insertion of the ductus arteriosus. In this case the blood cur- 
 rent finds its way to the lower portion of the trunk and the lower extremities 
 by a roundabout course through the dilated subclavian arteries and by their 
 branches anastomosing with the intercostal and epigastric arteries. The 
 arteries of the upper portion of the body may be demonstrated to be much 
 larger and fuller than in the lower, as in a comparison between the radial and 
 crural pulses. The prognosis of this developmental defect is good. The indi- 
 vidual may live to advanced old age. 
 
 7. Transposition of the Arterial Trunks. — This anomaly is not of 
 great interest to the practitioner, for it is usually associated with other grave 
 developmental defects that make extra-uterine life unlikely, and, of itself, it 
 leads to an early death. The vitiated blood flowing from the right auricle into 
 the right ventricle is distributed by the aorta springing from this ventricle again 
 to the body, while the aerated blood from the left auricle is conveyed back 
 again to the lungs. Continued existence at all is usually explained by an open 
 foramen ovale or by a communication between the pulmonary veins and the 
 right side of the heart. Osier describes an example in an eight-months' foetus, 
 in which there was a partial transposition, the right ventricle giving off a small 
 branch to the lungs, and the major part of its stream into the thoracic aorta, 
 while from the left side sprang an arterial trunk that divided into the innomi- 
 nate and left carotid arteries. Children thus affected are deeply cyanosed, have 
 dyspnoea, are prone to haemorrhages and rapid cooling of the skin and the ex- 
 tremities. They are apathetic and die early. Twenty out of twenty-five cases 
 did not survive the first year. A number of cases has been collected by 
 Rauchfuss and Yon Etlinger. 
 
 8. Numerical Anomalies or the Valve Segments. — The valve seg- 
 ments may be diminished in number by failure of development or as a result 
 of endocarditis. Of itself this anomaly has little importance clinically, but it 
 is often associated with other defects, as" in the ventricular septum, and is com- 
 monly followed by sclerotic changes in the valves. Supernumerary valves are 
 
CONGENITAL AFFECTIONS OF THE HEART. 973 
 
 not uncommon. As many as five semilunar valves have been observed. This 
 is nor likely to be accompanied by other abnormalities of the heart, and may 
 have no clinical significance. 
 
 9. Ectopia cordis is the result usually of fissured sternum and thorax, and 
 is commonly associated with a congenital fissure of the whole anterior body- 
 wall. The heart may also be displaced upward into the neck or downward 
 into the abdominal cavity. Other rare congenital malformations of the heart 
 are found in acardia. ill-developed heart, double heart, bifid apex, and absence 
 of the pericardium. 
 
 Symptoms. — The symptoms of all congenital heart defects have a certain 
 general resemblance, as has been noted in their description under the appro- 
 priate divisions. Cyanosis is common, more or less, to them all. Indeed this 
 term was long regarded as practically synonymous with congenital anomalies of 
 the heart, but in the writer's experience the following conditions, arranged in 
 the order of their frequency, have all been responsible for it : Pneumonia 
 (often syphilitic) ; premature birth ; asphyxia ; atelectasis ; degeneration of the 
 blood ; malformation of heart and blood-vessels ; interference with the nerves 
 of respiration ; malformations of respiratory tract ; congenital pleurisy, and 
 partial occlusion of the trachea. 
 
 Treatment. — The treatment of congenital heart defects comprises hygienic 
 management, protection from cold and physical exertion, and the administration 
 of the heart tonics to tide over attacks of threatened cardiac failure and to help 
 the development of a compensatory hypertrophy. Medicinal treatment alone, 
 however, is of little avail, except to meet temporary indications. If compen- 
 satory hypertrophy is not soon established to a satisfactory degree, the nrospect 
 of life is bad. 
 
ORGANIC DISEASES OF THE HEART. 
 
 By FLOYD M. CRANDALL, M. D., 
 
 New York. 
 
 Diseases of the Heart during childhood present, in their general out- 
 lines, conditions very similar to those seen in the adult. In their details many 
 and important differences occur. In the following pages these differences 
 receive the chief attention, it being taken for granted that the reader is con- 
 versant with the diseases of the adult heart and their methods of detection. 
 The following peculiarities are observed in the normal heart: 
 
 I. The apex lies higher in the chest and more to the left than in the adult, 
 being outside the nipple line. 
 
 II. The apex-beat in the infant is usually difficult of detection ; in the child 
 it is more clearly visible, and can be detected by touch more readily than in 
 the adult. 
 
 III. The area of dulness is comparatively large, so that the normal heart 
 may, without caution, be considered hypertrophied. 
 
 IV. Murmurs are heard over a comparatively wide area, being frequently 
 audible over the entire chest. 
 
 V. The rate may be increased and the rhythm disturbed by slight causes, 
 so that rapidity and irregularity are of but little importance. 
 
 VI. In rachitic children, owing to deformity of the chest, the apex may 
 appear in an abnormal position. 
 
 VII. Prominence of the prsecordia is sometimes marked. 
 
 Cardiac disease during early life is also modified by the fact that the heart 
 is undergoing numerous changes in growth and development. These are not 
 constant, but occur chiefly at certain periods. The relative weight of the heart 
 is greatest at birth, the right side predominating slightly over the left. During 
 the first seven years there is an increase in volume of about 80 per cent. 
 Between seven and fourteen the increase in actual volume is barely 10 per 
 cent. There is then a very rapid increase of almost 100 per cent. These 
 changes necessarily modify to a marked degree any diseased condition which 
 may be present, and are of especial importance as regards prognosis and 
 treatment. 
 
 I. Pericarditis. 
 
 Inflammation of the pericardium during childhood presents but few pecu- 
 liarities pathologically. At this period of life inflammation of the serous mem- 
 branes is more frequently marked by effusion than in the adult, and the peri- 
 cardium presents no exception to the rule. Fluid forms with great rapidity, 
 and is prone to be purulent. Endocarditis is a common accompaniment of 
 pericarditis, and the walls of the heart are always more or less weakened. Not 
 infrequently pericardium, endocardium, and muscle are all involved. Sturges, 
 in extensive post-mortem observations, invariably found acute rheumatic endo- 
 
 974 
 
DISEASES OF THE HEART. 975 
 
 carditis accompanied by more or less pericardial inflammation or adhesion, and 
 believes that endopericarditis is the most common cardiac affection of early 
 life. It is quite possible, however, that conditions present in cases so grave as 
 to permit of post-mortem observation may not be as frequently present in the 
 less serious cases which survive. 
 
 Etiology. — Pericarditis is seldom a primary affection. It may result from 
 injury or the extension of inflammation from a neighboring organ, but more 
 commonly occurs in the course of rheumatism or one of the infectious diseases. 
 "While rheumatism causes by far the greater number of cases, rheumatic peri- 
 carditis is not as common proportionately as in adult life. Scarlet fever, 
 empyema, and pneumonia are frequent etiological factors. In young infants 
 purulent pericarditis sometimes occurs as a result of septicemic conditions at 
 the umbilicus. Kheumatic pericarditis develops early, and sometimes precedes 
 the articular symptoms. In scarlet fever the pericardial inflammation com- 
 monly develops during the second or third week. 
 
 Symptoms. — The subjective symptoms of pericarditis are usually obscure, 
 and vary with the different stages of the disease. The early stage is frequently 
 insidious and passes unrecognized. The most frequent symptoms are pain and 
 palpitation. Pain may be confined to the precordial region, or may be reflected 
 into the shoulder or referred to the region of the stomach. It varies in inten- 
 sity from a simple uneasiness to a sharp, lancinating pain. The patient some- 
 times assumes a characteristic position, with the head elevated and the body 
 thrown somewhat toward the left. The trunk is held rigidly quiet, while the 
 legs are moved freely. The pulse is full, and there may be slight fever and a 
 hacking cough. 
 
 When effusion occurs the pain gives place to a sense of oppression. Res- 
 piration becomes labored, and the countenance assumes an anxious expression 
 or a look of actual suffering. The face is livid or ashy pale. Dyspnoea is 
 marked when the head is lowered. The pulse is weak, irregular, and inter- 
 mitting. In fatal cases, as the effusion increases, attacks of syncope occur, 
 hiccough develops, and delirium appears, followed by coma and death. In less 
 severe cases precordial heaviness and dyspnoea may be the only symptoms. 
 
 Physical Signs. — In the early stages the heart's action is usually forcible, 
 but irritable, and often irregular. Percussion shows nothing except, perhaps, 
 tenderness. A friction-sound is heard upon auscultation, the point of greatest 
 intensity being, as a rule, under the fourth rib, just at the left of the sternum. 
 This point varies with the position of the patient and with full inspiration. 
 The sound is superficial, and has but a slight area of diffusion. It is frequently 
 double, and usually creaking or rubbing in character, but may be crackling or 
 even blowing. It sometimes so closely simulates the mitral regurgitant mur- 
 mur as to be indistinguishable from it. Friction-sounds are more frequently 
 absent in children than in adults, and rarely, when present, remain more than 
 one or two days. The early detection of pericarditis in children is often one 
 of the most difficult problems in the domain of physical diagnosis. 
 
 In the stage of effusion the difficulties in diagnosis are but slightly dimin- 
 ished. Owing to the thinness and yielding character of the chest-wall both 
 the apex-beat and the normal heart-sounds may be readily detected when con- 
 siderable fluid is present. In some instances the pulse is full and fairly strong, 
 while the apex-beat is feeble or imperceptible. Occasionally an undulating 
 impulse may be felt under the palm when the actual point of impact cannot be 
 determined. Prominence of the precordia is sometimes extreme. The area 
 of percussion dulness is enlarged, but it is impossible to make definite state- 
 ments as to its exact shape and extent. It is modified by the shape of the 
 
976 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 chest, by pleuritic adhesions, and by pulmonary consolidation. If no adhesion 
 or other lesion be present, the area of dulness assumes a somewhat pyramidal 
 shape, being broad laterally at the lower portion and extending well up to the 
 first rib. There is danger of mistaking an extremely dilated heart with feeble 
 impulse for a pericardial effusion. Rotch, who has made a most careful series 
 of observations upon the subject, calls attention to the fifth right interspace as 
 a region of great importance in deciding between these two conditions. While 
 with a dilated heart partial dulness may extend to the right of the sternum in 
 the second or third interspace, it rarely appears in the fifth, and absolute dul- 
 ness never. Even a small amount of effusion, on the other hand, finds its way 
 into the fifth interspace, causing absolute dulness. Upon the left of the 
 sternum the area of dulness in the two conditions is almost identical. 
 
 In the late stages, when recovery takes place, there are no physical signs 
 by which pericardial adhesions may be positively detected. Intermittent or 
 disturbed cardiac action following a pericarditis without evidence of an endo- 
 cardial lesion offers strong presumption that such adhesions exist. According 
 to Sturges, a rubbing exocardial sound does not preclude the possibility of 
 pericardial adhesion. 
 
 Prognosis. — In infancy pericarditis is a serious and usually fatal disease. 
 During childhood the tendency is to recovery. Not infrequently the course is 
 rapid, complete resolution taking place within ten days. In other cases, while 
 ultimate recovery is complete, it is long delayed. In still others adhesions 
 remain which seriously cripple the heart. When the formation of fluid is 
 rapid, embarrassment of the heart's action becomes alarming and sudden death 
 may occur. Myocarditis is a frequent and serious source of danger. The 
 longer the effusion is present the greater this danger becomes. The dilatation 
 resulting from myocarditis is sometimes extreme, but if the child is in fair 
 general condition hypertrophy follows, and is usually fully compensatory. 
 
 Treatment. — Any constitutional condition to which pericarditis may be 
 secondary should be brought under control as quickly as possible. Pain and 
 cardiac irritability should be at once relieved. For this purpose opium stands 
 without a rival, and is the most important agent in the treatment of pericarditis. 
 Sufficient should be given to relieve pain and maintain a mild continuous effect 
 through the early stages. Though it may be administered more freely than in 
 endocarditis, the condition of narcotism should never be induced. Stimulants 
 are indicated when the pulse becomes feeble and weak. In attacks of syncope 
 quickly-acting stimulants like Hoffman's anodyne are demanded. Digitalis 
 aids materially in maintaining the integrity of the heart-muscle, and in most 
 cases is a drug of much value. Occasionally, when there are extensive 
 adhesions, it causes palpitation and increased irregularity, and must be discon- 
 tinued. 
 
 Locally, poultices or large hot anodyne applications are preferable to the 
 ice-water coil. Blisters should never be employed. Absorption is sometimes 
 hastened by mercurial ointment applied upon flannel over the praecordia. 
 
 Nutrition should be maintained at the highest possible point, but over- 
 loading of the stomach must be carefully guarded against. After the acute 
 stages tonics are usually indicated, for pericarditis is eminently a disease of the 
 weak, anaemic, and feeble. Absolute rest cannot be too strongly insisted upon. 
 Care in this direction should not be relaxed while the slightest evidence of 
 impaired cardiac action remains. In no other condition is weakening of the 
 heart-muscle so common. Weeks, or even months, must sometimes elapse 
 before active exercise can be safely permitted. 
 
 When the amount of fluid becomes so great as to seriously threaten life, 
 
DISEASES OF THE HEART. 977 
 
 paracentesis is demanded. Death, however, very rarely results from pressure. 
 Urgent symptoms are often transient, and disappear without mechanical inter- 
 ference. * Much has been said regarding the harmlessness of the operation, but 
 it is not without serious dangers. It should be resorted to, however, when the 
 fluid is found to be purulent or so excessive in quantity as to endanger life. 
 Dieulafoy's or Potain's aspirator should be employed with a Fitch needle, 
 which has a protector to be pushed over the point after it is introduced, thus 
 avoiding: the danger of puncturing the heart-wall. The fluid should be com- 
 pletely removed. The fifth intercostal space, just to the left of the sternum, 
 is the' point usually advised as the seat of puncture. Rotch, however, proposes 
 the fifth intercostal space of the right side as preferable, since it would here be 
 impossible to puncture a dilated heart — an accident which might occur on the 
 left side. 
 
 II. Acute Endocarditis. 
 
 Inflammation of the endocardium is a frequent disease of early life. 
 During foetal life the right side of the heart is usually involved, after birth the 
 left side. During childhood the serous membranes are especially sensitive, and 
 there is a marked tendency in the connective tissue to cell-proliferation. 
 Morbid changes are chiefly confined to the valves and chordae tendineae, but in 
 some instances the whole endocardium is implicated. As a rule, the fibrous 
 structure of the valves bears the brunt of the attack. The valves are simply 
 folds of serous membrane bound together by fibrous tissue. Inflammation is 
 attended by proliferation of cells within the endocardium, pushing it up into 
 papillary elevations, and also by proliferation of the fibrous tissue itself. This 
 latter change is the most characteristic and important process in endocardial 
 inflammation. The whole valve becomes thickened and stiff, and the chordae 
 tendineae are affected in a similar manner. Nodules are most numerous along 
 the edges of the valves, where they form rows of reddish semi-translucent 
 beads. As they lie directly in the blood-current, fibrin is gradually deposited, 
 forming the so-called vegetations. They may become so large as to cause 
 serious mechanical interference with valvular action, or portions may be 
 detached and swept into the circulation. Even when these vegetations are 
 quite numerous they may undergo resolution and disappear, but when marked 
 hyperplasia of connective tissue has occurred, the almost inevitable result is 
 contraction, with consequent puckering, thickening, and distortion of the 
 valves, shortening of the chordae, or narrowing of the valvular openings. 
 
 Etiology. — Sex cannot properly be called an etiological factor of endo- 
 carditis, although twice as many girls suffer from heart disease as boys. A 
 boy who has rheumatism is as liable to a cardiac complication as a girl, but 
 girls are more subject to rheumatism than boys. Of my own cases, 38 per 
 cent, were boys, 62 per cent, girls, the preponderance of girls being greatest 
 under eight years. 
 
 Age is a more important factor. Endocarditis occurs in infancy, and even 
 in intra-uterine life, but it is rare under five years. It is probably more com- 
 mon during the three years between eight and eleven than at any other similar 
 period of life. 
 
 Rheumatism is by far the most important exciting cause of endocardial 
 inflammation, but in children that disease is so uncertain in its manifestations 
 that it is readily overlooked. In the majority of cases it appears in a form 
 which in the adult would be designated as subacute. But the mildest and 
 most transient attacks are not infrequently accompanied by inflammation of 
 
 62 
 
978 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the endocardium, which would be overlooked without physical examination. 
 No attack of joint-pain in a child is too mild to preclude the possibility of an 
 accompanying endocarditis. I have seen it develop during the course of torti- 
 collis in a child of rheumatic parentage. Among 117 cases of cardiac disease, 
 I found rheumatism, either antecedent, concurrent, or subsequent, in 82 per 
 cent. A definite family history of rheumatism was obtained in 57 per cent., 
 excluding grandparents. Attention has been directed to the importance of 
 subcutaneous fibrous nodules in the diagnosis of rheumatism, and it is believed 
 that similar nodules form at the same time on the cardiac valves. While they 
 are strongly suggestive of endocarditis, they give no positive evidence of that 
 condition. I have seen a profuse crop of nodules develop without the slightest 
 evidence of cardiac disturbance. 
 
 While the intimate association of chorea and heart disease is well known, 
 the exact etiological relationship is still uncertain. Occasionally endocarditis 
 developing during a choreic attack disappears as the chorea subsides ; more 
 commonly it leaves a permanent lesion. In the great majority of cases the 
 murmur is not functional, but organic, and is due to well-defined pathological 
 changes in the valves. Thirty per cent, of my cases of cardiac disease suf- 
 fered at some period of their lives from chorea, but 24 per cent, gave also a 
 clear history of rheumatism. Although in the remaining cases no positive 
 history of rheumatism could be obtained, there is ground for belief that the 
 endocarditis of chorea is, in fact, rheumatic. 
 
 Scarlet fever is occasionally complicated by endocarditis. In rare 
 instances it appears early in the disease, but more commonly develops during 
 the stage of desquamation. It usually appears in patients showing evidence 
 of nephritis, and is probably due more to uraemia than to the poison of scarla- 
 tina. Diphtheria, measles, erysipelas, and septicaemia are occasionally com- 
 plicated by inflammation of the endocardium. 
 
 Symptoms. — Endocarditis is a very obscure disease. The symptoms are 
 few in number and occur in no fixed order. They may be wholly wanting, and 
 the disease may run its course without presenting any appreciable symptom. 
 The symptoms of the acute disorder during which it develops often mask or 
 wholly obscure those of the cardiac complication. When accompanying a 
 rheumatic attack there is frequently an increase in temperature, or slight fever 
 appears if none has previously been present. The child seems more ill than 
 the arthritis would account for. There may be a peculiar restless, anxious 
 expression, with a tendency to cyanosis. The heart's action is disturbed and 
 the pulse becomes very rapid The symptoms depend largely upon the amount 
 of myocarditis present. If the muscular tissue is much involved, palpitation, 
 precordial distress, cyanosis, and dyspnoea will be marked. In milder and 
 more common cases none of these symptoms are present to draw attention to 
 the heart. Anaemia is a very constant accompaniment of endocardial inflam- 
 mation, and develops rapidly. The appearance of subcutaneous fibrous 
 nodules should always lead to a physical examination of the heart. 
 
 The tendency to recurrence is a marked feature of endocarditis. An endo- 
 cardium that has once been inflamed is far more sensitive thereafter to irritating 
 blood-conditions. Fresh attacks are readily lighted up by slight causes. 
 
 The occurrence of an embolism first directs attention to the heart in some 
 cases. The spleen is the organ most frequently affected. The most distinctive 
 symptoms result from embolism of the brain, the middle cerebral artery of the 
 left side being commonly the seat of lesion, with resulting hemiplegia and 
 aphasia. Embolic pneumonia occurs in the child as in the adult. 
 
 Physical Signs. — The signs obtained by physical examination are the 
 
DISEASES OF THE HEART. 979 
 
 only means of positive diagnosis. An endocarditis may, in rare instances, be 
 present for several days, or even run its course, without developing a murmur. 
 Occasionally abnormal sounds, as roughness, muffling, or prolongation of the 
 first sound, precede an actual murmur. In most cases the murmur is heard 
 only at the apex. It is systolic, soft, and blowing, differing from the ordinary 
 mitral regurgitant in its limited area of conduction. It is more intense at the 
 apex, but it is not transmitted far to the right, and is rarely audible behind. 
 It usually appears early in an attack of rheumatism, and is organic. It some- 
 times disappears, leaving no valvular lesion. A similar murmur occasionally 
 appears late in the course of typhoid fever, and is probably due to muscular 
 insufficiency the result of anemia or myocarditis. The murmur of scarlatina, 
 chorea, and rheumatism is usually entirely diiferent in character. 
 
 Other sounds are heard at the apex much more frequently in children than 
 in adults. Of these reduplication of the second sound is most important. 
 Reduplication of the second sound at the base is frequently heard in Bright's 
 disease of the adult, but as heard at the apex in children it is probably due to 
 asynchronous action of the mitral and tricuspid valves, the result of stiffening 
 of the mitral. It is almost a certain forerunner of a mitral obstructive mur- 
 mur. Sometimes a soft blowing murmur is heard immediately after the second 
 portion of the double sound. This gradually increases in length and intensity, 
 and develops the well-known rumbling murmur of mitral stenosis. In very 
 rare instances an aortic murmur develops early in endocardial inflammation, 
 either alone or in connection with a mitral murmur. The same is also true 
 of tricuspid regurgitation. 
 
 When acute endocarditis is engrafted upon an old valvular lesion, its diag- 
 nosis is especially difficult. If the patient has been under observation and the 
 character of the murmurs is known, diagnosis is easy. Marked enlargement 
 of the heart is strong proof of an old lesion. Extreme subjective symptoms 
 of cardiac disease, especially oedema, are rarely seen in primary endocarditis, 
 but in chronic heart disease the symptoms are all aggravated by a fresh endo- 
 cardial attack. The character of the murmur may furnish some aid in diag- 
 nosis, but cannot be relied upon. A soft blowing murmur is usually recent ; 
 if harsh, musical, or rough, it is probably old. 
 
 Prognosis. — As endocarditis is not an idiopathic disease, the prognosis 
 depends largely upon the condition with which it is associated. A first attack 
 is rarely the direct cause of death. It is extremely variable in its course. It 
 may pass away, leaving no lesion or murmur, but more frequently a valvular 
 lesion is left behind. If the pulse becomes feeble, and the child loses strength 
 and grows rapidly anaemic, the prognosis is bad. It is bad if recurring attacks 
 of rheumatism appear or if fibrous nodules recur in successive crops. Endo- 
 carditis appearing during the course of a septic disease is usually ulcerative in 
 character, and the prognosis is extremely unfavorable. Early involvement of 
 the aortic valves is also unfavorable. It is not wise to give a too favorable 
 prognosis at first, especially as to duration, for exposure or lack of rest will 
 materially prolong an attack. Duration is more uncertain in children than in 
 adults. Loudness of the murmur is of but little importance, but the greater 
 the number of murmurs the more serious is the condition. The murmur 
 appearing during chorea occasionally disappears as the choreic movements sub- 
 side. This is sometimes apparent rather than real. After a time a murmur 
 which has almost disappeared may return and continue permanently — a result 
 that is probably due to the lighting up of a fresh valvulitis, consequent upon 
 the occurrence of a mild rheumatic or choreic attack. On the whole, the ulti- 
 mate prognosis is rather better in children than in adults. Tissue-growth is so 
 
980 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 rapid and compensation becomes so complete that an endocarditis of not excessive 
 severity may produce but little permanent injury. 
 
 Treatment. — The constitutional disease with which endocarditis is asso- 
 ciated should receive prompt attention. In the treatment of rheumatism it is 
 not sufficient to direct our efforts simply to the control of the arthritis and 
 relief of pain. The possibility of endocarditis must also be considered. The 
 ideal treatment is that which controls the arthritis, reduces fever, relieves the 
 pain, and, above all, prevents cardiac complications. In my experience the 
 ordinary treatment with salicylate of sodium has not fulfilled these requirements, 
 for it has not perceptibly removed the danger of endocardial inflammation. A 
 patient fully under the influence of the salicylate will not infrequently develop 
 a cardiac murmur — an accident which occurs much less frequently under the 
 alkaline treatment. In view of the great susceptibility of the endocardium in 
 childhood a judicious combination of the salicylates and alkalies offers the safest 
 and most efficient treatment. If endocarditis develops, the salicylate should be 
 dropped or administered with the utmost caution. 
 
 Treatment for the purpose of affecting the endocardium directly is of but 
 little avail, yet much may be accomplished by drugs. It is important that the 
 rapidity and irritability of the heart be lessened, and that a condition of 
 cardiac rest be attained as far as possible. Aconite lessens the rapidity, but 
 it also weakens the force, and with children is an unsafe drug. Digitalis must 
 be used cautiously. In acute endocarditis developing in an old cardiac case it 
 is often of supreme value. When the heart's action is tumultuous, but rapid 
 and weak, it may be given with the most satisfactory results, as it reduces the 
 frequency, increases the force, and corrects the irregularity. A child of six 
 years may take four drops of the tincture every four hours for one or two days, 
 when the dose should be diminished. Opium is also of great value in rheu- 
 matic endocarditis. It not only relieves the articular pain, thus rendering 
 general bodily quiet possible, but it has a most happy effect in steadying and 
 quieting an irritable, irregular, and rapid heart. Two minims or more of the 
 deodorized tincture may be given every four to six hours at six years. When 
 pericarditis is also present opium is the sheet-anchor. Stimulants should be 
 avoided until definitely indicated. When dilatation is marked they are de- 
 manded, and must be administered freely. When the fever has abated a tonic 
 is indicated, for anaemia appears early, and is frequently persistent and extreme. 
 Citrate of iron and quinine is admirably adapted to these cases, and may 
 be given in doses of three to four grains three times a day. The bitter 
 wine of iron is also an excellent preparation. One or two drops of Fowler's 
 solution may be added, but full doses of arsenic are inadvisable. When the 
 fever ranges high during the acute stages, quinine may be given in moderate 
 doses, but antipyrine and acetanilide are too depressing to be employed with 
 safety. Phenacetin is, perhaps, admissible. Administered in small doses.it is 
 an excellent analgesic. 
 
 Absolute rest and protection of the surface from cold and dampness are of 
 far more importance than medicinal treatment. Without these precautions 
 treatment is of little avail in preventing permanent valvular lesions. The 
 child should wear a flannel jacket or night-dress, and be placed between flan- 
 nel blankets instead of the usual sheets. Even in mild cases of acute endo- 
 carditis strict rest should be enjoined and insisted upon long after every rheu- 
 matic and cardiac symptom has disappeared. If a permanent murmur results, 
 it is often difficult to determine when it is safe for the child to leave the bed and 
 resume play, but it is wise to err on the side of caution. This enforced rest is, 
 perhaps, the most difficult of accomplishment of any measure in the treatment 
 
DISEASES OF THE HEART. 981 
 
 of children, particularly in families where discipline is lax. It can be obtained 
 with almost any child with determination and patience, and when the import- 
 ance is so great these qualities should certainly not be lacking. 
 
 Local applications, while less efficacious than in pericarditis, are of con- 
 siderable value. Poultices sometimes give marked relief from precordial dis- 
 tress, but caution must be exercised to prevent chilling of the surface. The 
 application of a weak chloroform liniment upon flannel held in position by a 
 flannel band is safer and accomplishes fully as much. The chest should always 
 be closely protected with flannel. 
 
 HE. Chronic Heart Disease. 
 
 Chronic valvular disease is the sequel of acute endocarditis. The lesions 
 in childhood do not differ materially from those of the adult. Thickening and 
 distortion of the valves are the changes most frequently observed, but vegeta- 
 tions occasionally appear. They are most common on the auricular surface of 
 the mitral valve. Adherent pericardium, the result of previous pericarditis, is 
 very common, while hypertrophy of the cardiac wall is more frequent and exten- 
 sive than in later life. 
 
 Etiology. — Acquired valvular lesions result from acute endocardial inflam- 
 mation. The causes of such inflammation are considered in detail in their 
 appropriate place. 
 
 Clinical History. — Cardiac disease presents three conditions or periods : 
 
 1. Period of acute inflammation. 
 
 2. Period of compensation. 
 
 3. Period of heart failure. 
 
 It must not be supposed that these conditions always follow each other in 
 the order mentioned, or that the disease runs a course through three definite 
 stages to a fatal termination. This may occur, but more frequently the first 
 condition is several times repeated, and the third is often transformed into the 
 second by rest and treatment. Compensation occurs with great rapidity and 
 completeness in children. Failure of compensation never occurs without cause. 
 The most frequent causes are anaemia and impaired general nutrition ; acute 
 intercurrent diseases, particularly rheumatism with endocarditis ; and sudden 
 heart-strain from excessive muscular exertion. 
 
 Symptoms. — When compensation is perfect there are no symptoms. It 
 not infrequently happens, therefore, that a murmur is discovered when there is 
 nothing whatever in the child's history or appearance to direct attention to the 
 heart. Dyspnoea is by far the most frequent symptom, with palpitation but 
 little less common. They are most marked when the aortic valves are involved, 
 but dyspnoea on exertion is usually present with mitral stenosis. Pain as an 
 urgent symptom is not common, and is more frequently associated with mitral 
 stenosis than with any other cardiac lesion. Cyanosis and oedema are rare, 
 and do not appear until other symptoms become urgent. (Edema rarely 
 pursues a typical ascending course. Epistaxis is not uncommon. Persistent 
 cough and subacute bronchitis are frequent accompaniments of mitral ste- 
 nosis. The condition often observed in the adult, marked by dyspnoea so 
 extreme as to prevent sleep, by tumultuous palpitation and extreme cardiac dis- 
 tress, cyanosis, and dropsy, is rarely seen under twelve years. 
 
 Mitral Regurgitation. — Imperfect closure at the mitral orifice is the most 
 common cardiac defect during childhood. It usually results from pathological 
 change in the valves, but may be due to dilatation of the ventricle causing a 
 failure of coaptation of the edge of the valves. The murmur is systolic, is 
 
982 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 heard with greatest intensity at the apex, and is conveyed to the left. Such 
 a murmur developing during the course of a rheumatic endocarditis is organic 
 and probably permanent. If developed under other conditions it may quickly 
 disappear. The great relative frequency of this murmur is shown by the fol- 
 lowing table, compiled from my own history books : 
 
 Mitral regurgitation in 131 cases (94.7 per cent.), alone in 99 cases. 
 Mitral obstruction " 17 " 11.8 " " " 4 " 
 
 Aortic regurgitation " 9 " 6.3 " " " " 
 
 Aortic obstruction " 28 " 20.1 " " " 3 " 
 
 Mitral Stenosis. — The frequency of the presystolic mitral murmur in 
 childhood is comparatively great. In my cases it occurred in relation to mitral 
 regurgitation as 1 to 7.71. Rheumatism was a factor in its production, but 
 was less strongly marked than in either of the other murmurs, confirming the 
 statement of Sansom that mitral stenosis is intimately associated with rheu- 
 matism, but most frequently with insidious varieties. Symptoms are somewhat 
 more marked than in simple mitral regurgitation. Pain is more common than 
 with any other lesion, and dyspnoea on exertion is the rule. Palpitation is also 
 common, while bronchitis and cough are frequent and obstinate. The mitral 
 obstructive murmur is very rare in infancy. I have never seen it under five 
 years. It is slow in its appearance, never developing suddenly, as does the mitral 
 regurgitant. The character of the abnormal sound is subject to change from 
 time to time — more so than any other murmur. It may become very faint or 
 even imperceptible, but it is very sure to return, and hopes based on its 
 disappearance are almost certain to be disappointed. Frequently there is no 
 perceptible cause for this changeability. 
 
 The mitral obstructive is probably more frequently overlooked than any 
 other murmur, yet it is quite distinct and characteristic. It is, as a rule, harsh 
 and of a rattling, blubbering character. It differs decidedly from other mur- 
 murs in one particular : instead of rising to a maximum, and then gradually 
 decreasing or shading off into silence, it rises rapidly to a maximum, and sud- 
 denly ceases as the apex strikes the chest-wall. Its area of diffusion is limited. 
 As the stethoscope is carried from the apex a point is quickly reached at which 
 the murmur suddenly and completely ceases. If a regurgitant murmur is also 
 present and the heart is acting rapidly, the two murmurs may run so closely 
 together as to be with difficulty separated. In this case the first portion, or 
 obstructive murmur, suddenly ceases at a given point, while the regurgitant 
 remains unchanged. If the second sound is reduplicated at the apex, the 
 certainty of mitral stenosis is increased. A thrill is by no means so com- 
 mon as in the adult. It is sometimes absent in well-marked cases, and is occa- 
 sionally present when the murmur is faint and uncertain. The left auricle is 
 dilated and hypertrophied in cases of long standing, and the right side of the 
 heart is engorged and frequently dilated. Right-side enlargement, however, 
 cannot always be determined by physical examination. 
 
 Aortic Stenosis. — Aortic murmurs are much more definitely associated 
 with rheumatic histories than are the mitral, and indicate a more extensive 
 endocarditis. An aortic obstructive murmur may permanently disappear. 
 This has occurred in my own experience twice, two years being required in 
 one case and over three years in the other. A change in character is not 
 uncommon, a loud, harsh murmur becoming soft and blowing or even disap- 
 pearing temporarily. While symptoms are in many cases obscure, they are, 
 as a rule, somewhat more distinctive than when mitral regurgitation alone is 
 present, it being remembered that a mitral murmur is almost invariably an 
 accompaniment of the aortic. Dyspnoea is frequent, and with a double aortic 
 
DISEASES OF THE HEART. 983 
 
 murmur dyspnoea and palpitation upon exertion are almost constant. Both 
 symptoms are more continuous, and depend less upon exertion than in the case 
 of mitral disease. Anaemia is very common ; it is persistent and often extreme. 
 Physical signs differ but little from those observed in the adult. 
 
 Aortic Regurgitation. — This is the most infrequent left-side valvular 
 lesion. It rarely, if ever, occurs alone in childhood, and in but one instance 
 have I heard a double aortic murmur without an accompanying mitral. The 
 symptoms are somewhat more marked than those of simple aortic stenosis, for 
 it appears only after extensive endocardial inflammation, and is an additional 
 burden to an already disabled heart. 
 
 Tricuspid Regurgitation. — This condition is more frequently detected 
 bv the pathologist than by the clinician, because in the young it is extremely 
 difficult of differentiation from mitral regurgitation. In early infancy a mur- 
 mur heard with greatest intensity at or just to the right of the apex is pre- 
 sumably tricuspid. If the lesion is serious, right-side enlargement will be 
 present, which may be detected by an area of dulness at the right of the sternum 
 and by epigastric pulsation. When added to mitral and aortic disease the 
 symptoms are distinctive. Visceral enlargements and dyspepsia are invariably 
 present, but jugular pulsation is not constant. Palpitation, dyspnoea, cough, 
 pain, cyanosis, and oedema develop to form the last stage of a fatal malady. 
 
 Prognosis. — The elements of prognosis are numerous and complicated. 
 Murmurs alone usually furnish insufficient evidence upon which to base an 
 opinion. The action of the heart, the condition of hypertrophy or dilata- 
 tion, the completeness of compensation, and the general physical condition of 
 the patient must all be taken into account. The social condition, surround- 
 ings, and mode of life are important factors and must be duly considered. 
 Parental discipline is also an element of great importance. In a wayward and 
 uncontrolled child the prognosis is decidedly worse than in one under firm and 
 judicious discipline. On the whole, the prognosis may be said to be better in 
 the child than in the adult. 
 
 The period from ten to fifteen years is a critical one. The remarkable 
 increase in the volume of the heart at the time of puberty has already been re- 
 ferred to. A patient sometimes progresses satisfactorily till this age is reached, 
 when the whole aspect of the case is changed. Compensation becomes imper- 
 fect, the child grows anaemic, and gives evidence of impaired nutrition. Devel- 
 opment is retarded, though there may be growth in height, the child being thin 
 and without strength or vigor. Sometimes he develops into a fairly healthy 
 youth, but in other cases, going from bad to worse, finally succumbs. For- 
 tunately, the majority of patients pass safely through this trying period, often 
 without perceptible inconvenience. Such children, if a mitral regurgitation 
 only is present, usually develop into healthy men and women and never show 
 symptoms of cardiac disease. 
 
 The etiology aids somewhat in prognosis. The more distinctly rheumatic 
 the patient, the worse the prognosis, for recurring attacks of endocarditis are 
 to be feared. Failure of compensation resulting from an attack of rheumatism 
 or scarlet fever is of far greater importance than that developing from muscular 
 strain, anaemia, over-study, or nervous excitability. Among symptoms cya- 
 nosis and oedema are of the most serious import. 
 
 If mitral regurgitation alone is present and the child is strong and well- 
 nourished, the probability of maintaining compensation is good, provided 
 recurring attacks of endocarditis can be prevented. The prognosis turns 
 almost entirely upon this last contingency, and this, in turn, depends in large 
 measure upon the personal and family history as regards rheumatism. Hence 
 
984 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the history is a matter of decided importance in prognosis. Mitral stenosis is 
 always a grave condition, but is somewhat less serious in young children than 
 in adults, largely because the pulmonary arteries adapt themselves more readily 
 to the abnormal strain placed upon them. Compensation sometimes becomes 
 perfect, and remains so, but when the lesion is extreme, it does not admit of 
 complete and permanent compensation. When pulmonary symptoms are marked 
 the prognosis is especially bad. In aortic disease, if obstruction alone is pres- 
 ent, without rheumatic history, the prognosis is very favorable. The murmur 
 may entirely disappear. If, on the other hand, it is associated with a mitral 
 murmur and a rheumatic history is obtained, the case is a grave one : the dis- 
 ease is the result of an extensive endocarditis, which will probably recur to 
 cause more and more distortion of the valves. Aortic regurgitation is a far 
 more serious condition than aortic stenosis, and when both murmurs accompany 
 a mitral the prognosis must be very guarded. Tricuspid regurgitation is always 
 a serious condition, and the prognosis is unfavorable. 
 
 Treatment. — The successful management of cardiac disease requires, on 
 the part of the physician, a clear conception of its various stages and an under- 
 standing of the exact condition of his patient. If the compensation is perfect, 
 there will be no symptoms of heart disease and nothing to treat. All that can 
 be accomplished in any case not suffering from acute inflammation is to estab- 
 lish compensation. If that is already accomplished, it is the height of impro- 
 priety to treat the patient for heart disease. The error must not be made upon 
 the other extreme, however, that the physician has no duty in the case. The 
 child should be kept under observation, for the condition of compensation may 
 be at any time changed to that of heart failure. Nutrition should be main- 
 tained at the highest possible point by diet and properly regulated outdoor 
 exercise. The child should be especially guarded against exposure to the 
 exanthematous diseases, and, above all else, should be protected from conditions 
 which tend to precipitate an attack of rheumatism. If that disease does de- 
 velop, it should receive prompt and vigorous treatment. Anaemia is a condition 
 full of peril in heart disease, for when it is extreme compensation is not long 
 maintained. It should be combated by iron, arsenic, cod-liver oil, the vege- 
 table bitters, and a generous but simple and digestible diet. The question of 
 exercise is one of the greatest importance. Violent games may do irreparable 
 harm, while, on the other hand, if the child be debarred from reasonable out- 
 door exercise, heart failure may develop from anaemia and impaired general 
 nutrition. Quiet games and plays are to be definitely prescribed, with the 
 strictest injunction against football, baseball, and all games requiring violent 
 muscular exertion and running. The clothing should also receive the physician's 
 attention, flannels being prescribed for both summer and winter. 
 
 If failure of compensation appears, absolute rest should be rigidly enforced. 
 The cause should be sought and removed if possible. The appetite usually 
 disappears utterly, and the stomach becomes irritable and enforced alimentation 
 is necessary. If the stomach rejects milk and lime-water, animal broths, or 
 koumyss, it may retain milk peptonized for two hours, to which a little lemon- 
 juice may be added. If this is rejected, nutritive enemata of completely pep- 
 tonized milk must be given every four to six hours. Medical treatment will 
 prove of little avail if the child is permitted to lose strength from lack of 
 nourishment. 
 
 Among drugs digitalis still holds its position as first and most important, 
 but it must be employed judiciously. Much harm may result from lack of judg- 
 ment and nice discrimination in the use of the cardiac stimulants and sedatives. 
 By increasing the force of the systole, prolonging the diastole, and contracting 
 
DISEASES OF THE HEART. 985 
 
 relaxed arterioles digitalis restores the balance of the circulation when deranged by 
 valvular lesions or weakness of the heart-muscle; in other words, it re-establishes 
 compensation. Its use is indicated when the heart's action is rapid, feeble, and 
 irregular and the pulse shows low arterial tension. Rational symptoms offer 
 more reliable indications for its use than do the physical signs, but both should 
 be duly considered. Dyspnoea, cough, cyanosis, oedema, and scanty urine are 
 indicative of failing heart-power, and call for a cardiac stimulant. Mitral 
 regurgitation is the valvular lesion for which digitalis proves most generally 
 useful. With mitral stenosis irregular heart action is sometimes aggravated by 
 its use. In that case convallaria may prove efficient. When an aortic murmur 
 is present digitalis is not so frequently efficacious as in mitral disease alone. If 
 compensation is good, its use may cause alarming symptoms, and in any case it 
 should be prescribed cautiously at first. Iron, strychnine, and the alkalies are, 
 as a rule, more efficacious. In tricuspid regurgitation digitalis must be used 
 with extreme caution. The tincture is the preparation most commonly employed, 
 the dose varying according to the age and cardiac condition from one to five or 
 six minims. It is often very badly tolerated by the stomach. The solid prep- 
 arations cause far less gastric disturbance, and may be usually continued for 
 weeks without trouble. The dose of the powdered leaves is from one-fourth 
 grain to one-half grain, and of the extract one-fourth of these amounts. 
 
 In case of great restlessness on the part of the child, with palpitation 
 and cardiac distress, a sedative may be required. Bromide of sodium should 
 be first tried in doses of three to ten grains every six hours. If this be unavail- 
 ing, opium may be cautiously administered, paregoric being selected for younger 
 children, and the deodorized tincture for those of more advanced years. Exces- 
 sive palpitation, with dyspnoea appearing in paroxysms, is often quickly 
 relieved by a few drops of compound spirits of ether combined with a small 
 dose of opium. 
 
 If the urine becomes scanty and oedema appears, a hot digitalis poultice 
 should be applied across the loins. This is made by boiling two ounces of 
 digitalis leaves in a pint of water, and then stirring in sufficient linseed meal. 
 Digitalis should be administered freely, and in this condition the infusion is 
 most effectual. At the same time the bowels should be freely acted upon by 
 calomel. The compound diuretic pill for children who can swallow it often 
 relieves the symptoms with marvellous rapidity. It consists of equal parts of 
 calomel, digitalis, and squill ; one-third to one-half grain of each may be given 
 at twelve years. For younger children the tincture of digitalis and tincture 
 of squill may be combined with spirit of nitrous ether or citrate of potas- 
 sium. 
 
THE FUNCTIONAL AFFECTIONS OF THE HEART 
 (THE CARDIAC NEUROSES). 
 
 By J. C. WILSON, M. D., 
 
 Philadelphia. 
 
 The functional affections of the heart include those motor and sensory 
 derangements which occur in the absence of demonstrable anatomical changes 
 in the organ. 
 
 The qualifying adjective "functional" is used in its ordinary sense, to 
 denote the absence of anatomical lesions demonstrable during life or after 
 death. It is appropriately employed in this connection to designate disorders 
 not primarily of the heart itself, but rather of its innervation. Hence these 
 affections are also properly spoken of as cardiac neuroses. 
 
 It is important to note that all the morbid phenomena observed in func- 
 tional disorders may and frequently do attend the structural diseases of the 
 heart. 
 
 The functional affections of the heart which occur in childhood are — 
 
 A. Motor: 
 
 1. Derangements of rhythm. 
 
 a. Arrhythmia. 
 
 b. Rapid heart — tachycardia. 
 
 c. Slow heart — bradycardia (brachycardia). 
 
 2. Momentary arrest — syncope. 
 
 B. Sensory: 
 
 Subjective sensations referred to the prascordia. 
 
 a. Heart-consciousness. 
 
 b. Distress. 
 
 c. Pain. 
 
 C. Motor and Sensory combined: 
 
 Palpitation. 
 
 Etiology. — The influences which predispose to affections of the heart are 
 the same in childhood as in adult life. They consist in (a) a weak and delicate 
 organization associated with an impressionable nervous system ; (b) anaemic 
 conditions ; (c) lithsemia and allied derangements of metabolism and excretion ; 
 and (d) morbid conditions directly affecting the nervous system, as organic 
 diseases of the brain and cord, chorea, epilepsy, and the acute and chronic 
 infections. To this list must be added adenoid hypertrophies of the pharyn- 
 geal vault. 
 
 Certain of these conditions are inherited, others acquired. Thus the chil- 
 dren of nervous or insane parents, those begotten of elderly persons, those born 
 prematurely, those who have in infancy been exposed to privation and neglect, 
 or who have suffered from serious or protracted disease, are especially prone to 
 functional disturbances of the heart. To a less extent is this true of the 
 
 986 
 
FUNCTIONAL AFFECTIONS OF THE HEART. 987 
 
 children of gouty families and of the offspring of tuberculous and syphilitic 
 parents. The tendency to functional cardiac trouble, rarely observed in early 
 infancy, usually shows itself at the approach of the seventh or eighth year. 
 
 The exciting causes include (A) those acting upon the nervous system ; (a) 
 directly, as intense mental emotion, fever, anger, passionate grief; or (b) 
 reflexly, as dentition, gastro-intestinal irritation from indigestion, intestinal 
 worms, foreign bodies in the intestinal canal ; and (B) those acting, by means 
 of mechanical disturbance of the circulation, upon the heart, as violent exer- 
 cise or exertion, especially after meals. 
 
 Functional derangements of the heart are much less frequent in childhood 
 than in adult life, for the reason that the Pandora's box of vicious habits, the 
 brunt of which the heart must sooner or later bear, is only opened by degrees, 
 and, happily, not often early in life. 
 
 Symptoms. — In general terms the symptoms of the functional disorders 
 of the heart in childhood, as in adults, consist in derangement of the motor 
 functions and abnormal sensations referred to the pnecordia. These motor and 
 sensory derangements are not always associated. More commonly the move- 
 ment of the heart is deranged, its action being accelerated, retarded, or irregu- 
 lar, without abnormal sensations ; occasionally deranged rhythm of frequency 
 occurs in connection with precordial distress or pain or a sense of oppression, 
 and in comparatively rare instances prsecordial pain occurs in the absence of 
 perturbation of the movements. Angina pectoris is not a disease of childhood, 
 nor is it common to encounter the agonizing pains of pseudo-angina early in 
 life. 
 
 When the functional disorder is paroxysmal or of a high grade of intensity, 
 it is usually accompanied by increased frequency and shallowness of respira- 
 tion, and very often by pallor of the face and slight cyanosis. Especially is 
 pallor associated with the temporary arrest of the heart's action known as 
 fainting, a condition also usually preceded by momentary nausea. 
 
 The child, ignorant alike of the existence of his heart and of its functions, 
 uncomfortable as he may be in other respects, escapes the anxiety and mental 
 distress which in the adult forms so important an element in the paroxysmal 
 functional affections of this organ. 
 
 When the derangement is not paroxysmal, but persistent, the rhythm of the 
 respiration is not usually disturbed. 
 
 It is to be borne in mind that in childhood both the respiration and the 
 action of the heart are normally far less constant in rhythm than in adults, 
 that they are more readily deranged by slight causes, and that the action of 
 the heart is often irregular during sleep and much influenced by inspiration 
 and expiration. The pulsus paradoxus, in which the heart-beats during 
 inspiration are more frequent, but less full, than during expiration, may often 
 be observed in perfectly healthy children during sleep. 
 
 Physical examination yields a limited number of definite signs. The fre- 
 quency of the heart's action and the degree and character of the arrhythmia 
 are recognized upon palpation. By this method of examination we also detect, 
 especially on palpation, the change in the character of the impulse, which is 
 increased in force. We observe also by this means and by inspection that the 
 impulse is extended. We determine by the position of the apex-beat, and 
 may confirm by percussion, the observation that the heart is not enlarged. 
 Upon auscultation the first sound is found to be sharp and valvular and short- 
 ened in duration, while the second sound remains distinct or is accentuated. 
 In very rapidly-acting or very irregular hearts transient murmurs, usually mitral 
 systolic, sometimes develop. 
 
AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Arrhythmia. — The various forms of arrhythmia are encountered in the 
 functional cardiac affections of childhood. The paradoxical pulse, as has been 
 mentioned, is frequently observed in healthy children during sleep. When 
 encountered during the waking hours it is more frequently a manifestation of 
 organic than functional derangement of the heart. 
 
 The rhythm of the foetal heart, embryocardia, a condition in which the 
 acoustic properties of the two sounds are almost identical and the pauses 
 nearly equal in duration, frequently occurs when the heart's action is rapid. 
 Other forms of arrhythmia, as the alternate heart-beat in which strong and 
 weak contractions occur with regular alternation, the bigeminal and trigemi- 
 nal pulsation in which the ventricular contractions occur in series of two or 
 three separated by an interval or by feebler contraction, the gallop rhythm and 
 dicrotism, are rarely observed. The disturbances of rhythm in which with 
 rapid action there is irregularity, not conforming to definite type, are the most 
 common. This condition in its more marked degrees has been described under 
 the term delirium cordis. With less rapidity of action there may be recog- 
 nized, upon physical examination, short series of three or four forcible heart 
 contractions followed by great irregularity and feebleness of action, this succes- 
 sion being irregularly repeated. True intermission or the missing of a car- 
 diac beat — "heart dropping," as it is frequently called, a condition common in 
 adult life — has not come under my observation in childhood. 
 
 Rapid Heart (Tachycardia). — The action of the heart, normally 130 
 to 140 per minute in the new-born, gradually decreases in frequency until the 
 end of the third year, when it ranges about 90. It is readily accelerated by 
 slight causes. Great increase in the rapidity of the heart's action is encoun- 
 tered in fevers. Rapidity of the heart is also induced by violent emotion and 
 undue exercise. The rapid action thus induced may sometimes persist for hours 
 or days. The paroxysmal tachycardia occasionally encountered in adults does 
 not occur in children. 
 
 Slow Heart (Bradycardia, Br achy car dia). — This condition is not com- 
 mon in childhood. Slowness of the pulse, the rate falling to 60 or somewhat 
 below it, is, however, occasionally encountered during convalescence from the 
 acute infectious diseases, in acute rheumatism, in disorders of the digestive 
 system, in jaundice, and in anaemia. Slowness of the heart's action has been 
 observed in post-epileptic coma. 
 
 Syncope occasionally occurs in nervous and impressionable children. 
 It may result from sudden shock or intense excitement. On several occasions 
 I have known children of six or seven years of age to faint at the sight of 
 blood. I have seen a ooy of seven faint at the sight of the denuded spot upon 
 his arm caused by vaccination. A healthy girl eight years old, of shy and 
 timid disposition, fainted at the dinner-table upon being suddenly addressed by 
 a person whom she did not know. For some hours she remained quiet upon 
 the sofa, the pulse-rate not exceeding 60. Actual loss of blood, even when 
 slight, profuse diarrhoea, extreme fatigue, and severe pain are capable of pro- 
 ducing syncope in impressionable children. 
 
 Heart Consciousness is fortunately extremely rare in children. The 
 most tumultuous action of the heart may take place apparently without sub- 
 jective sensations. It occasionally happens, however, that older children 
 complain of the beating of the heart without pain under conditions of excite- 
 ment or fatigue and in the absence of over-action amounting to palpitation. 
 
 Precordial Distress is occasionally encountered. It is usually reflex 
 in character and caused by gastro-intestinal irritation. As a rule it is transient. 
 
 Precordial Pain is rare. A remarkable instance of distressing precordial 
 
FUNCTIONAL AFFECTIONS OF THE HEART. 989 
 
 pain in a lad has come under my notice. The patient was the feebler one 
 of twins, and suffered in various ways from the reflex nervous disturbances due 
 to adenoid vegetations in the pharyngeal vault. Among these were attacks 
 of pain in the region of the heart, unaccompanied by disturbances of rhythm or 
 over-action, and occurring in paroxysms repeated on several successive days. 
 
 Palpitation may be defined as over-action of the heart with abnor- 
 mal precordial sensations. These sensations are always distressing and very 
 frequently amount to actual pain. Palpitation is attended by increased rapidity 
 of respiration and a sense of oppression. It is among the more common of the 
 functional heart affections of childhood, usually induced by over-exertion or 
 violent emotions, and sometimes occurring without recognizable cause. The 
 condition of convalescence from acute disease, debility, anaemia, and lithsemia 
 are predisposing influences. 
 
 Course. — The course of the functional affections of the heart in childhood is 
 in the main transient. If recurrences take place, they gradually cease as the 
 general health improves. This is especially true of the attacks which occur 
 as the result of reflex gastro-intestinal derangements, of anaemia, or during 
 the convalescence from acute disease. The attacks which are met with in con- 
 stitutionally feeble children, in those who are lithaemic or who have habitually 
 an abundance of calcium-oxalate crystals in the urine, yield less readily and more 
 slowly to treatment. The mere "impressionable heart" is likely to be func- 
 tionally deranged by slight causes throughout life. It is not, however, incom- 
 patible with fairly good general health and a reasonable expectancy of life. 
 
 Diagnosis. — The diagnosis rests upon the presence of the symptoms and 
 signs which have been described, in association with the constitutional or local 
 conditions in which functional derangements of the heart are known to occur, 
 or the history of a direct exciting cause. The absence of the physical signs 
 of organic heart disease, and of the rational symptoms of transference of blood- 
 pressure from the arterial to the venous side of the circulation, must further be 
 established. 
 
 Prognosis. — The prognosis is as a rule favorable, both as regards the 
 separate attack and the ultimate recovery. I have not seen organic disease 
 of the heart develop as a sequence of either frequently-recurring or long- 
 continued functional disorder. 
 
 Treatment. — In the paroxysmal forms the treatment must be directed to 
 the immediate condition. The child must be placed at rest in the recumbent 
 or sitting posture, the clothing loosened, every effort made to allay fear and calm 
 excitement. The face and hands should be bathed, and by degrees the atten- 
 tion diverted. If necessary, ammonia may be inhaled or a few drops of the 
 aromatic spirit of ammonia in water administered. 
 
 In the case of syncope the recumbent posture should be maintained for 
 some time and a current of air admitted. The face may be sprinkled with cold 
 water, and the venous circulation in the limbs favored by centripetal frictions. 
 
 Efforts should be made to correct those conditions which act as predispos- 
 ing influences. Attention to hygiene is of the first importance. Systematic 
 feeding and a diet at once nutritious, easy of digestion, and abundant, are 
 imperative. Fresh milk, eggs, broiled and roasted meats, bread-crusts, fresh 
 vegetables and fruits, selected and regulated according to the age of the child, 
 constitute the dietary. Quality is of supreme moment; variety is not neces- 
 sary. A spoonful of preserves or jam occasionally should be regarded as a 
 treat. The breakfast should be taken early, the dinner at midday, supper at 
 five or six o'clock, and bed-time should not be later than eight. The bath 
 should be given in the morning, cold or at most only tepid, and followed by 
 
990 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 brisk towelling till the skin glows. By day and night the clothing must be 
 warm, light, and loose. Exercise in the open air should be systematic and 
 regular. Even in changeable climates delicate children, when properly clad, 
 may go out to walk, except in extremely cold weather or in actual storms, 
 almost every day — not only without injury, but even with positive gain. 
 
 Anaemic conditions require prompt and careful attention. Among the 
 drugs most useful in their management are alcohol, cod-liver oil — which, in 
 well-made emulsion, children take very well — syrup of iron iodide, and the 
 various preparations of mercury and of arsenic in minute doses. 
 
 Lithgemia, whether inherited or acquired, demands very careful study and 
 management. Here a milk diet is especially useful, and an occasional laxa- 
 tive. Where the fault lies with the nervous system, long hours of rest, 
 especially rest in the middle of the day, and the bromides, are of advantage. 
 Adenoid vegetations of the pharyngeal vault must, when discovered, be forth- 
 with removed. 
 
 Wholesome moral influences and discipline at once gentle, affectionate, and 
 firm are of untold value in the care of delicately organized and impressionable 
 children. Those who have the care of the young ought to possess in a high 
 degree that rare greatness which shows itself in the ruling of one's own spirit — 
 said to be beyond that which enables one to take cities. 
 
 If disturbances of the cardiac function occur during dentition, the stoma- 
 titis which often arises must be promptly treated, and if the gum over a pre- 
 senting tooth be tense, livid, and tender, it may be freely incised. 
 
 Derangements of digestion are best managed by withholding ordinary food 
 for a time, giving small amounts of milk and lime-water, a calomel purge, and 
 the subsequent administration of an efficient pepsin. 
 
 If intestinal worms be present, they are to be expelled by appropriate 
 treatment. 
 
 The functional derangements of the heart which occur in acute disease and 
 during convalescence disappear with returning health, and as a rule demand no 
 especial treatment. 
 
 It remains to speak of the group of drugs familiarly known as heart tonics. 
 They are rarely indicated, often used with no good effect. What the heart 
 most needs for its best nutrition, both in childhood and afterward, is well- 
 oxygenated, healthy blood and moderate and fairly regulated work ; and these 
 constitute the greatest need also of the nervous system, which controls and 
 regulates the heart. 
 
 Digitalis, nux vomica, and belladonna are often required. They must, 
 however, be given only in response to clear indications. Their employment in 
 short courses under proper circumstances is highly beneficial : as a matter of 
 routine they are not only generally useless, but also often hurtful. 
 

 PART X. 
 DISEASES OF THE GENITO-URINARY SYSTEM. 
 
 HEMATURIA, PYURIA, CHYLURIA, ANURIA, 
 AND INCONTINENCE OF URINE. 
 
 By E. M. BUCKINGHAM, M. D v 
 
 Boston. 
 
 HEMATURIA. 
 
 Blood reaches the urine from any part of the urinary passages. Its 
 quantity varies within the widest limits, and the color of the urine containing it 
 ranges from bright red to smoky red, dark greenish-brown, or almost black. 
 The longer it remains in contact with urine, and the more thoroughly mixed 
 with it, the darker it becomes, especially if it be in small quantity. A very 
 large haemorrhage is more likely to be from the bladder, and a small one from 
 the kidney. It has therefore been assumed that the presence of bright blood 
 shows a vesical, and of dark blood a renal, haemorrhage. This is not neces- 
 sarily true, for in individual cases large haemorrhages have been seen by means 
 of the electric light to issue from the ureters, and small ones may certainly come 
 from the bladder. If blood is fresh and in sufficient quantity to render the 
 urine alkaline, it may settle to the bottom of the containing vessel, leaving a 
 clear upper layer of urine. Clots occur only when the blood is in tolerably large 
 quantities, and especially when not thoroughly mixed with urine. They may 
 be large enough to cause pain from consequent retention, and they may decom- 
 pose and give rise to cystitis. By their shape they sometimes give evidence 
 of their place of origin, but moulds of the ureters may resemble those formed in 
 the prostate. It is possible for urine to be discolored like that of hseroaturia 
 without containing blood. Icteric urine has this appearance if sufficiently 
 charged with bile, and red stains of uric acid upon the diapers are occasionally 
 taken for blood. In haemoglobinuria no red corpuscles are present, but the 
 urine is nevertheless stained with blood-pigment. When urine contains any 
 appreciable amount of blood, it also contains albumin in appreciable quantity. 
 Blood-cells are probably found by the microscope, but they become swollen and 
 disintegrated in very dilute or ammoniacal urine. 
 
 If the blood has its source in the urethra, its appearance is usually confined 
 to the beginning of micturition. The cause may be traumatism, including the 
 passage of small ragged calculi. There is a case on record of hematuria in a 
 child from urethritis depending upon decomposition of urine the result of mal- 
 position of the meatus, and entirely and quickly relieved by operation. Blood 
 from prostatitis — rare in children — precedes the urine if the seat of inflamma- 
 tion be in the anterior part of the gland, or it flows backward into the bladder 
 
 991 
 
992 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and mixes with urine if it comes from the posterior part. Generally the last 
 few drops contain most of the blood. In either case micturition is frequent 
 and painful, and is generally followed by tenesmus. Rupture of a vessel at 
 the neck of the bladder might cause similar symptoms. If pain and frequent 
 micturition are both absent, this region can with tolerable certainty be excluded 
 as the source of haemorrhage. If cystitis or pyelitis causes hematuria, the 
 urine contains pus. The pain of cystitis is more likely by far to be referred 
 to the bladder, and that of pyelitis to the back, but this distinction is not abso- 
 lutely diagnostic. Both conditions are rare in childhood, but either may be 
 excited by calculus, tubercle, or acute disease. 
 
 Calculi in any part of the urinary tract may occasion hematuria, and renal 
 calculi may do this without causing other symptoms. Vesical calculi are not 
 uncommon in children, but do not, as a rule, give rise to much bleeding. This 
 is more likely to come from a calculus impacted in the ureter, in which case 
 there is probably severe pain. 
 
 The symptoms of tubercular bladder resemble those of cystitis. In making 
 this diagnosis one should eliminate the more common causes of bleeding, and 
 examine elsewhere for tuberculosis, which is seldom if ever primary in the 
 urinary organs. Bacilli in the urine would help the diagnosis, but they are 
 stated by Osier to be scanty in pyelitis ; and this would be expected where the 
 tubercular surface is constantly washed with urine. Therefore, their absence 
 would not exclude this disease. 
 
 Prolonged bleeding with intermissions very probably comes from one kid- 
 ney or its pelvis, intermissions being due to plugging of the ureter. Exacer- 
 bations of pain during intermissions increase this probability. Chill or vomit- 
 ing may accompany them. Generally, however, haemorrhage starting above 
 the bladder is not painful. 
 
 Blood from the kidney generally contains enough renal casts and epithelium 
 to suggest its source, but one should inquire further. Bloody urine is a symp- 
 tom of acute nephritis. There is generally the history of an exciting cause, 
 and often much oedema. The urine not only contains blood, but is at first 
 scanty and of high specific gravity, with albumin and numerous renal casts. 
 Hyperaemia, not amounting to nephritis, also causes bleeding. The difference is 
 one of degree. Passive hyperaemia from a weak heart may produce it. It may 
 occur in the course of chronic parenchymatous and of interstitial nephritis, 
 especially toward the close, but is by no means universal in them as in acute 
 nephritis, nor are these diseases so common in childhood. Some drugs cause 
 hyperaemia or nephritis, and therefore haematuria. Among them are turpentine, 
 cantharides, potassium chlorate, carbolic acid, and amyl nitrite. Rhubarb is 
 said to invariably cause it in certain persons. 
 
 Neoplasms occasionally cause haematuria, but less frequently in children, 
 because carcinoma, which often bleeds, is rare with them, while sarcoma, 
 which is more common, bleeds less. Villous growths in the bladder give rise 
 to serious haemorrhage. If in the prostatic region, there may be pain at the 
 end of micturition, owing to the tumor being squeezed by the empty bladder. 
 Berkeley Hill writes that we may infer that blood comes from a villous growth 
 if bleeding is profuse at first and painless, and lasts from a few days to a week 
 or more. It stops as suddenly as it begins, and is uninfluenced by rest or 
 exercise. Fragments are occasionally washed out in the urine. Such growths 
 have been removed by the ecraseur, but bleeding often stops of itself. Harri- 
 son reports the removal of a small fibroid from the bladder of a boy of seven- 
 teen, giving complete relief to a haemorrhage which recurred at intervals of two 
 weeks. There was severe pain in the penis. 
 
HJSMA TUJRIA. 993 
 
 Certain parasites occasion hematuria. The rhabditis genitalis, as de- 
 scribed by Seheiber, was found by A. Baginsky in the urine of a child three 
 and a half years old with hemoglobinuria, and by Peiper and Westphal in the 
 urine of a feeble child of nine, who had had scarlatinal nephritis four years 
 before. In the latter patient, pleuritis occurred in October, and in Novem- 
 ber severe hematuria, followed by negative urine ; then for a short time there 
 was much blood and pus in the urine. A month later a less severe haemor- 
 rhage occurred, at the beginning of which the amount of urine was tempo- 
 rarily lessened. In two days the microscope detected worms, hardly half as 
 large as trichine, which on comparison appeared to be the Seheiber worms. 
 Many were found, but all were dead. None were detected in the blood, stools, 
 or preputial secretion. Soon hematuria ceased, but slight albuminuria lasted 
 six weeks, when more, but degenerated, worms were passed. Albuminuria then 
 ceased. Meanwhile, marked improvement in enuresis of two years' standing 
 occurred. The authors are cautious about assuming relation between these 
 worms and this symptom. 
 
 Berkeley Hill mentions the filaria sanguinis hominis as causing hematuria : 
 this sometimes occurs in chyluria, believed to be generally due to this parasite. 
 
 The Bilharzia hematobia, first described by Bilharz of Cairo, is found in 
 streams in Africa from the Mediterranean to the Cape of Good Hope. The 
 mature worm is too small to be seen by the unaided eye. Eggs have been found 
 in various parts of the body. The view of Bilharz, that it is swallowed 
 in unfiltered drinking-water, is commonly accepted. Allen of Pietermariz- 
 burg, South Africa, reasons from its greater frequency in boys, who bathe in 
 rivers, and from the urethra being a favorite residence for it, that it may also 
 enter by the meatus. He states that he can sometimes feel a colony in the 
 upper urethra by means of a metallic catheter, and reports relief from urethral 
 injections. Hemorrhage occasionally causes retention from clots, and may be 
 serious from prolonged oozing, but patients may recover after years of suffer- 
 ing. Davis reports that the use of kamala appeared to limit the number of 
 embryos passed. 
 
 Malarial hematuria is found in many parts of the world. In the United 
 States it is confined to severe cases, and generally to highly malarial regions. 
 It is not uncommon in the South, but seems less frequent in cities than in the 
 country, which apparently emphasizes the need of a high degree of malarial 
 poisoning to produce it. Cases are reported in children as young as four years ; 
 these were of a distinct adult type, marked with severe chills and fever, rather 
 than of the partly masked form. Castle states that malarial hematuria 
 is not invariably accompanied by chill. Some cases are remittent and 
 some pernicious. The presence of blood-pigment may be continuous, or the 
 urine may become entirely clear between paroxysms. It may contain many 
 blood-corpuscles or only a few with much hemoglobin, or blood-corpuscles 
 may be entirely absent, although the urine is colored with blood-pigment. 
 Day states that the urine of comparatively mild cases is more likely to contain 
 red corpuscles than that of severe ones. It has been urged that they are 
 present at first and decompose, but there is reason to believe that they become 
 altered in the vessels, allowing the escape of free hemoglobin. Various theories 
 have been advanced to account for malarial hemoglobinuria: (a) the action of 
 bile on the blood while still in the vessels, supported by the fact that injection 
 of bile or bile acids into the blood has produced bloody urine ; (b) the general 
 disturbance of the spleen and liver, organs which have a part in the formation 
 and destruction of red cells ; (c) the effect of external cold on the stagnant blood 
 of the extremities during paroxysms ; (d) the direct destructive action of the 
 
994 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Plasmodium inalarie upon the red cells. Malarial hemoglobinuria is more or 
 less combined with real haemorrhage, therefore the name hematuria is probably 
 the better one. It is a grave condition at best, and is probably often fatal 
 despite every method of treatment. 
 
 Some writers of the Southern States assert that malarial hematuria is not 
 due directly to malaria, but to quinine. This causes congestion in other 
 organs, and, considering the enormous doses used, in the South, 1 it possibly 
 sometimes excites nephritis ; but there is a malarial hematuria not due to 
 quinine. Hematuria sometimes precedes any treatment. Owen has suddenly 
 put a stop to it, together with other malarial symptoms, by the subcutaneous 
 injection of quinine, and a series of 286 cases collected by Howell shows that 
 those treated with quinine and calomel made the best recoveries. 
 
 There is a considerable English literature relating to cases of paroxysmal 
 hematuria, in which evidence of malaria is absent or so slight as to cause doubt 
 if it be a factor in the etiology. Herringham reports the cases of two sisters of 
 four and a half and three and a half years ; and four other cases of his were 
 under five. These sisters were observed from November to May during several 
 attacks. They were at first coincident with exposure to cold, but one occurred 
 while the child was kept in bed. There was generally no albuminuria, except a 
 trace before some paroxysms, showing that it was mostly hemoglobin rather 
 than blood that entered the urine. It was reported that both children had been 
 syphilitic, and he states that Murri of Bologna believes paroxysmal hematuria 
 to be syphilitic. Berkeley Hill also states that hereditary syphilis gives rise 
 to this symptom. Verco reports the case of a man who could produce hema- 
 turia whenever he pleased by merely going into the cold. It was accom- 
 panied by chill and a temperature of from 101° to 103° F. There was no 
 albuminuria in the intervals, and no periodicity. He was not known to have 
 had malaria. Rosenbach is quoted in the American Medical Journal (vol. iii, p. 
 544) as reporting a case excited by a cold bath in summer. Other patients have 
 paroxysms only in winter. In considering the etiology, it must be remembered 
 that malaria once contracted may give rise to symptoms without fresh exposure, 
 and may be irregular in its course. On the other hand, the reports from the 
 South, where it is common, show malarial hematuria only when accompanied 
 by well-marked malarial symptoms. Some cases of paroxysmal hematuria 
 have lasted for long periods and have recovered. 
 
 Paroxysmal hematuria may result from physical exercise, being perhaps 
 analogous to the so-called physiological albuminuria of soldiers after forced 
 marches. Herringham also mentions mental exercise as a cause, and reports a 
 case where it was brought on many times in an adult by worry or excitement. 
 Lannois reports the case of a patient whose first attack was at the age 
 of nine years, and who had not recovered at thirty-two. Paroxysms were 
 excited by gymnastics, railroad travelling, light work, and especially by long 
 walks. They always disappeared with rest and light diet. At first there was 
 but little blood, and that disappeared the next day. At one time albuminuria 
 persisted a few days. During the height of paroxysms the microscope showed 
 red blood-cells, many leucocytes, and renal epithelium. The peculiarity of 
 this case is its long duration. There were no malarial phenomena nor any 
 history of malaria or syphilis, nor had the patient been in the tropics. Since 
 childhood he had occasional pain in the side, which led Lannois to suspect some 
 obscure disease of the kidney. 
 
 Among badly-fed children scurvy occasionally causes hemorrhage into the 
 
 1 I am not criticising the doses in question : no one has a right to do that without the 
 experience in malaria that Southern physicians have. 
 
PYURIA— CHYL URIA— ANURIA. 995 
 
 urine as well as elsewhere. The diagnosis of scorbutic hematuria includes 
 the diagnosis of scorbutus. (See article on Scurvy.) It is conceivable that 
 hematuria may occur in natural bleeders, but I cannot find the report of a case 
 within ten years. 
 
 The treatment of hematuria will be indicated by the exciting causal con- 
 dition. 
 
 Pyuria. 
 
 Pus may enter the urine at any point. When it occurs it results from 
 some underlying cause, but it is seldom found in the urine of children, because 
 they seldom have the diseases that cause it. It is said, indeed, that boys may 
 have a non-venereal urethritis from debility. Mild vulvitis and vaginitis from 
 this cause are rather common. Cystitis and pyelitis are very occasional sequelae 
 of several acute diseases. They may be occasioned by the irritation of drugs 
 and of saccharine urine. The presence of calculi is possibly the most frequent 
 cause of this rather uncommon symptom. 
 
 Ohyluria. 
 
 Chyluria is especially a disease of certain tropical and subtropical regions, 
 but enough cases of European and North American origin have been reported, 
 particularly in the southern parts of the United States, to prevent our considering 
 it absolutely tropical. As it lasts a long time and does not absolutely disable 
 the patient, it may be imported anywhere. Prout reports a case at eighteen 
 months. Cases are either parasitic, apparently the most common, or non-para- 
 sitic. Hunt reports a traumatic case, probably due to rupture of a lymphatic 
 in the kidney. The urine remained chylous but a short time. At first it 
 smelt of milk, afterward of sour milk. The same and also a putrid odor have 
 been observed in other cases. Parasitic chyluria is due to the presence of a 
 minute parasite, the filaria sanguinis hominis, itself the product of a parent 
 parasite, the filaria Bancrofti. The filaria sanguinis hominis probably estab- 
 lishes a fistula between the lymphatics and the urinary organs. It is found 
 in the blood, but, as a rule, only in the late afternoon and night, though by 
 changing the meal hours it may be found at other times. Although usually 
 a parasite of warm countries, it was found by Weiss in the urine of a child who 
 had never been out of Illinois. 
 
 Patients are not generally very ill, but chills and abnormally high or low 
 temperatures are reported, and the disturbance to nutrition from prolonged and 
 occasionally profuse haemorrhage leads to debility. Attention is generally first 
 attracted by the presence of chyle, which may merely make the urine turbid 
 or as white as milk. Blood may precede it. The presence of urinary casts is 
 the exception. Elephantiasis may be a complication, and chyle may exude from 
 swellings in various parts of the body. Cases may last continuously for years 
 or may intermit. Suzuki, by limiting diet, and especially by omitting meat 
 and fat, decidedly lessened the chyle in the urine. Grimm found that he could 
 regulate the amount of chyluria by regulating the fat ingested. In his case 
 there was enough coagulation to cause pain in the bladder, but no renal colic. 
 He therefore concludes that chyle entered the urine between the ureter and the 
 urethra. Sigmund mentions a case in which advantage was taken of a pro- 
 lapsed bladder to see clear urine issuing from the left ureter. 
 
 Anuria. 
 
 Complaint is sometimes made that the urine of a little child, generally a 
 baby, is suppressed. This may depend on congenital malformation or an acute 
 
996 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 renal disease, but usually it is a symptom of short duration and no danger. 
 There is often slight fever and a history of imperfect digestion, possibly of 
 difficult dentition. A liberal supply of drinking-water is the only treatment 
 required. 
 
 Incontinence of Urine. 
 
 After a time, differing with the intelligence of the child and the pains taken 
 with its education, probably also with muscular development, children learn to 
 use the chamber-vessel. The age when this takes place averages about eighteen 
 months, but is sometimes much later. An undetermined proportion lose con- 
 trol of the bladder after acquiring it; this occurs before the age of six or seven. 
 Incontinence is not uncommon in any class of society, and patients often come 
 incidentally under observation after suffering for a long time, the delay being- 
 due to the prevalent belief that spontaneous recovery occurs about puberty. 
 Some patients have incontinence of fgeces as well as of urine. In some 
 this condition prevails both by day and by night, in some few by day only, 
 but by far the most numerous class is that which has nocturnal inconti- 
 nence of urine alone. Occasionally patients pass from one class into an- 
 other. Among nocturnal cases urine is passed while absolutely unconscious, 
 or the child dreams of the act and w T akes to find itself wet. This hap- 
 pens once in the night or oftener. Temporary recoveries sometimes occur, to 
 be followed by relapses, and incontinence is far more troublesome in winter 
 than in summer. These considerations should make us careful about claiming 
 results for treatment unless the patients are watched a long time, especially so 
 if recovery occurs in the spring. Many remedies have been proposed, and 
 papers written to show the brilliant results of one or another treatment, yet the 
 number of cases that do not improve continues large. The failure of some 
 practitioners where others seem to succeed is due partly to hasty generalizations 
 at the bottom of many enthusiastic papers, partly to the after-history of patients 
 being obtained for too short periods. But, with all allowances, a study both 
 of the literature and of our individual patients should convince us that we are 
 not dealing with one condition, but with a symptom common to many con- 
 ditions. Unfortunately, we cannot always find this underlying cause, and with 
 our present knowledge many patients must be treated empirically. When we do 
 find it, we sometimes accomplish much more than can be done by blind groping. 
 
 A few cases occurring in the day-time depend on postponement of micturi- 
 tion owing to the demands of play, yet there are cases of day-time occurrence 
 that are unavoidable. I have notes of the case of a lady who is never 
 troubled at night, but who wets her under-clothing so often by day that she 
 always wears a guard. This condition has lasted since early girlhood, and is 
 increased by excitement. Large doses of strychnine, continued for some weeks, 
 gave temporary relief. I do not think nocturnal cases are due to carelessness 
 in any appreciable number. Children are generally mortified at this failing, 
 and would be only too glad to avoid it. 
 
 Profound sleep, if not a cause, is often at least an accompaniment. This 
 fact, first noticed by Trousseau, receives more attention from French than from 
 English-speaking or German writers. I have often found that the one child of 
 a family that wets its bed is also the soundest sleeper. Therefore waking the 
 child when its parents retire for the night may be something more than a pal- 
 liative, and here may be the explanation of some recoveries as patients grow 
 older, when sleep becomes less sound than in early childhood. Recovery at 
 puberty is more often attributed to some obscure influence of maturity on the 
 genitals. In favor of this view it may be said that some women recover at 
 
INCONTINENCE OF UBINE. 997 
 
 the time of their marriage. Whatever the reason, however, many recoveries 
 do occur about the time of puberty. 
 
 Many patients are debilitated, and debility often, if not the only causal 
 factor, is nevertheless one so powerful that on its removal the child recovers. 
 A large proportion of such patients in my former dispensary service were 
 anaemic, and recovered as soon as given enough iron. These cases were 
 not sufficiently followed up for me to speak as to relapses ; but patients, 
 after long and varied treatment without result, do sometimes get well, and 
 stay well, on proper attention being paid to the general health. Such at- 
 tention does not, of necessity, exclude other treatment. I have notes of the 
 case of a boy treated with belladonna, strychnine, and electricity many times 
 during some years, but with no permanent result, he being always in poor 
 health. When eleven years old, while at the seashore, as badly off as ever and 
 without treatment, he learned to swim, and returned permanently relieved, and 
 with a taste for athletics for which he had been formerly too weak. Whether 
 such incontinence as this is caused simply by a weak sphincter, itself a part of 
 a generally weak system, or whether by a neurotic condition due to anaemia, is 
 a matter upon which one may speculate. Certainly, some of the subjects are 
 neurotic. Possibly both explanations hold good — sometimes one, sometimes 
 the other, and sometimes both together. 
 
 Nux vomica and its equivalent, strychnine, are often used successfully. They 
 have a good effect on many neurotic people and are general tonics. They are espe- 
 cially indicated when we know the sphincter to be weak. This may occur if 
 the child has been compelled to hold its water too long, as sometimes happens 
 at school. Cold douches to the perineum are probably local in effect, and the 
 same is true of electricity and massage. Good results are claimed for all of 
 them. Electricity is generally used in the form of faradization, with one pole 
 on the lumbar part of the spine and one in the urethra, the vagina, or on the 
 perineum, the sittings lasting a few minutes each day or every other day and 
 the current being as strong as the child will bear. I object to introducing the 
 electric or any other sound into the child's urethra or vagina — especially in 
 girls approaching puberty — if it can be avoided, and therefore prefer the peri- 
 neum. This care, perhaps excessive, combined with a possible bad selection 
 of cases, may partly account for my non-success with this treatment. Certainly, 
 I in common with others have not obtained the good results claimed. 
 
 Local massage has its advocates. Some good results have been reported, but 
 this method, like all others, has its failures. Sanger massages the sphincter by 
 introducing a probe into the bladder and exercising gentle pressure backward 
 and from side to side. The danger of teaching masturbation is, I think, to be 
 considered. 
 
 There is a class of cases in which the urine is sometimes passed with great 
 force, evidently from some other factor than a weak sphincter. There are 
 grounds for believing many of them to be hereditary ; many are neurotic. I 
 have met in one family of three children, one case of somnambulism, two of 
 chorea, and one of nocturnal incontinence, the last ejecting the stream violently 
 by day. Chorea is itself supposed to be a cause. It is assumed that there is 
 want of co-ordination between sphincter and detrusor. In other words, such 
 cases are choreic. Such considerations lead to treatment designed to allay 
 irritability of the bladder, by the use of belladonna, potassium bromide, and 
 ergot. Belladonna, originally given by Trousseau in a single night dose, has 
 since been administered in three daily doses. Baruch gave it in the late after- 
 noon and early evening in a series of cases, thus avoiding the probably unneces- 
 sary morning dose, and better graduating that in the evening. This is of 
 
998 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 some importance, as it is often necessary to approach a poisonous dose ; that is, 
 to get some effect on the pupil ; and also because the continued use of this 
 drug is not always innocuous. At least, I believe that I have seen gastric dis- 
 turbance and general malaise result from its prolonged use. It is, however, 
 in many cases the most efficient treatment known, and is perhaps to be 
 preferred where we can make no probable diagnosis of the underlying cause. 
 Relief is sometimes temporary, sometimes permanent. 
 
 Epilepsy is responsible for a certain number of cases. So is the general 
 disturbance attending the onset of acute disease. Ergot, by lessening conges- 
 tion in the spinal cord, is sometimes of use where there is a very irritable 
 bladder. 
 
 Children whose mode of life affords frequent opportunity for micturition, 
 make use of it, and thus accustom the bladder to contract when not very full. 
 In such cases a dry bed can sometimes be secured by gradually training the 
 bladder to contain greater amounts, thereby educating the sphincter. This 
 plan must not be carried out too heroically, or a strained instead of a strength- 
 ened sphincter will result. It is said that sleeping on the back, by causing 
 urine to press upon the most sensitive part of the bladder, is an exciting cause, 
 and may be relieved by elevating the foot of the bed. 
 
 Urine loaded with uric acid, urates, oxalates, or phosphates may cause incon- 
 tinence, as well as an irritable bladder ; hence the urine should always be 
 examined. Albuminuria is said to be a cause. I have met with diabetes in a 
 child, where the real diagnosis would have been overlooked but for the routine 
 examination for sugar in this affection. Possibly the effect of ptomaines on the 
 brain may be to produce incontinence in some children, as it does night-terrors 
 in others. Whatever the explanation, attention to the digestive organs is some- 
 times of great use. 
 
 The influence of phimosis is exaggerated. I have met with several 
 cases in circumcised Jews, while half of Townsend's cases were in girls. Fur- 
 thermore, patients have been operated on without relief. Yet phimosis is 
 sometimes a cause. Patients previously carefully treated without result do 
 sometimes get well immediately after circumcision or even after breaking up 
 adhesions between prepuce and glans. Phimosis is merely one of several con- 
 ditions giving rise to reflex incontinence. Among others are a small meatus, 
 rectal polypi and fissures, pin-worms, hardened faeces, and even, in one 
 reported case, a brass button in the nose. Masturbation is said to sometimes 
 result in incontinence. 
 
 Davenport reports a case, and refers to another, in which malposition of 
 the orifices of the ureters was the cause. 
 
 Among palliatives is avoidance of drinking large quantities of liquid late 
 in the day. This must not be overdone, for a too concentrated urine may be as 
 irritating as one too abundant. Regular habits of life seem of some use. I 
 had opportunity to observe a boy admitted to the hospital on the day that 
 an epidemic of measles began there. As he had been exposed, it was not 
 thought desirable to begin treatment until he had had the disease. He had 
 regular diet and hours with no excitement. Before the incubation period was 
 over the incontinence had ceased. He did not contract measles, and after a 
 reasonable time of observation was discharged. 
 
 This symptom, then, arises from the most varied causes and repays careful 
 study of the individual. The general health is never to be lost sight of. 
 Hopes of relief are reasonable, but it is never to be promised, and we are 
 not justified in assuming treatment to be successful until after a long lapse 
 of time. 
 
DIABETES MELLITUS, DIABETES INSIPIDUS 
 AND LITHIASIS. 
 
 By JAMES TYSON, M. D., 
 
 Philadelphia. 
 
 I. Diabetes Mellitus. 
 
 Diabetes Mellitus is a constitutional disease especially characterized by 
 the secretion of an abnormally large amount of urine charged with sugar. 
 "While in adults there is good ground for admitting at least two forms of dia- 
 betes mellitus, a mild and a severe form, in children I have as yet met only the 
 latter, of which the course is more rapid than in adults. 
 
 Etiology. — The etiology of diabetes in children is even more obscure than 
 in adults. In both heredity is an acknowledged influence, but with this ex- 
 ception the cause of diabetes in children may be said to be unknown. In 
 adults, while in the majority of cases a sufficient cause is sought in vain, there 
 are certain well-recognized influences, such as prolonged overwork, anxiety, 
 and grief, which favor its causation : these agencies cannot operate in children. 
 The sex-relation of diabetes is reversed in children as compared with adults, 
 it being more common in girls than boys. 
 
 Morbid Anatomy. — In the matter of morbid anatomy, too, we are unable 
 to find lesions which can be held responsible for the disease. Rather are they 
 the result of it. It is true that recent studies have shown an increasingly 
 close relation between diabetes and pancreatic disease, originally pointed out by 
 Lanceraux a number of years ago. Extirpation of the pancreas, according to 
 Yon Mehring, Minkowski, and Lepine, is invariably followed by diabetes if the 
 extirpation is complete ; and although De Dominicis, to whom we are indebted 
 for the original experiment, and De Renzi and E. Reale deny this, it is still 
 true that this operation is followed by glycosuria in a vast majority of cases, 
 while every year furnishes autopsies in which pancreatic lesions are far more 
 common than any other. At the same time, typical cases of diabetes are con- 
 stantly occurring in which there is no pancreatic disease. 
 
 Among anatomical lesions — in addition to those of the pancreas — which 
 are found in connection with diabetes, may be mentioned enlargement and 
 hardening of the liver, cirrhosis, dilatation of its capillaries, amyloid changes 
 in its cells ; hyperemia, and even slight grades of parenchymatous inflamma- 
 tion, of the kidney ; tuberculous foci and cheesy degeneration of the lungs ; 
 and a variety of lesions of the nervous system, especially in the neighborhood 
 of the medulla oblongata, among which tumors and traumatic lesions are the 
 
 . , *~™^~ 
 most common. 
 
 Symptoms. — In children, as in adults, a frequent desire to pass water, 
 with increase in quantity, intense thirst, and sometimes great appetite, are 
 the symptoms which commonly first attract attention. Examination of the 
 urine discovers the presence of grape-sugar or glucose, and a specific gravity 
 
 999 
 
1000 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 usually higher than normal, 1030 and upward, although a lower specific 
 gravity does not preclude the presence of sugar in considerable amount. 
 Rapid" emaciation, shrinking and dryness of the tissues, and constipation are 
 early associated. If we add the peevishness and restlessness which grow out of 
 these conditions, and occasional intense itching of the genitalia, we include most 
 of the symptoms which occur in children. The neuralgic pains and rheumatic 
 complications, the lung involvement so often seen in adults, are not com- 
 monly present in children. Cataract I have met in a single case, a boy of 
 sixteen. It was double. 
 
 The state of the urine, which contains sugar and is increased, varies as it 
 does in the adult. In a little girl four and one-third years old, under my care 
 for some time, whose case may be considered a fair example, the quantity 
 ranged from 65 to 200 ounces (1950 to 6000 cc.) in the twenty-four hours, 
 and the proportion of sugar from 13 to 34 grains to the ounce (3 to 7.5 per 
 cent.), the specific gravity 1018 to 1040. Toward the close of the disease 
 diacetic acid and aceton are found in the urine, and death by diabetic coma is 
 not unusual. Concurrent with the diaceturia and acetonuria are a diacetaemia 
 and acetonemia. 
 
 Albuminuria occurs in a certain number of cases of diabetes in children, 
 as in adults, from two causes : first as the result of irritation of the tubular 
 structure of the kidney by the sugar-charged urine, and second as a coin- 
 cidence. 
 
 Pneumonia is prone to occur, as in adults, tuberculosis to a less degree, but 
 gangrene I have not met in children. The suggestion that in a large number 
 of these cases the albuminuria is due to the excessive quantity of eggs con- 
 sumed in the diabetic diet I do not consider sustained by the facts. 
 
 Diagnosis. — With such a train of symptoms as those noted there should 
 not be much delay in recognizing diabetes mellitus, even without an examina- 
 tion of urine. All cases, are not, however, so clear, and such examination is 
 always necessary to a proper study of any case. The occasional confusion due 
 to the reducing effect of uric acid on the proto-salts of copper should be borne 
 in mind. The darker hue and scantiness of the uric-acid urines should excite 
 suspicion, while the absence of all other symptoms of diabetes should protect 
 against error. 
 
 The tests for sugar at once most delicate and to be relied upon are the cop- 
 per tests, and of these the most satisfactory is the solution known as Fehling's. 1 
 In using Fehling's solution for qualitative testing take 1 cc. of the solution and 
 dilute with four times its bulk of water ; boil the mixture thus obtained, and, 
 if it remain clear, it is fit to be used in completing the test. If, however, there 
 should be a precipitate of the red suboxide on boiling before any urine is added, 
 the solution is spoiled and a fresh one should be obtained. If the fluid remain 
 clear after the first boiling, the urine should be added, drop by drop, until a 
 bulk equal to the original mixture of Fehling's solution and water is ob- 
 tained; and if no yellow or red precipitate takes place, the urine may be 
 said to be free of glucose. It is scarcely necessary to say that the gray floccu- 
 
 ^ Fehling's solution is thus made : Dissolve 34.639 grams of pure crystallized sulphate of cop- 
 per in 200 cc. of distilled water ; 173 grams chemically pure crystallized neutral sodic-potassium 
 tartrate in 480 grams of solution of caustic soda of sp. gr. 1.14; and into this basic solution 
 pour the copper solution, a little at a time ; then dilute the resulting mixture to 1 litre with 
 distilled water. The tendency of Fehling's solution to deteriorate is well known. This may be 
 obviated by substituting glycerin or mannite for the tartaric acid, but more effectually by dis- 
 solving the sodic-potassium tartrate in 480 grams of solution of caustic soda and diluting to 
 500 cc. ; the copper in 500 grams of distilled water ; and keeping the solutions separate until 
 such time as they are wanted, when 1 cc. of each will furnish 2 cc. of Fehling's solution. 
 
DIABETES MELLITUS. 1001 
 
 lent precipitate of phosphates which sometimes occur should not be mistaken 
 for a precipitate of suboxide of copper. 
 
 A sufficiently accurate quantitative test may be made with Fehling's solution 
 thus used if it be remembered that it is of such strength that if the cupric oxide 
 be exactly reduced — that is, if the color is exactly removed by an equal bulk 
 of urine — that particular specimen of urine contains one-half of 1 per cent, of 
 sugar : if the color is removed by half of the bulk of urine, the sample contains 
 1 per cent.; and if twice the bulk of urine is required, the sample contains ^ 
 of 1 per cent. ; and so on. Moreover, if, as is usually the case, it is necessary, 
 by reason of the large percentage of sugar, to dilute the urine, the proportion 
 should be 1 to 9 of water. Then we proceed as before, multiplying the result 
 by 10. When it is remembered that it is impossible to judge accurately of the 
 progress of any case of diabetes mellitus without a quantitative analysis for 
 glucose, the importance of having an easy clinical quantitative method will be 
 appreciated. 
 
 In the absence of Fehling's solution the original form of the copper test sug- 
 gested by Trommer may be thus used : The urine is first alkalized by about one- 
 fourth its bulk of liquor potassae, and then a drop or two of a preferably weak — 
 say 1 to 30 — solution of cupric sulphate should be added. A precipitate ensues, 
 but if sugar be present the first drop or two of the copper solution is redissolved 
 on shaking. The addition should therefore be continued until a slight excess 
 remains, when heat is applied, and in a few seconds a precipitate of the yellow 
 cuprous hydroxide occurs. This subsequently loses its water and becomes the 
 red cuprous oxide. 
 
 Of the remaining tests for sugar it will be sufficient to give the fermenta- 
 tion test, which is easy and serves a quantitative as well as a qualitative 
 purpose, while it has fewer sources of error than any of the other tests. The 
 objections to it are that it requires several hours for its operation, and that 
 quantities less than a half of 1 per cent., or 2 J grains to the ounce, cannot be 
 detected. The simplest method of its application is as follows : Having taken 
 the specific gravity of the sample to be tested, fill a four-ounce bottle with the 
 urine, to which add a small piece — say the size of a pea— of German yeast 
 or a teaspoonful of brewer's yeast, after which shake thoroughly ; put aside in 
 a warm place, temperature 60° to 80° F., for at least twelve hours. At the 
 end of this time, sugar, if present, will have been converted by fermentation 
 into carbonic acid and alcohol, and the specific gravity proportionately low- 
 ered. For practical purposes it may be allowed, as originally ascertained by 
 Dr. Roberts, that for every degree of reduction of specific gravity on the urin- 
 ometer there is 1 grain of sugar to the fluidounce. Thus, if the original specific 
 gravity is 1040, and the specific gravity after fermentation 1020, there are 20 
 grains to the fluidounce. From this the percentage may be ascertained by 
 multiplying such difference by .23. Thus in the illustration named the per- 
 centage would be 4.6. 
 
 The matter of the selection of a specimen of urine for analysis is of the 
 greatest importance. It goes without saying that the most suitable sample is 
 a portion of the whole twenty-four hours' urine collected for the purpose. But 
 it is evident that it is often — indeed, almost always — impossible to do this. 
 Then my practice is to take two samples for analysis — one a portion of that 
 passed on rising in the morning, the other a portion of that first passed after 
 the evening meal, usually that passed at bed-time. If pains be taken always 
 to examine samples thus selected under the same conditions, comparisons may 
 be made from day to day or week to week which suffice for clinical purposes. 
 
 Prognosis. — The prognosis is unfortunately very bad in children. The 
 
1002 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 
 only case of a child I have ever known to recover was a girl of twelve under 
 the care of a friend. Life may, however, be prolonged for a time by careful 
 attention to dietetic, hygienic, and medicinal treatment. The course is, however, 
 always much more rapid than with adults, and the fatal termination comes 
 sooner. 
 
 Treatment. — In children, as with adults, the most efficient treatment is 
 the dietetic, and the greatest difficulty is that of getting a substitute for bread. 
 Of the various so-called gluten flours and breads, so far as I know, the only 
 ones made in this country which contain so little starch as to justify the name 
 pure gluten or almost pure gluten are the gluten flour of Theodore Metcalf & 
 Co., of Boston, Mass., 1 and the No. 1 gluten biscuit and No. 1 gluten meal 
 of the Sanitarium Food Company of Battle Creek, Mich. No new prep- 
 aration of gluten should be accepted for what it claims to be unless the claim 
 is sustained by analysis. In England and France diabetics are more fortu- 
 nate, as they can secure flour, bread, and biscuits containing a minimum amount 
 of starch. The great objection to all pure gluten preparations is that they are 
 more unpalatable than the bread made of flour from w T hich the starch has not 
 been removed. But it should be made clear to the friends of the patient that 
 he must make his choice of the two evils. 
 
 It is not always necessary that the purest attainable gluten preparations 
 should be used in mild cases, as in these a certain amount of starch is 
 assimilable ; but such latitude must be based on trial of fixed quantities of the 
 given breads associated with careful quantitative analyses of the urine selected 
 as directed. To such the so-called " bran bread " made out of unbolted flour, in 
 which the ratio of starch is of course less, and oatmeal gruel with cream, may 
 be allowed. Unfortunately, mild cases of diabetes are not commonly found in 
 children. 
 
 Among the substitutes for the white flour so much used is almond flour, 
 and it is totally without objections, so far as its composition is concerned. 
 The patient is apt to tire of it as of anything else from exclusive use, and 
 fair digestive capacity is required. 
 
 Various other flours have been suggested. One of these is the flour of the 
 soya bean [Soya hispicla), a native of Japan, but now extensively grown 
 in Europe, said to contain only 4 per cent, of starch. It is, moreover, 
 very rich in nitrogenous substances. From this are made bread and biscuit. 
 A flour known as poluboskos contains a small quantity of starch, and is a 
 suitable food for most diabetics. Fromentine is another of these flours made 
 from the embryos of wheat, which, so far as I know, is not yet obtainable 
 in this country. Like the soya flour, it contains a considerable quantity of 
 oil, which not only renders pannification difficult, but disposes to early ran- 
 cidity. Efforts are also being made to isolate for the same purpose legumine, 
 the caseine of the leguminous vegetables. The substance so isolated is known 
 as embryonine. 
 
 1 The following are the directions suggested by Dr. John A. Jefiries in common use for 
 making gluten biscuit out of the Metcalf flour : 
 
 Gluten flour 1 cup. 
 
 Best bran, previously scalded 1 cup. 
 
 Baking powder . . > 1 teaspoonful. 
 
 (Or the equivalent of bicarbonate of soda and cream tartar. ) 
 
 Salt to taste. 
 
 E £gs • ' • two. 
 
 Milk or water 1 Cll p. 
 
 Mix with a spoon. 
 
DIABETES MELLITUS. 1003 
 
 The appended table is one which has been my guide for many years, and 
 I believe it includes most of the articles admissible : 
 
 Food axd Drink Admissible in Diabetes Mellitus. — Shell-fish. — 
 Oysters, mussels, and clams, raw and cooked in any way, without the addition 
 of flour. 
 
 Fish of all kinds, fresh or salted, including lobsters, crabs, sardines, and 
 other fish in oil ; fish-roe, caviar. 
 
 Meats of every variety except livers, including beef, mutton, chipped dried 
 beef, tripe, ham, tongue, bacon, and sausages ; also poultry and game of all 
 kinds, with which, however, sweetened jellies and sauces should not be used. 
 
 Soups. — All made without flour, rice, vermicelli, or other starchy sub- 
 stances, or without the vegetables named below as not allowed ; animal soups 
 not thickened with flour, such as bouillon, beef-tea, and broths. 
 
 Vegetables. — Cabbage, cauliflower, Brussels sprouts, broccoli, green string 
 beans, the green ends of asparagus, spinach, tomato, dandelion, mushrooms, 
 lettuce, endive, coldslaw, olives, cucumbers, fresh or pickled, radishes, sorrel, 
 young onions, water-cresses, mustard and cress, turnip tops, celery tops, arti- 
 chokes, gherkins, okra, parsley, or any other green vegetables. 
 
 Fruits. — Cranberries, plums, cherries, gooseberries, red currants, straw- 
 berries, acid apples, lemons, oranges sparingly, all without sugar. Acid fruits 
 may be stewed with the addition of bicarbonate of sodium instead of sugar. 
 
 Bread and cakes made of gluten, soya, almond flour, inulin, "poluboskos," 
 fromentine, or embryonine, with or without eggs and butter. Griddle-cakes, 
 pancakes, biscuit, porridges, etc., made of these flours. In cases requiring 
 less stringency the so-called "bran bread," made of unbolted flour, the crust 
 of bread, and oatmeal porridge with cream. 
 
 Eggs in any quantity, and prepared in all possible ways, without sugar or 
 ordinary flours ; butter and cheese. 
 
 Nuts. — All except chestnuts, including almonds, walnuts, Brazil nuts, 
 hazelnuts, filberts, pecan-nuts, butternuts, cocoanuts. 
 
 Condiments. — Salt, vinegar, and pepper in moderate quantities. 
 
 Jellies. — None but those unsweetened, except by saccharin. They may 
 be made of calf s-foot or gelatin and flavored with wine. 
 
 Drinks. — Coffee, tea, and cocoa-nibs, with milk or cream, but without 
 sugar ; also Vichy, Vals, and Carlsbad waters, carbonated waters, and all 
 mineral waters freely ; lemonade without sugar, acid wines, including claret, 
 Bordeaux, Rhine, and still Moselle wines, diluted with Vichy or similar waters, 
 very dry sherry ; unsweetened brandy, whiskey, and gin. No malt liquors, 
 except those ales and beers which have been long bottled and in which the 
 sugar has largely been converted into carbonic acid and alcohol. Saccharin 
 may be used for sweetening. 
 
 To be Especially Avoided. — Potatoes, white and sweet, rice, beets, carrots, 
 turnips, parsnips, peas, and beans ; all vegetables containing starch or sugar 
 in any quantity ; sweet wines, including sherry, Madeira, port, and cham- 
 pagne. 
 
 The hygienic treatment of diabetes mellitus is important. The patient 
 should be bathed frequently, and brisk friction should succeed the bathing in 
 order to stimulate the circulation. Out-door life and muscular exercise, short 
 of that sufficient to excite fatigue, should be insisted upon, the idea being to 
 stimulate every process which may result in the oxidation of sugar. For a like 
 reason the sleeping-room should be well ventilated and the purest air supplied 
 to it. 
 
 The medicinal treatment of diabetes is limited, as there are few drugs 
 
1004 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 having power to control the defective assimilation resulting in sugar excretion. 
 The most efficient of these is undoubtedly opium and its preparations and alka- 
 loids, any one of which possesses this power. Codeine is, however, the prepa- 
 ration usually selected, because it is less apt to produce the harmful effects of 
 the other chief alkaloid, morphine. It is, however, much more expensive. 
 While generally better borne than morphine, it does sometimes nauseate as 
 well as constipate. That it controls the sugar output is abundantly proven. 
 Moreover, I have reason to believe from my own experience that it occasionally 
 happens that where sugar has disappeared during treatment by codeine, it does 
 not return after discontinuance. It is desirable, however, to put off the use of 
 opium, as a rule, until other measures and drugs fail. If the efficiency of 
 opium in diabetes be based upon its sedative action, then the bromides should 
 also be useful, and it does occasionally happen that they serve a good purpose ; 
 but in my experience they are of limited utility. 
 
 After opium, arsenic is perhaps the drug which has longest maintained its 
 reputation as a remedy in diabetes mellitus, but its usefulness, like that of 
 most drugs, is limited to the milder cases. There is no better preparation than 
 Fowler's solution, of which the dose is so easily regulated. The action is unex- 
 plained, although a reasonable theory has recently been advanced by Cuth- 
 bertson of Chicago, who says it is partly local upon the stomach, bowels, or 
 respiratory organs, and partly on blood-cells, increasing their activity, and 
 therefore the oxidation of sugar. The dose must be regulated by the age, 
 from a drop to five drops three times a day, increased until slight oedema of 
 the face results. It is often combined with lithium carbonate, 1 to 5 grains, 
 by which its effect is sometimes increased. The bromide of arsenic, originally 
 recommended by Clemens, is sometimes given, but I have not found it more 
 efficient than Fowler's solution. The preparation commonly used is Clemens's 
 solution of bromide of arsenic, of which the dose is 2 to 5 minims, the smaller 
 dose for children. 
 
 Ergot is a drug which is sometimes efficacious, but I value it less highly 
 than I used to. That it sometimes exerts a controlling effect I have not the 
 least doubt. The best form is the fluid extract in doses of five minims to 
 a drachm. 
 
 That the coal-tar series of antipyretics, including antipyrine, antifebrin, 
 phenacetin, and sulfonal, prominently brought forward by the French school 
 of physicians, have in the milder forms of diabetes a controlling influence, I can 
 also assert from my own experience. As claimed by the French school, 
 their efficiency is increased by combinations with alkalies, sodium carbonate 
 being commonly used in the proportion of twice the dose of the antipyretic. 
 Thus, if 15 grains of antipyrine are given, 30 grains of sodium bicarbonate are 
 added, and these doses are recommended by Dujardin-Beaumetz and Germain- 
 See for adults. They are bulky and apt to derange the stomach, and they 
 should not be given after meals. My method has been to give the com- 
 bined drugs in equal doses before meals. For children they should be much 
 smaller — 3 to 10 grains of the drug, with an equal quantity of sodium bicar- 
 bonate. If the antipyretic is given alone, it may be given after meals, 
 although a somewhat larger dose is then required. 
 
 Salicylate of sodium has some reputation, and may be used, especially 
 when the diabetes is associated with rheumatism. 
 
 Alkalies alone, doubtless, have an effect in the diabetic process, and it is 
 this constituent to which the alkaline mineral waters of Vichy, of Vals, and of 
 Carlsbad owe their chief efficiency. None of the negative mineral waters in 
 this country, so much vaunted by their owners as specifics, have in my expe- 
 
DIABETES INSIPIDUS. 1005 
 
 rience any effect whatever. Persons visiting the sources of these waters may 
 be benefited, but the associated diet, and not the waters, is the efficient agent. 
 
 A great many remedies have from time to time been suggested as useful in 
 diabetes, and I have tried most of them as opportunity presented, generally 
 with negative results. One of the most recent of these is jambul (Syzygium 
 jambolanum). A careful and systematic trial by myself in three cases has 
 resulted in signal failure. The dose given is from ten drops to a drachm. 
 
 The latest of these remedies is creasote, which I have not yet tried. It is 
 recommended by Audibert as producing excellent results where diet did not 
 seem in any way to influence the intensity of the glycosuria. The quantities 
 used were : first 2, then 4, and finally 6, grains daily for adults. The gly- 
 cosuria steadily diminished in one case in spite of the fact that the patient, 
 despairing of any results, deliberately neglected all dietetic rules. 
 
 II. Diabetes Insipidus. 
 
 Diabetes insipidus is a nervous affection, mainly functional, characterized 
 by the secretion of a large amount of urine of low specific gravity. 
 
 While diabetes insipidus is a much rarer disease than diabetes mellitus, it is 
 believed to be relatively more frequent in children than the latter. Out of 70 
 cases collected by Roberts, 22 were under ten years of age, and 13 between ten 
 and twenty ; out of 85 by Strauss, 21 were under ten ; and of 87 by Von der 
 Heijden, 7 were under ten and 19 between ten and twenty. 
 
 Etiology. — Nervous influences, such as those which produce hysteria — 
 viz. shock, fright — are the principal causes of diabetes insipidus. Thus a boy 
 of ten years, recently treated by myself, was choreic at various times prior to 
 the attack of polyuria, and was very nervous throughout the illness, from 
 which he recovered. 
 
 Morbid Anatomy. — No definite morbid anatomy has been found asso- 
 ciated with simple polyuria. The kidneys have been found sacculated in 
 various degrees, more likely as a consequence of the enormous accumulation 
 of liquid filling the bladder and pressing backward through the ureters upon 
 the kidney structure, causing its atrophy. Tubercular and gliosarcomatous 
 tumors in the neighborhood of the floor of the fourth ventricle have been 
 found. 
 
 Symptoms. — The chief symptom is a profuse polyuria associated with 
 a proportionate thirst. The quantity of urine exceeds that of all ordinary 
 cases of diabetes mellitus. The boy of ten referred to would pass a quart at 
 a single sitting, while the frequency of the desire to pass water made it impos- 
 sible to attend school. The specific gravity is proportionately low, generally 
 1002 to 1006, and I have known it to be scarcely above 1000. For the 
 twenty-four hours' urine the other constituents remain usually normal, while 
 albuminuria is much more rare than in diabetes mellitus. 
 
 As a natural result of such a condition there is great dryness of the skin 
 and mucous membranes. On the other hand, there is never that extreme 
 emaciation seen in children with diabetes mellitus, and the patients are often 
 fairly well nourished. This is favored by the fact that the appetite is apt to 
 be increased, from which, indeed, derangements of digestion may result. 
 
 Other nervous symptoms frequently attend or precede diabetes insipidus, 
 such as chorea, restlessness, and sleeplessness. 
 
 Diagnosis. — The diagnosis of diabetes insipidus is easy. The enormous 
 quantity of urine passed, its low specific gravity, and the absence of sugar, 
 if maintained for any length of time, can mean nothing else. It is barely 
 
1006 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 possible that the milder forms might be confounded with chronic interstitial 
 nephritis in adults, but in children this seems impossible. The presence of a 
 trace of albumin should, however, lead to an exhaustive examination of the 
 urine for casts and other signs of interstitial nephritis— a very rare disease in 
 children. 
 
 Prognosis. — The prognosis in my experience is generally favorable, the 
 patient sooner or later getting well. 
 
 Treatment. — Cases under my care have usually yielded sooner or later to 
 ergot or gallic acid, the former in beginning doses of 10 minims of the fluid 
 extract, or less according to age, and increasing until results are obtained or 
 full doses reached without effect. Gallic acid may be given in 5-grain doses at 
 the beginning and increased. For antipyrine and antifebrin great efficiency in 
 the treatment of this affection has recently been claimed. While I have as yet 
 had no opportunity to try them, my experience with these drugs in diabetes 
 mellitus leads me to expect that they will be even more efficient in diabetes 
 insipidus. The same reasoning leads me to expect that bromide of potassium 
 would be useful, as it sometimes is. 
 
 Valerian is one of the older remedies for simple polyuria, and it can be 
 easily understood why it should be useful in nervous cases. The older physi- 
 cians used powdered valerian and valerianate of zinc, but at the present day 
 the more elegant preparation of elixir of the valerianate of ammonium, in doses 
 of half a drachm, a drachm, or more according to age, should be substituted. 
 The exceedingly disagreeable smell of the substance is in the way of its gen- 
 eral use. Opium is also recommended in diabetes insipidus, but has made for 
 itself no reputation like that it has attained in saccharine diabetes. 
 
 A blister at the nape of the neck or on the epigastrium was suggested by 
 Roberts, and might be expected to be of service by its impression on the ner- 
 vous system. The constant galvanic current would be reasonably useful from 
 the same standpoint, and is recommended by Seidel and Kuelz, the former of 
 whom applied daily one pole of a strong battery over the loins near the spine 
 and the other as deeply as possible over the hypochondrium. 
 
 In the matter of drinking water a moderate restriction should be exercised 
 in diabetes insipidus, but to cut down the amount of water largely is a cruelty 
 unjustified by the results. The cry for water is a demand to make up a loss 
 from the economy by the kidneys. It is an effect, and not a cause. Yet it is 
 possible to carry drinking to excess after a habit is once acquired, and for the 
 effect thus to become the cause. To prevent this a reasonable oversight should 
 be exercised. 
 
 HE. Lithiasis. 
 
 Lithiasis is the deposition of certain solids of the urine in the urinary 
 tract, any portion of which, from its beginning in a Malpighian capsule to its 
 terminal expansion, the bladder, may be the seat of such deposit. The 
 sediments thus precipitated include, in the order of frequency, first, uric acid 
 and its compounds of sodium, potassium, and ammonium ; second, oxalate of 
 lime ; and, third, the phosphates of calcium, magnesium, and ammonium. A 
 clot of blood or fragment of foreign matter may be the nucleus of calculi thus 
 formed. They may be so minute as to be barely visible to the naked eye, 
 constituting sand or gravel, or they may be a couple of inches or more in diam- 
 eter, when they are spoken of in common language as stones in the kidney or 
 bladder. 
 
 As stated, the most frequent sediments are uric acid, which are often found 
 in the shape of red sand in the very first urinary discharges of the new-born 
 

 LITHIASIS. 
 
 1007 
 
 infant. Calculi may form, consisting of pure uric acid or its compounds, but 
 thev are seldom large. Less common are small stones of pure oxalate of lime. 
 More commonly large stones consist of nuclei of uric acid or oxalate of lime, 
 around which phosphates are deposited in concentric layers. Phosphates rarely 
 form the nuclei of stones. The alkaline reaction of urine, which is necessary 
 to the deposit of phosphates, is not common in children fed on milk. It is 
 not until vegetable substances are added to the diet that the alkaline reaction 
 becomes conspicuous. More frequently the alkalinity necessary to the pre- 
 cipitation of phosphates is the consequence of organic matter generated in 
 inflammatory processes, especially those excited by calculi themselves. This 
 occurs as soon as they reach a sufficient size to act as irritants producing local 
 
 Fig. 1. 
 
 Calculi impacted in the Ureters. From a boy of 5 years (Tyson). 
 
 inflammation. They thus become surrounded by alkaline urine, whence phos- 
 phates are deposited in concentric layers around the uric-acid or oxalate-of- 
 lime nucleus. 
 
 It has been said that calculi may form in any part of the urinary tract. 
 Hence they may be found imbedded in the kidney, circumscribed and encap- 
 sulated in the centre of the organ. Thus situated, they may grow by accretion 
 until they have almost destroyed the entire organ, filling up its pelvis and cal- 
 yces, converting the entire kidney into a pus-sac ; or they may even make their 
 way through the capsule of the kidney into the perinephric tissues, and thence 
 
1008 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 down into the pelvic cavity. Appended is a drawing of a remarkable specimen 
 occurring in the practice of the writer in a boy of five years, twice success- 
 fully operated upon for stone in the bladder, the first time when but three years 
 old. He perished finally of exhaustion. The necropsy only revealed the extent 
 of the mischief. The stone in the left ureter was spirally spindle-shaped, and 
 measured b.5 cm. long and 1.5 cm. wide in the thickest part. The stone in 
 the right ureter was 10.5 cm. long and 1 cm. through at its thickest part. The 
 bladder also contained a small stone 2.5 cm. long and ranging in diameter from 
 .5 to .75 cm. 
 
 Etiology. — It would scarcely be profitable to attempt to discuss the causes 
 why in one child there is a tendency to deposit uric-acid sediment, or why in 
 another under apparently the same conditions an oxalic-acid lithiasis should 
 exist. The conditions which favor phosphatic deposits have been mentioned. 
 Whatever may be the cause of each, there can be no doubt that in every case 
 the deposit of sediments is favored by a reduction in the amount of water sep- 
 arated by the kidneys — a condition which depends largely on the amount of 
 liquid ingested. The reaction of the urine, whether acid or alkaline, also plays 
 an important role. Phosphatic sediments are never spontaneously deposited 
 from an acid urine, nor uric acid from an alkaline urine. The law cannot be 
 so sharply laid down with regard to oxalate sediments, crystals of oxalate of 
 lime being deposited in alkaline as well as acid urines, although I believe the 
 reaction of urine containing them is most frequently acid. 
 
 Calculi may present themselves at any age, and probably begin their 
 formation sometimes even before birth. At any rate, large stones have been 
 removed from the bladders of children in the first year after birth — too large, it 
 would seem, to have been produced in the short time which had elapsed since 
 birth. 
 
 Symptoms. — The symptoms of lithiasis in the child vary very greatly 
 according to seat and degree. For convenience, such symptoms may be divided 
 into those caused by sand or gravelly deposits, those caused by calculi in the 
 bladder of such size as to justify the term " stone," and those caused by calculi 
 impacted higher up in the urinary tract, in the pelvis of the kidney and in 
 the ureters. 
 
 Sand or Gravel in the Bladder. — A simple peevishness or fretfulness or 
 other evidence of pain in an infant, with retractions of the limbs, may be caused 
 by gravel, evidence which is confirmed by red-pepper-like sediment on the 
 napkin or an unusually dark staining of the latter by urine. The same condi- 
 tion in an older child may give rise to more intelligible manifestations of dis- 
 comfort, which may be located in the lumbar region, in the groin, or in the 
 urethra. A very common mode of manifestation of discomfort in the latter 
 situation and in the neck of the bladder is traction upon the prepuce, which 
 often becomes elongated in consequence. At this early age a frequent desire 
 to pass water, and especially wetting the bed at night, should lead to examina- 
 tion of the urine, the presence wherein of uric-acid or oxalate-of-lime sediments 
 would, together with dark color and high specific gravity, add further probability 
 of the presence of such a cause. 
 
 Stone in the Bladder manifests itself by very much the same symptoms, though 
 intensified, especially the disposition to draw upon the prepuce and frequency of 
 micturition. Tenderness in the region of the kidney will be found where the 
 pelvis is the seat of detention of the calculus, and not infrequently bulging, 
 and even fluctuation from the presence of pus, may be detected. Abdominal 
 palpation should not be neglected, as enlargements of the kidney are very apt 
 to be anterior in direction. Examination of the urine may give negative 
 
LITHIASIS. 1009 
 
 results, or it may show the presence of the crystals already mentioned ; more 
 frequently the secretion contains evidence of irritation of the bladder in the 
 presence of mucus or pus, while a trace of albumin will attend the presence of 
 pus. When mucus or pus is absent, the microscope may still discover mucus 
 threads or so-called mucus-casts, which always mean irritation of the genito- 
 urinary passages short of what is sufficient to produce mucus or pus in the urine. 
 Such urines, if not already alkaline when passed, readily become so, and the 
 alkalinity thus produced tends to make the urine viscid and glutinous. Where 
 the alkalinity takes place in the bladder in the presence of pus, this 
 glairv material is formed in the viscus, and micturition becomes difficult or 
 impossible. 
 
 Such a set of symptoms will of course suggest the use of the bladder-sound, 
 by which a stone is commonly readily recognized. 
 
 The continuance of symptoms of such severity as are caused by the larger 
 stones soon affects the general health of the patient, as attested by feverishness 
 and gradually growing emaciation, which may terminate in death. 
 
 Diagnosis. — This is successful according as the lines of investigation may 
 be thorough or otherwise in the examination of urine, palpation, and the use 
 of the sound. 
 
 Prognosis. — This is generally favorable, the use of appropriate solvent 
 medicines and diet being sufficient to correct the states wherein only gravelly 
 sediments are present ; while the surgeon's knife even more promptly removes 
 the stone from the bladder or kidney, nephrotomy to-day saving many lives 
 which would have formerly been lost. It is only, for the most part, those cases 
 which have advanced too far, or which present the peculiar conditions presented 
 in Fig. 1, which are beyond the reach of any remedy, and gradually wear 
 out the patient. 
 
 Treatment. — As soon as a stone of size sufficient to be recognized by a 
 sound, or by localized pain or tenderness in the kidney itself, is discovered, 
 there is but one course to be pursued. The case must be handed over to the 
 surgeon. At the present day no intelligent physician expects to dissolve away 
 a stone by medicinal treatment. 
 
 From the physician's standpoint, treatment is therefore limited to such 
 cases in which the lithiasis is confined to gravelly sediments. Of these there 
 can be no rational treatment except after a thorough chemical and microscopi- 
 cal study of the urine, and, although symptoms may be relieved without such 
 study, the success attained is accidental, and reflects no credit on him who 
 employs it. The management demanded by different conditions is often dia- 
 metrically opposite. 
 
 If, on examination, the urine is found highly acid in reaction, depositing 
 uric-acid sediments, the treatment is pre-eminently by alkalies. It does not 
 much matter what alkalies are used. They should, however, be associated with 
 an abundance of liquid, in order the better to furnish a solvent for the uric 
 acid. The liquor potassae of the U. S. Pharmacopoeia is an excellent remedy in 
 doses of 5 to 20 minims, the dose being adapted to the age of the patient and 
 administered three or four times a day. The object should be to alkalize the 
 urine, and in testing it a time of day should be selected when the urine is most 
 likely under ordinary circumstances to be acid. Such a time is the early morn- 
 ing before food is taken. Milk is an admirable medium for liquor potassas. The 
 salts of potash are also useful, and there is less danger of an overdose. The citrate 
 and carbonate are equally efficient in doses of 5 to 15 grains three or four times 
 a day, or oftener if necessary to secure an alkaline reaction. With alkalinity 
 established, uric acid cannot be precipitated. On the other hand, care must 
 
 64 
 
1010 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 be taken to avoid the opposite extreme — having escaped Scylla, to steer clear 
 also of Chary bdis. If the urine be made too highly alkaline, the phosphates 
 will fall and the sediments of these urinary constituents arise. The alkaline 
 mineral waters, of which the imported Vichy waters are the type, and even 
 negative mineral waters, are useful in the uric-acid lithiasis. 
 
 The new substance, piperazine, is an admirable solvent for uric acid in 
 doses of 3 to 5 grains for children. 
 
 On the other hand, if we have an alkaline urine to contend with and per- 
 sistent phosphatic deposits, we must seek to make the urine acid. This, unfor- 
 tunately, is not so easy. There are very few medicines which have this tend- 
 ency. Benzoic acid and boric acid are the only ones, and neither of them 
 is well borne in large doses by children. But they should be given in doses 
 of 1 to 5 grains every three hours, or often enough to secure the acid reaction 
 sought for. 
 
 Oxalate of lime, unfortunately, is insoluble in both acids and alkalies. At 
 the same time, it is sometimes formed under the same conditions as uric acid. 
 The same general plan of treatment may be carried out. 
 
 Oxalate-of-lime sediments frequently attend dyspeptic states, which are 
 successfully treated by acids, especially nitromuriatic, which should be cau- 
 tiously administered in combination with suitable doses of tincture of nux 
 vomica, or even strychnine, with pepsin or pancreatin. 
 
 Where the composition of gravel cannot be determined, it is a great deal 
 better to give an abundance of distilled water than the alkalies and alkaline 
 mineral waters, by which we only add fuel to the flame if it happens that we are 
 dealing with phosphatic gravel. 
 
 As to diet, if the gravel be uric acid, meats and albumens should be limited, 
 as they tend to produce an acid urine and uric-acid sediments. On the other 
 hand, milk and vegetables tend to alkalize the urine. Abundant experience 
 has taught me that not only during childhood, but also during infancy, parents 
 are too indifferent about giving their children pure water to drink. Children 
 should be encouraged to drink water between meals, and infants should be 
 given pure water to drink two or three times a day. They soon grow fond of 
 it, and in this way liquid is furnished to flush out the excretory channels of the 
 economy, and to dissolve the solids which can only be removed in solution. 
 
 In children, no less than in adults, pain must be relieved by appropriate 
 anodynes. The milder preparations of opium, as paregoric, should be made 
 to suffice, because of the danger of the stronger preparations. The sup- 
 pository is a convenient and effectual medium. Phenacetin will often relieve 
 the milder, and sometimes even quite severe, degrees of pain, especially if it 
 be renal. Five to ten grains may be given at a dose. 
 
ACUTE AND CHRONIC NEPHRITIS, AND AMY- 
 LOID DISEASE OF THE KIDNEY. 
 
 By I. N. DANFORTH, M. D., 
 
 Chicago. 
 
 I. Acute Tubal Nephritis. 
 
 Synonyms. — Acute catarrhal nephritis ; Acute desquamative nephritis ; 
 Acute croupous nephritis ; Acute parenchymatous nephritis ; and Acute 
 Bright's disease. 
 
 Etiology. — In adult life exposure to cold and wet is the most common 
 cause of acute tubal nephritis, but it is a curious and interesting fact that the 
 disease is very rarely produced in children in this way. My experience quite 
 accords with that of Ralfe, who says, ■' I have never yet succeeded in obtaining 
 a history of exposure to cold and wet in a case of acute nephritis occurring in 
 childhood." The usual causes are acute febrile diseases, especially the exanthe- 
 mata ; septic diseases, like diphtheria and erysipelas ; and traumata, such as 
 burns, scalds, and injuries involving the nervous centres. Certain drugs in 
 use among children, notably cantharides and turpentine, are capable of inflam- 
 ing the kidneys, and I have known the extravagant use of highly-flavored 
 confections produce the same result. 
 
 Symptoms. — The symptoms of a well-marked case of acute nephritis are 
 always pronounced and aggressive. The patient is sometimes seized with an 
 initiatory chill, but if this is absent pyrexia is always present, the temperature 
 ranging from 100° to 103°, or even 104°F., and maintaining this altitude for 
 from six to twelve days. The pulse is frequently tense, and has a peculiarly 
 quick, short, nervous beat, thus giving expression to the cardiac irritation 
 characteristic of the uraemic state. The tongue is coated, the appetite lost, and 
 the bowels constipated. There is generally deep dull pain in the lumbar 
 region, due to the swollen condition of the kidneys. Headache is a prominent 
 symptom, vertigo is not uncommon, transitory strabismus sometimes occurs, 
 and if relief is not promptly obtained uraemic convulsions supervene, to be fol- 
 lowed by partial or perhaps profound coma, with probably dilated, but 
 certainly uncontracted, pupils. If the coma is not complete, obstinate 
 nausea with violent retching will probably occur; that is, the vomiting of 
 uraemia. 
 
 The urine is diminished in quantity from the first, and this significant 
 symptom progresses until complete suppression may occur. The reaction is 
 usually acid; the specific gravity increases from 1.025 to 1.040, in the early 
 stage, but diminishes later ; the color varies from pink to a vivid red. the 
 intensity of the color denoting roughly the quantity of blood present, for it 
 rarely happens that acute nephritis is not attended by well-marked haematuria. 
 Albumin is always present in large quantities, at least one-quarter, and 
 frequently three-quarters, by volume ; that is, when a specimen of urine is 
 
 1011 
 
1012 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tested by heat and nitric acid in a test-tube and allowed to stand for twelve 
 hours, the albumin will occupy from one-quarter to three-quarters of the space. 
 A copious sediment will fall when the urine is set aside ; this is made up of 
 hyaline, epithelial and blood-casts, free blood-globules, many of them crenated, 
 renal epithelium, granular urates, and amorphous matter. In the early stage 
 blood-casts will predominate ; later on, epithelial and hyaline casts are more 
 abundant, and before convalescence is established some fatty or granular casts 
 may appear, although they are usually few and far between, unless the case 
 falls into a chronic condition. 
 
 Dropsy appears very early in the case, generally manifesting itself first in 
 the lower eyelids, cheeks, or the loose tissues of the neck ; it then invades the 
 feet and travels upward, reaching the scrotum or labise, then the abdominal 
 cavity, and it may be the pleural or pericardial cavities. (Edema of the lungs 
 may occur ; the glottis may be distended with fluid, threatening or even 
 causing death by asphyxia, although this can generally be avoided. As 
 already intimated, the heart's action is rapid and the systole is quick, powerful, 
 and " angry," because of ursemic irritation and increased arterial tension. 
 
 The foregoing account of symptoms relates to a well-marked typical case. 
 Of course mild cases occur, when the symptoms are much less pronounced ; bux 
 it is also true that cases of greater severity and more rapid progress are occa- 
 sionally seen, which generally prove rapidly fatal from acute uraemia. 
 
 Morbid Anatomy. — The kidney is swollen, not hypertrophied, but dis- 
 tended with blood and also by the contents of the convoluted tubes. Dickin- 
 son relates a case in which the capsule of both kidneys was ruptured by the 
 intense distention caused by congestion, but this is a very exceptional occur- 
 rence. The color of the kidney is much darker than normal, and the stellate 
 veins stand out with great distinctness. If the organ be laid open lengthwise, 
 blood will drip freely from the cut surface, and it will be seen that the cortical 
 substance is apparently much increased. The Malpighian bodies sometimes 
 project above the level of the incised cortex, and may be felt as little rounded 
 bodies under the finger. Microscopic section shows the small vessels much 
 dilated, especially those of the glomeruli ; in fact, these are in many instances 
 ruptured. The convoluted tubes are much distended by casts, blood-globules, 
 cast-off epithelia, and granules or crystals of urinary salts, and the straight 
 tubes are in less degree distended by similar contents. If the disease passes 
 into the chronic stage, of course the kidney will show granular or fatty degen- 
 eration. 
 
 Diagnosis. — The diagnosis of acute nephritis can scarcely be said to pre- 
 sent any difficulties. The rapid invasion, early occurrence of dropsical effusion, 
 arterial tension, and especially the scantiness of the urinary secretion, together 
 with its pink or red color, at once indicate the nature of the illness. Of course 
 an examination of the urine will at once remove all doubts. Acute nephritis 
 may be complicated with, or rather preceded by, chronic nephritis, but a 
 microscopic examination of the urinary sediment will at once reveal the 
 characteristic fatty or granular casts, which will establish the real facts in the 
 case. Moreover, a careful inquiry into the history of the patient will result in 
 the discovery of symptoms indicating pre-existing renal disease. Cyanotic 
 induration of the kidneys may possibly be mistaken for acute nephritis, but a 
 careful examination of the heart will clear up the doubt, since this disease 
 is almost invariably associated with some obstructive lesion of the cardiac 
 valves, especially the mitral. Careful inquiry will also develop the fact that 
 the disease has existed for a length of time which rules acute nephritis out of 
 the question. As cyanotic induration is not very uncommon in children, 
 
PLATE XXI. 
 
 
 .. . 
 
 9 ♦.. 
 
 
 m 
 
 I 
 
 TUBE-CASTS AND URINARY SEDIMENTS. 
 
 Fig. 1. Hyaline Cast, Lithic-Acid Crystals, Granular Epithelia (Acute Tubal Nephritis). \ 150 diameters 
 
 Fig. 2. Epithelial Cast, Lithic-Acid Crystals (Acute Tubal Nephritis). \ 150 diameters. 
 
 Fig. 3. One Epithelial and Two Hyaline Casts (Chronic Interstitial Nephritis). \ 150 diameters. 
 
 Fig. 4. Hyaline Cast and Renal Epithelia, stained (Chronic Interstitial Nephritis). \ 150 diameters. 
 
 Fig. 5. Waxy Cast (Amyloid Degeneration). X 150 diameters. 
 
ACUTE TUBAL NEPHRITIS. 1013 
 
 it should always be borne in mind when renal symptoms are under investi- 
 gation. 
 
 Prognosis. — Acute nephritis is always a grave disease, and is by no means 
 free from danger. Yet, if recognized early and treated appropriately, there 
 are few serious diseases that yield better results. Of course, I am now 
 speaking of uncomplicated diseases. But the danger is greatly increased 
 if the child has cardiac insufficiency, bronchitis, tuberculosis, or any other 
 organic affection. If proper treatment be not instituted until inflammatory 
 exudation has been poured into the tubes and capsules of Bowman, the 
 chances of recovery are diminished, although the case is not hopeless. Sup- 
 pressio urinae and uremic convulsions indicate a condition of extreme danger, 
 but I have seen several perfect recoveries even after these untoward symptoms 
 have appeared. Children are more apt to recover than adults ; in fact, granted 
 an otherwise healthy child, an early diagnosis, and prompt and vigorous treat- 
 ment, the great majority of cases will recover without damage to the kidneys. 
 
 Treatment. — Promptitude without precipitation and vigor without rash- 
 ness should guide the physician in the treatment of acute nephritis. It is fre- 
 quently the case that a judicious blow at the right time saves a life, and, on 
 the other hand, it is equally true that hesitation and delay cost the life or 
 blight the future of many a child. If the child be strong and vigorous and 
 the attack be violent, it will be wise to apply three or four leeches over each 
 kidney, or, if the leeches cannot be obtained, blood should be taken by means 
 of cups. The amount must of course depend on the age and strength of the 
 child, but two ounces would be none too much to take from each renal region 
 if the child be from six to eight years of age and in vigorous health at the 
 time of the attack. Immediately following the bleeding a large hot linseed 
 cataplasm should be applied, so as to entirely encircle the body at the level of 
 the kidneys. If the poultices be covered with rubber cloth or oiled silk, they 
 need not be changed oftener than every six hours. It is very important that 
 they be made to " fit " the body closely, and if a little powdered mustard be 
 incorporated in each poultice, it will be an improvement. But no stimulating 
 applications, like turpentine stupes, should be employed in the early stage of 
 the disease. 
 
 The practitioner should next turn his attention to the all-important neces- 
 sity for securing elimination of the urinary factors by other agents than the 
 kidneys. Fortunately, the alimentary tract and the skin afford ample means 
 for accomplishing this. A vigorous cathartic should be given, and I am much 
 in favor of administering from one to three grains of calomel, and following it 
 in three or four hours with an appropriate dose of solution of citrate of mag- 
 nesium. The bowels should be kept loose for several days or until the danger 
 from the acute invasion has passed ; and this for two reasons : first, for the 
 purpose of compelling the bowels to take up a portion of the work of the kid- 
 neys, so that the latter may have the benefit of a season of physiological rest ; 
 secondly, for the purpose of using the vast alimentary area as a "derivative " 
 surface. Cathartics produce more or less hyperemia of the intestinal mucous 
 membrane, and if the circulatory current is "determined " toward the intestine, 
 it is proportionally drawn away from the engorged kidneys — a result that is 
 very desirable. I have many times seen the good results of this practice, and 
 am therefore confident that it is something more than a mere theory. Of course 
 the most useful cathartics are those which produce free watery evacuations. 
 The skin is also a vast eliminating organ, and the reciprocal relations existing 
 between the skin and kidneys are well known to physiologists. The physician 
 should take full advantage of this fact in the treatment of acute nephritis, and 
 
1014 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 encourage copious as well as constant diaphoresis. For this purpose jaborandi, 
 or its alkaloid pilocarpine, and the hot-air or vapor bath are both prompt, 
 efficient, and certain. I have seen such excellent results from the use of 
 hot dry air that I do not hesitate to urge its employment in every severe 
 case of acute nephritis. My method is as follows : The patient, all but his 
 head, is placed ina" tent " (made by supporting the bed-clothes upon arches 
 or semicircles of half-hoops or bent wire) and the bed-clothes are drawn closely 
 about the neck, so as to exclude cold air and include hot air ; the perforated 
 tin box (1) is then placed under the bed-clothes by the side of the patient 
 
 Fig. 1. 
 
 Apparatus for the Administration of the Hot-air Bath. The top and inner side of the box are made of 
 
 perforated tin. 
 
 and about six inches away from him; a current of hot air from a spirit lamp (3) 
 is now conducted into the perforated tin box (which acts as a "register" 
 or " radiator ") through the tin pipe (2), as shown in the figure. The result is 
 usually very copious diaphoresis, which may be maintained for many successive 
 hours, or even days in cases of emergency. In one case which seemed well- 
 nigh hopeless, the hot-air apparatus was kept in action almost constantly for ten 
 days, and the patient made a perfect recovery. In some cases the hot dry air 
 evokes sensations of "faintness" or "smothering;" when this happens the 
 heat should be increased very slowly, so as not to alarm or excite the patient. 
 Now and then a case will be encountered which will not bear dry heat at all, 
 while moist heat will be tolerated with both comfort and benefit. A few 
 heated bricks, wrapped. in wet cloths and placed around the patient under 
 the tent, will produce active diaphoresis. This method, however, is less effi- 
 cient than dry heat, and the latter will almost invariably be tolerated after a 
 few trials. 
 
 In jaborandi we have a most powerful and certain diaphoretic, and one 
 which is entirely safe if used at the proper time and place. In practice the 
 
ACUTE TUBAL XEPHRITIS. 1015 
 
 alkaloid pilocarpine, the active principle of jaborandi, will be found the most 
 convenient and efficient and by far the easiest of administration. In cases 
 of unusual danger, where copious or excessive diaphoresis is imperatively 
 necessary, pilocarpine in connection with the hot-air bath is invaluable. But 
 a proportionally larger dose must be given to a child than to an adult. To a 
 child of seven or eight years one-eighth of a grain of the nitrate of pilo- 
 carpine will be a medium dose, and if copious sweating does not commence 
 in half an hour the dose should be repeated. It may be given either by the 
 mouth or hypodermatically, although in an urgent case the latter method should 
 be adopted, and it is always preferable. In a given case experience will soon 
 determine what dose should be employed. When bronchial catarrh is present, 
 pilocarpine is said to have produced profuse and even fatal transudation of fluid 
 into the bronchial tubes, so that patients have been "drowned" in their own 
 secretions. I have seen no such results, and I believe the danger of this acci- 
 dent has been overestimated ; but where any considerable pulmonary or bron- 
 chial lesion exists I place the patient in the hot-air bath ten or fifteen minutes 
 before giving the pilocarpine, so that the flow of blood shall be predetermined 
 toward the surface of the body. Three very desirable results follow the use 
 of pilocarpine in acute nephritis : namely, the reduction of arterial tension, 
 the reduction of the temperature, and the free elimination of urea by the skin, 
 as shown by its enormous increase over the normal amount in the perspiration 
 (Bartholow). In cases of danger, where dropsical effusions threaten the heart 
 or lungs, or where uraemic symptoms are imminent, or where progressive coma 
 indicates transudation into the intracranial cavities, the hot-air pilocarpine 
 sweat should be repeated daily, or even twice in the twenty-four hours, until 
 the immediate peril is averted. Here and there a case will be encountered in 
 which the hot-water bath — placing the patient in the bath-tub with the water 
 at the temperature of 95° to 105° F. — will answer best, because both the dry 
 air and steam are equally repugnant. When this is the case, by all means 
 let the hot bath be employed, but let it also be remembered that the hot 
 dry air is therapeutically the most efficient, because it produces the most 
 copious diaphoresis ; the steam-bath is next best, while the hot-water bath 
 possesses the least eliminative power. 
 
 It would be a waste of time to discuss the older and now wellnigh obsolete 
 diaphoretics in view of the certainty which follows the use of those already 
 mentioned. 
 
 While the above methods of treatment are being pushed, certain internal 
 remedies may be used as adjuncts for the purpose of lowering temperature, 
 lessening arterial tension, calming nervous excitement, and unloading the 
 kidneys of the products of exudation and waste. These various indications 
 may be met by such remedies as aconite, codeine, or the bromides, and the 
 potassic salts, especially the acetate or citrate, or the acetate of sodium. I fre- 
 quently prescribe some such mixture as the following : 
 
 ty. Tr. aconit fess. 
 
 Codeine . . . . gr. ij . 
 
 Potass, citrat 3iij- 
 
 Glycerini f3ij- 
 
 Aquae cinnamom q. s. ad fSviij. — M. 
 
 Sig. A dessertspoonful every two hours in half a glass of pure water. 
 
 This formula is intended for a child of seven or eight years of age ; of course 
 the quantities must be increased or diminished according to age. In some 
 
1016 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 
 cases it will be found that the codeine provokes nausea ; when this happens, 
 sodium bromide or potassium bromide may be substituted. In other cases the 
 potassic citrate will cause gastric eructations or troublesome flatulency; this will 
 call for the use of potassic acetate or sodium acetate in its place. The above 
 formula is given simply as a suggestion ; it must be varied so as to suit the 
 indications as they arise. The practitioner should first have a clear and definite 
 comprehension of what he wishes to accomplish ; then, and then only, can he 
 set about an intelligent adaptation of means to ends. 
 
 If the foregoing measures are promptly and vigorously carried out, it is not 
 probable that ursemic convulsions will supervene ; but if they do, the physician 
 must be prepared to act, as it were, by instinct. He must act, and deliberate 
 afterward. Place the child immediately in a bath at the temperature of 
 100° F. ; administer chloroform by pouring 10 to 20 drops upon a napkin and 
 holding it very near, but not in contact with, the nose until the spasms are 
 controlled ; if the child be vigorous, healthy, and plethoric, apply a couple of 
 leeches to each temple, and allow the bites to bleed until the temporal arteries 
 soften and cease throbbing ; administer 5 to 10 grains of sodium bromide every 
 hour till its effect is manifested; give a brisk cathartic — and I know none 
 better than a full dose (say 5 grains) of calomel ; after the convulsions cease 
 remove the child from the hot bath to the hot-air tent (as before described), and 
 administer hypodermatically \ grain of pilocarpine. 
 
 It will be of very little use to administer diuretics at this time, as the 
 kidneys are not at all likely to respond under such circumstances, but it will 
 be entirely in order to administer 10 grains of the acetate or citrate of potas- 
 sium every two hours, dissolved in a liberal quantity of water. 
 
 It will generally be found, however, that the renal congestion will be so 
 much relieved by the action of the cathartic and diaphoretic that the kidneys 
 will resume their functions spontaneously. For several days after a uraemic 
 convulsion, or until the kidneys resume their action, the child should be care- 
 fully watched, should be kept in bed, and given a milk diet, and the action of 
 the diaphoretics and cathartics should be kept up in a moderate degree. While 
 urgemic convulsions in children seem frightfully dangerous, it is nevertheless 
 true that in most cases the danger is more apparent than real, and recoveries 
 are by no means unusual. 
 
 The treatment above given is that which is adapted to the first stage of 
 acute nephritis only. It is now incumbent upon us to consider what should be 
 done after the violence of the first attack is past and convalescence has fairly 
 commenced. 
 
 The problem before us is to restore to their structural integrity kidneys 
 which have been intensely congested, which have suffered laceration of many 
 of their minute blood-vessels, whose glomeruli and tubules have been invaded 
 by copious fibrinous exudation, which is still taking place, although in a com- 
 paratively slight degree. 
 
 In all cases of albuminuria with scantiness of urine the temptation to 
 administer diuretics is very great, and yet in the great majority of cases no 
 more unwise measure could be adopted. It is always true that stimulating or 
 irritating diuretics should be carefully avoided unless some very imperative 
 demand for their employment exists. In fact, diuretics bear the same relation 
 to inflammation of the kidneys that cathartics do to inflammation of the 
 alimentary canal. A mild aperient for a specific purpose may be proper in a 
 case of enteritis ; so, under similar conditions, a mild diuretic may be proper in 
 a case of nephritis ; but in neither case can the remedy be regarded as curative 
 of the lesion. In nephritis, as we have seen, the renal tubes become occluded 
 
ACUTE TUBAL NEPHRITIS. 1017 
 
 by fibrinous casts, and experience has demonstrated that these casts are solu- 
 ble in the alkaline salts of potassium. It is therefore advisable to administer 
 10 grains of the citrate of potassium, dissolved in half a glass of water or 
 lemonade, every three hours, it being well known that citric acid and the 
 citrates are converted into alkalies after ingestion. If there be any serious 
 indication of cardiac exhaustion, digitalis may be combined with the potassium, 
 but not unless it is clearly indicated. I am persuaded that the indiscriminate 
 and ill-judged use of digitalis and other cardiac tonics is productive of more 
 harm than good. It should be remembered that digitalis and other cardiac 
 tonics are not direct but indirect diuretics, acting by virtue of their power of 
 increasing arterial tension. But the potassic salts are "direct" diuretics; that 
 is, they actually increase elimination of the factors of the urine, especially urea, 
 the most important of them all. Thus they subserve two useful purposes : they 
 remove from the occluded tubes the plugs of fibrin and other material, and they 
 rouse the dormant epithelia of the convoluted tubes into action without unduly 
 exciting them. The vegetable potassic compounds, more particularly the 
 citrate or acetate, may very properly be continued in medium doses until the 
 albumin has disappeared from the urine. 
 
 One of the constant results of nephritis is anaemia, frequently of a very 
 pronounced type. This is due to loss of blood, loss of albumin, but perhaps 
 quite as much to the body waste which attends pyrexia and the cessation of 
 assimilating power. No acute disease produces such rapid and extreme anaemia 
 as acute nephritis. It is important that it be recognized early, before the 
 anaemic or "run-away" heart is developed, which is so prone to result in 
 valvular disease and a life of suffering. The remedies are rest in the recum- 
 bent position, appropriate food (of which I shall speak presently), and the 
 chalybeate tonics. Of the latter, the "mistura ferri et ammonii acetatis " 
 (otherwise known as " Basham's mixture ") or the ferri et potassii tartras, or 
 the ferrum dialysatum have given me the best results, and I have mentioned 
 them in the order of their comparative value. Basham's mixture is an elegant 
 diuretic tonic, usually very well borne and easily assimilated. It can be given 
 as soon as the temperature falls to the normal point, and thus the practitioner 
 can anticipate and prevent the extreme anaemia so sure to follow if the case be 
 allowed to drift on. When the urine is scanty and the sediment abundant, it 
 is an excellent plan to combine equal parts of a saturated solution of potassium 
 citrate with Basham's mixture, of which a teaspoonful every three hours may 
 be given to a child eight years old. A very good formula is the following : 
 
 Jfy. Sol. potassii citratis (sat.), 
 
 Mist, ferri et ammonii acetatis . . . . da f,^j. 
 
 Glycerini f.lj. 
 
 Aquae q. s. ad fsiv. — M. 
 
 Sig. A dessertspoonful every three hours in water. 
 
 I am much in the habit of adding glycerin to diuretic formulae, because 
 it seems in some unexplained manner to promote their action. At a later 
 period, when the kidneys no longer require any specific medication and a 
 stronger tonic is desirable, the potassic tartrate of iron may be substituted in 
 doses of from 3 to 5 grains three times a day. No other therapeutic measures 
 will be required unless special complications arise : if this be the case, they 
 must be met according to the indications in each particular instance. 
 
 The diet of a child suffering from acute nephritis, or, in fact, any lesion 
 inducing renal inadequacy, is of the utmost importance. Both theory and 
 
1018 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 experience concur in the necessity for excluding a nitrogenous dietary. In 
 the early stage of acute nephritis all solid food should be cut off. This exclu- 
 sion should extend also to broth, beef-tea, soups, and all forms of liquid diet of 
 which beef or mutton forms the basis. The ideal food is milk, and during the 
 period of invasion this should be taken sparingly. Milk and water (half and 
 half) is an excellent combination, as it combines nutrition with a natural 
 diuretic. As the kidneys regain their activity and fever subsides pure milk 
 may be given, together with bread, oatmeal, or crackers. A little fruit, as a 
 baked apple or the juice of an orange, may also be allowed, but the diet should 
 be increased slowly and cautiously, and flesh food must be prohibited until the 
 casts and albumin have been absent for several consecutive weeks, and even 
 then it should be given only in small quantities once a day. 
 
 A few general suggestions may not be improper. The patient — be he child 
 or adult — should not be discharged as " cured," but should be kept under 
 observation long after all signs and symptoms of trouble have disappeared. If 
 frequent examinations of the urine are kept up, as they should be, the practi- 
 tioner will be surprised every now and then to find a little albumin and a few 
 small structureless hyaline casts appearing, even after they have been absent 
 for many weeks. So long as this is the case there is great danger of a sudden 
 return of the acute symptoms with a fatal result, or of the supervention of 
 chronic nephritis, with equally sad, although less sudden, consequences. It is 
 therefore the duty of the physician to warn parents of the lurking perils, and 
 to exercise a personal supervision over the patient until health is fully restored. 
 
 Again, muscular exercise is dangerous to a patient recovering from acute 
 nephritis, because it strains the heart and loads the urine with nitrogenous 
 products of disassimilation, thus throwing work upon the kidneys which they 
 cannot safely do. The patient should therefore be kept quiet for a much 
 longer time than seems necessary to parents and friends. Lastly, the patient 
 should be warmly clad and carefully guarded from exposure to wet and cold. 
 Woollen garments and confinement within doors should be insisted upon until 
 the child's symptoms and the weather give concurrent testimony that gentle 
 exercise in the open air may be cautiously entered upon. To some these 
 suggestions may seem superfluous, but to observe them will do no harm, while 
 if they are neglected the lives of helpless children may pay the fearful penalty. 
 
 II. Chronic Tubal Nephritis. 
 
 Synonyms. — Chronic diffuse nephritis ; Chronic catarrhal nephritis ; 
 Chronic croupous nephritis ; Chronic parenchymatous nephritis ; and Chronic 
 Bright's disease. 
 
 Etiology. — Acute nephritis is the most common cause of chronic nephritis 
 in children. Scarlatina stands next in order ; then comes exposure to cold 
 and wet, especially when combined with malarious or other unhealthful sur- 
 roundings, as is so frequent among the children of the neglected poor. Long- 
 continued suppuration, although more likely to produce amyloid degenera- 
 tion of the kidneys, may cause chronic tubal nephritis, probably, as Bartels 
 suggests, because " something is developed in these collections of pus which 
 is taken up into the blood by absorption and excreted by the kidneys, 
 and which, during its excretion, excites an inflammation of these excretory 
 organs." Nearly twenty years have elapsed since these words were written, 
 and we do not yet know what that " something " is, but in the light of modern 
 pathological research we can easily understand that the toxic derivatives of 
 chronic suppuration might easily worry the kidneys into chronic inflammation. 
 
CHBOXIC TUBAL NEPHRITIS. 1019 
 
 Diphtheria must certainly be regarded as a cause of chronic as well as of 
 acute nephritis, and so must measles, but less frequently. Few cases of 
 diabetes mellitus terminate without the supervention of chronic tubal nephritis. 
 Finally, anything which demands constant overwork of the kidneys, or which 
 results in a slight but long-continued irritation of them, may prove the ground- 
 work of chronic tubal nephritis. 
 
 Symptoms. — The symptoms vary very much in different cases, being 
 modified by the rapidity with which the disease progresses. When the progress 
 is rapid the symptoms are more pronounced, and vice versa. In a typical case 
 of chronic tubal nephritis the first symptom attracting attention is likely to be 
 great debility and well-marked anaemia. The pulse is small, rapid, and feeble, 
 and annemic cardiac murmurs are common. There will probably be no rise of 
 temperature, or, if any, very slight and inconstant. The digestion is impaired, 
 the tongue coated, and the bowels torpid or loose and irregular. Following 
 these symptoms, and frequently coincident with them, is dropsy, generally first 
 manifested on the dorsum of the foot and around the ankle-joints, or perhaps 
 it is first seen in the swollen and transparent eyelid. There is also a marked 
 pallor or waxy appearance of the face, which is quite characteristic. The 
 dropsy extends up the lower extremities, invades the abdomen, may reach the 
 chest and oppress the lungs and heart, so as to become a source of serious 
 danger, although this can generally be avoided. 
 
 The disease is usually divided into three stages ; this division, though some- 
 what arbitrary, is convenient. During the first stage the urine is generally 
 scanty, dark, and turbid ; of variable, but with a tendency to high, specific 
 gravity (1020 to 1025), and heavily loaded with albumin (2 grams or more to 
 the litre), as determined by Esbach's " albuminometer " — the best, because the 
 simplest, apparatus yet devised for the practical quantitative estimation of albu- 
 min. After standing, the urine deposits an abundant precipitate composed of 
 hyaline and epithelial casts, with occasionally a blood-cast, renal epithelia, and 
 granular matter of indeterminate origin. Chemical examination will show the 
 percentage of urea to be much less than normal, while the chlorides, sulphates, 
 and phosphates, though diminished somewhat, are nearer the normal point. 
 
 With the development of the second stage the urine increases in quantity, 
 but becomes pale in color, sometimes all but colorless, of low specific gravity 
 (1005 to 1010), less turbid, but not quite clear, and the sediment diminishes 
 very much in quantity, and also becomes nearly colorless. But the quantity 
 of albumin remains large, rarely falling below 1J grams to the litre, and the 
 solid excreta are still markedly deficient. The casts also change. The blood- 
 casts disappear entirely ; the hyaline casts increase in number, and many of 
 them are large and somewhat distorted, showing that they are formed in tubes 
 which have shed their epithelium. The epithelial casts present a granular 
 cloudy appearance, and their borders are eroded or " nibbled," showing that 
 fatty change has commenced in the epithelia and that the walls of the tubes 
 have become roughened and irregular. As the disease progresses an occasional 
 wave of renal hyperemia may occur, when the urine again becomes scanty, 
 dark, and cloudy, and the casts characteristic of the first stage reappear, but 
 intermingled with these will be found the granular casts which belong to the 
 second stage, so that no serious confusion as to the diagnosis need occur. 
 
 With the commencement of the third stage the urine again becomes scanty 
 and cloudy, but is still pale and watery. The albumin does not diminish, but 
 is more likely to increase. The casts now become "fatty ; " that is, they are 
 large, short, irregular, with rough borders, and contain fine fatty granules, 
 minute drops of fat, and epithelial cells in an advanced state of fatty degenera- 
 
1020 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tion. During this stage periods of partial or incomplete suppression of urine 
 are apt to occur, followed by ursemic convulsions, succeeded by coma, or per- 
 haps sudden death without coma : or drowsiness may gradually steal over the 
 patient, until it becomes coma ending in death. Meantime the dropsy becomes 
 general, the limbs swell almost to bursting, the abdomen becomes distended 
 with fluid, the thoracic cavity gradually fills, pulmonary oedema with impeded 
 respiration occurs ; the heart labors violently until it suddenly fails from ex- 
 haustion, and death ensues. It must not, however, be inferred that all cases 
 present these distressing symptoms. In the majority they are either not wit- 
 nessed at all or are easily anticipated and prevented. 
 
 Diagnosis. — Chronic tubal nephritis may be confounded with (a) chronic 
 interstitial nephritis ; (b) amyloid disease of the kidney ; (e) cyanotic indura- 
 tion of the kidney. 
 
 (a) Chronic interstitial nephritis is very rare in children, but it is not diffi- 
 cult to differentiate it from tubal nephritis. Chronic interstitial nephritis 
 (renal cirrhosis) is characterized by its slow and insidious development ; by the 
 increased volume of urine ; by its low specific gravity and small amount of 
 albumin ; by the absence of dropsy, except in the last stage ; by the early de- 
 velopment of cardio-vascular tension ; and, generally, by well-marked lithgemia. 
 None of these symptoms are present in chronic tubal nephritis. 
 
 (b) Amyloid disease of the kidney is most likely to occur in children, and, 
 as it sometimes occurs in connection with tubal nephritis, a certain diagnosis 
 may be impossible. The distinctive features of amyloid disease are an increased 
 quantity of urine with a comparatively large amount of albumin ; absence of 
 leucocytes and epithelial cells, but the presence of numerous small hyaline 
 casts which are perfectly structureless, but some of which are likely to give 
 the characteristic reaction with iodine. There is usually considerable disturb- 
 ance of the digestive tract, with hypertrophy of the liver and spleen, and this 
 disease is almost always caused by and associated with syphilis, tuberculosis, or 
 some chronic disease involving suppuration. These diagnostic points are quite 
 sufficient to distinguish an uncomplicated case of chronic tubal nephritis from 
 an uncomplicated case of amyloid disease. 
 
 (c) Cyanotic induration of the kidneys only occurs where there is some 
 obstructive lesion of the organs of circulation which retards the movement of 
 blood through the kidneys and produces venous stasis. There is little albumin 
 in the urine ; the casts are few, generally small, and of the hyaline variety ; 
 dropsy is generally limited to the lower extremities ; respiration is difficult ; 
 much exercise is impossible ; and the circulation is much embarrassed. None 
 of these peculiar features belong to chronic tubal nephritis. But careful atten- 
 tion to the history and constructive symptoms of the latter almost invariably 
 enables the practitioner to arrive at a correct diagnosis. 
 
 Morbid Anatomy. — In a given case the morbid appearances will depend 
 entirely upon the stage at which the examination is made. I shall briefly de- 
 scribe the macroscopic and microscopic changes which are peculiar to each of 
 the three stages, which are themselves founded upon the anatomical changes so 
 uniformly present. 
 
 During the first or hyperaemic stage the kidney is either of normal size or 
 only slightly enlarged ; the capsule is somewhat cloudy, but strips off easily, 
 leaving the surface of the kidney smooth and red or purple. On section blood 
 oozes from the cut vessels, and the cortex is seen to be relatively increased. 
 The vessels in the "boundary layer" are turgid and frequently tortuous, and 
 the vasa recta stand out as well-defined red lines running toward or into the 
 apices of the cones. Between the straight vessels numerous white or grayish 
 
CHXOJTIC TUBAL NEPHRITIS. 1021 
 
 lines will be seen ; these are the straight tubes occluded and distended bv 
 casts and epithelia. Microscopic study of a section of the cortex will show 
 that the blood-vessels are dilated and tortuous — that the convoluted tubes are 
 stuffed with fibrinous casts, perhaps blood-globules, and enlarged epithelial 
 cells, some of which are in a state of "cloudy swelling." 
 
 The second or hypertrophic stage results in considerable, and sometimes 
 extreme, enlargement of the kidney ; the capsule is but little changed and 
 strips off easily, leaving the surface generally smooth, but with here and there 
 a slight cicatrix-like depression. Its color is variable and mottled, showing 
 pale grayish or whitish spots or islands surrounded by interlacing groups of 
 •• stellate " vessels, which are beautifully displayed. The pale spaces are the dis- 
 tended fatty convoluted tubes lying near the surface. On laying the kidney 
 open longitudinally it will be seen that the cortex is increased, but pale or 
 yellowish, and that it is anaemic rather than hypersemic. The Malpighian 
 bodies are not enlarged and prominent as in the stage of hyperemia. The 
 vessels in the boundary-layer are thickened and enlarged, but not distended 
 with blood. The cones or pyramids have undergone no essential change. 
 This is the so-called "large white kidney" or "large fatty kidney." The 
 microscope shows the convoluted tubes distended with epithelia in an advanced 
 state of fatty degeneration ; they also contain granular casts and fine fatty 
 granules which have not fused into drops. The Malpighian bodies are some- 
 what enlarged, and the space between the glomerulus and the capsule of 
 Bowman is apt to be occupied by exuviated epithelial cells in a state of fatty 
 transformation. The walls of the blood-vessels may be somewhat thickened, 
 but not markedly so. It will be seen that the " hypertrophy " is more apparent 
 than real, and that it is mainly due to the distention of the tubuli contorti, each 
 one of which occupies far more space than it does normally. The connective 
 tissue is not materially increased. 
 
 The third or last stage is very appropriately known as the stage of 
 "atrophy." The kidney is small, shrivelled, mottled, but the predominant 
 color is gray or grayish yellow. It is never red. The capsule is generally 
 slightly thickened, but strips off easily, except that here and there it may 
 bring a small bit of the kidney with it. The surface of the organ is no longer 
 smooth, but broken by alternating elevations and depressions. On section it 
 is seen that the cortex is wasted or atrophied, while the medullary portion is 
 not materially changed. The cut surface is frequently oily to the touch, and if 
 it be scraped with a scalpel, drops of oil will appear upon the blade. Microscopic 
 sections show many of the tubules shrivelled and wasted — many others dis- 
 tended with fatty casts, free fat-drops, and epithelial cells in complete fatty 
 degeneration. The walls of the blood-vessels are much thickened, and the 
 connective tissue is somewhat increased, but has not entered upon the con- 
 tractile process which produces cirrhosis. It should also be observed that the 
 kidney is pale throughout its entire extent, which fact differentiates it from the 
 "cirrhotic kidney," to be considered presently. 
 
 Prognosis. — During the first or inflammatory stage recoveries are common. 
 They ought to be more so. An early and correct diagnosis and an appropriate 
 line of treatment, administered with some faith in its efficacy, are indispensable 
 to the successful treatment of chronic nephritis. Unfortunately, the impression 
 is quite too general among the profession that chronic Bright's disease is always 
 incurable, and impressions ingrained for years are apt to become dogmas. 
 Nevertheless, chronic tubal nephritis, at any time up to the actual develop- 
 ment of the second or degenerative stage, is a curable disease, and especially 
 so in children, in whom the constructive forces are at their best. 
 
1022 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 After the development of the second stage, or that of pseudo-hypertrophy, 
 the prognosis is far less favorable, yet not absolutely hopeless. I have seen 
 recoveries take place when all the symptoms indicated the inception of fatty 
 changes in the kidney. Each day's delay renders the prognosis less hopeful, 
 and as the hyaline casts diminish and the fatty casts increase in numbers the 
 prognosis increases in gravity. 
 
 With the development of the third stage, or that of atrophic wasting, all 
 hope of recovery ends. As functional organs the kidneys are now practically 
 destroyed. Distressing symptoms may be relieved and life may be prolonged, 
 but that is all. Yet the • physician must be sure of his diagnosis before he 
 abandons hope, and in the practice of medicine it is far better to err on the 
 optimistic than on the pessimistic side. The disappearance of hyaline casts or 
 their very infrequent appearance, the prevalence of large irregular fatty casts, 
 which are short, broken, and loaded with fatty epithelium and fat-drops, 
 together with progressive diminution in quantity of the urine, are the most 
 reliable diagnostic factors. 
 
 Treatment. — The treatment of every case of chronic nephritis should stand 
 by itself, and should be carried out in accordance with a well-digested plan 
 founded upon an accurate determination of the stage of the disease. 
 
 During the first stage, where the condition of the kidneys is something 
 similar to that in acute nephritis, the chief object is to place the inflamed 
 organs at rest. The patient should therefore be kept as quiet as possible and 
 carefully guarded from exposure to cold. The bowels should be kept freely 
 open by means of saline cathartics. The skin must be actively stimulated and 
 made to do vicarious duty by means of hot air and pilocarpine. The kidneys 
 should be relieved of tube-casts and other obstructive material by the use of 
 the potash salts, much as indicated in the article on Acute Tubal Nephritis. 
 In fact, the general indications are practically the same, and the same measures 
 should be employed, only less vigorously. The diet should be the same — 
 namely, milk in some form with a little fruit — and the patient should be urged 
 or tempted to drink water freely. A little fish, a bit of broiled quail, or a 
 chicken's wing may occasionally be allowed for the purpose of varying the 
 monotony, but grills and roasts must be forbidden. The child should be kept 
 warm and the inner garments should be of wool. I particularly insist on 
 woollen stockings — a point that will surely be neglected by mothers and nurses 
 unless insisted upon by the medical adviser. As the case progresses toward 
 recovery chalybeate tonics are indicated, and I advise the employment of those 
 already mentioned in the article on Acute Nephritis, to which reference may 
 be had for details. 
 
 During convalescence the patient should be carefully watched, and it must 
 not be forgotten that convalescence is not perfect recovery. Albuminuria will 
 disappear slowly, and will reappear after long intervals of absence, thus show- 
 ing that the renal vessels have not yet recovered their tonus ; the heart will 
 remain irritable and weak for a long period ; and the homogenetic power of 
 the little patient will be recovered slowly. Hence careful but not ostentatious 
 or over-officious watching will be required for several months after all symp- 
 toms have disappeared. 
 
 When the disease becomes chronic, as indicated by the symptoms denoting 
 "fatty kidney," the treatment will be somewhat different. The kidneys must 
 now be relieved as much as possible by bringing the skin and intestinal tract 
 into play. Minute doses of pilocarpine — fa of a grain for a child of six or 
 eight years— may be given four times a day. A warm salt-and-water bath 
 three times a week, followed by smart friction, is a very useful adjunct to the 
 
CHRONIC TUBAL NEPHRITIS. 1023 
 
 pilocarpine, the bath of course being given in a warm room. If the skin is 
 rough and dry, it is a very good plan to rub the child with fresh and well- 
 warmed olive or sweet almond oil after each salt bath. These measures may 
 be continued indefinitely. 
 
 Cathartics must be employed frequently, but wisely. Violent catharsis is 
 rarely required ; gentle stimulation of the bowels is frequently needed, and is 
 very useful, both for its derivative and its eliminant effect. The saline cathar- 
 tics are most useful, but an occasional cholagogue, like the following, will not 
 be amiss : 
 
 1^. Resin, podophylli gr. j. 
 
 Hydrarg. chlorid. mit gr. x. 
 
 Sodii bicarbonatis gr. xxx. — M. 
 
 Ft. chart. No. X. 
 Sig. One powder to be given every third night. 
 
 Diuretics should be used sparingly, and not with any expectation of " cura- 
 tive results." The acetate or citrate of potassium, and the bitartrate in the 
 form of " imperial drink " [U. S. P.], are the safest and most efficient. They 
 should be given freely diluted. Cardiac tonics will doubtless be required as 
 the case progresses, but they should be reserved until they are actually needed, 
 as their premature employment exhausts the heart-muscle unnecessarily. Of 
 the various heart tonics, digitalis and strophanthus are the most reliable. The 
 chalybeate tonics will be indicated, and the mixture of the acetate of iron and 
 ammonia, the potassio-tartrate of iron, and the newer preparation called " fer- 
 rum dialysatum," have my preference in the order written. Special symptoms 
 will require attention. Dropsy, if excessive, demands active diuretics, as 
 squill, apocynum cannabinum, or that excellent preparation, " Trousseau's 
 diuretic wine," which consists of — 
 
 Junip. contus., 3x ; Pulv. digitalis, £ij ; Pulv. scillae, 3J ; Vini Xerici, Oj ; 
 macerate for four days, and add potass, acetatis, £iij ; express and filter. Dose, 
 one teaspoonful in water every three hours for a child of six or eight years, 
 (Tyson's BrigMs Disease and Diabetes). 
 
 Hydragogue cathartics and active diaphoresis must be employed in con- 
 junction with the diuretics ; among the former, calomel and jalap, concen- 
 trated solutions of salines, and elaterium are the best, in about one-third 
 the dose of an adult for a child from six to eight years old. As to diapho- 
 retics, the hot-air apparatus (see page 1014), with pilocarpine, stands first 
 always ; but the hot bath or warm pack, aided by pilocarpine, may be employed 
 for the want of something better. It may be found necessary to make minute 
 punctures through the skin of the ankle or dorsum of the foot, so that the 
 dropsical fluid may drain away. I prefer the point of a sharp tenotomy blade 
 for this purpose. If uremic symptoms appear, they must be treated as already 
 indicated. Ursemic asthma is likely to arise ; it may be temporarily relieved 
 by nitrite of amyl, spirits of chloroform, elixir of valerianate of ammonium, or 
 any other antispasmodic at hand, but it is a consequence of uraemia and calls 
 for increased elimination. Insomnia may be relieved by sulphonal, chloral, 
 somnal, or any of the newer hypnotics. I am accustomed to giving paregoric 
 to children with chronic Bright's disease who are kept awake by distressing 
 symptoms, and with the happiest effects, although the practice is not in strict 
 accordance with therapeutic orthodoxy. 
 
1024 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 m. Amyloid Disease of the Kidney. 
 
 Synonyms. — Waxy kidney ; Lardaceous disease ; Depurative disease. 
 
 Etiology. — The most common causes of amyloid kidney are syphilis ; 
 exhaustive and long-continued suppuration, especially if associated with necro- 
 sis of the vertebrae, as in Pott's disease, or of disease of the large joints, as in 
 coxalgia ; phthisis pulmonalis ; chronic ulcerative disease of the Dowels ; and 
 chronic albuminuria. As some of these affections are not uncommon in 
 children, it follows that they are liable to amyloid disease of the kidney. 
 The most perfect or complete specimen that I have ever seen occurred in a 
 girl of ten years, who was fairly worn out with repeated abscesses due to 
 Pott's disease. Amyloid disease rarely occurs in a child under five years, for 
 the reason that the above-named causes rarely exist prior to that age ; yet 
 Dickinson cites a case of amyloid spleen in a boy two and a half years old who 
 had an exhausting abscess of the thigh. 
 
 Pathological Anatomy. — In the early stage the kidneys are about 
 normal in size and present little change except to the experienced observer, 
 who will note a peculiar paleness, together with a translucent appearance, when 
 thin sections are held between the eye and a strong light. The capsule is non- 
 adherent. When the kidney is laid open no essential change in the relative 
 proportion of cortex and medulla is seen, but all parts appear pale and com- 
 paratively bloodless. If a few drops of an iodine test-solution be applied, mul- 
 titudes of mahogany red or reddish-brown points will appear, thus locating the 
 infiltrated Malpighian bodies. 
 
 At a more advanced stage the kidneys are enlarged, sometimes consider- 
 ably, though not to an extreme degree, unless amyloid disease and chronic 
 tubal nephritis coexist. The pale waxy or bacony appearance will now be 
 very apparent, and the iodine reaction will extend to the convoluted tubes, the 
 vessels of the labyrinth, and the vasa recta. 
 
 In the last stage the kidney is atrophied, contracted, and deformed. The 
 capsule is thickened and adherent, the cortex is wasted, and one is reminded 
 of the cirrhotic kidney, except that the latter is red or brownish red, while the 
 one under discussion still preserves its pale waxy appearance. Microscopic 
 sections show the glomeruli, the capillaries of the labyrinth, the vasa recta, and 
 most of the tubules infiltrated with the characteristic waxy material. The 
 application of the iodine test-solution 1 enables the observer to accurately differ- 
 entiate the infiltrated from the normal structure. 
 
 Prognosis. — As a clinical fact, amyloid disease is incurable. In a given 
 case, if the cause can be effectually and permanently removed before the kid- 
 neys are damaged beyond the power of carrying on their functions, life may be 
 prolonged indefinitely. Moreover, if the patient be a child of six or eight 
 years, subsequent growth and development may practically restore the structure 
 and function of the diseased organs. So much for theory. In practice we 
 generally find that the cause cannot be removed ; that the liver is almost sure 
 to be infiltrated with amyloid deposit to quite as great an extent as the kidneys ; 
 and that in most cases the spleen suffers as well. In other words, we are taught 
 that, under certain conditions, amyloid disease is curable, but in practice these 
 fortunate conditions are hardly ever met with ; hence the disease is scarcely 
 ever cured. 
 
 1 I recommend the following formula : 
 
 R • lodi . gr. iij. 
 
 Potassii iodidi gr- vj. 
 
 Glycerini fgj. 
 
 Aquae dest ad f^j.— M. 
 
CHBOXIC INTERSTITIAL NEPHBITIS. 1025 
 
 Treatment. — Obviously the most important thing is the discovery and 
 removal of the cause. As I have already said, if this can be accomplished, the 
 progress of the disease may be arrested and the patient may live out his days. In 
 clinical experience this can rarely be done. The next best thing is to reduce 
 suppuration to the minimum, and secure free drainage and asepsis for sup- 
 purating cavities ; to remove dead bone if it exists, and encourage the process 
 of repair if possible ; to adopt the most approved treatment for tuberculosis if 
 present, including change of climate when it is necessary and practicable ; to 
 institute antisyphilitic treatment when indicated ; and, in fine, to search out and 
 remove the cause if possible. We possess no specific agents for the cure of amy- 
 loid disease. The iodides — especially of iron and potassium — have been highly 
 recommended and much employed, but I have never seen any positive results 
 follow their uso. Theoretically, I should expect more from arsenic or the chlo- 
 ride of gold an :1 sodium. Diuretics must be given if symptoms of suppression 
 show themselves. Diarrhoea, which is likely to be troublesome, must be treated 
 on general principles. Anaemia — always pronounced in amyloid disease — should 
 be combated by iron, malt, cod-liver oil, arsenic, and especially by a liberal 
 diet, which may be safely given unless nephritis should complicate matters. If 
 dropsy becomes troublesome, the diaphoretics, diuretics, and cathartics already 
 recommended will answer every purpose. Uraemia is not likely to occur, as 
 the functional power of the kidney is destroyed so slowly that the system 
 acquires "toleration;" but if it occurs it must be treated promptly and 
 vigorously as already indicated. If nephritis arises, it will require the prompt 
 employment of the measures recommended in a previous article ; it is of course 
 a dangerous complication and one of not very infrequent occurrence. Other 
 complications may arise, just as they may in the course of any other chronic 
 disease, and must be met and treated according to the indications presented 
 in each individual case ; but the physician should remember that the elim- 
 inating power of the kidneys is more or less damaged, and he must exercise 
 due care in the use of certain drugs, like digitalis, which have a cumulative 
 tendency. 
 
 IV. Chronic Interstitial Nephritis. 
 
 Synonyms. — Renal cirrhosis; Gouty kidney; Granular degeneration; 
 Contracted kidney ; Renal sclerosis, etc. 
 
 Etiology. — Among the most frequent causes of interstitial nephritis are 
 rheumatism and gout (more correctly called lithaemia), alcoholism, lead-poison- 
 ing, valvular disease of the heart, malaria, mental strain, heredity, and chronic 
 lesions of the genito-urinary tract. As these causes are hardly ever active in 
 childhood, it follows that cirrhotic kidney is exceedingly rare under puberty. 
 All authors to whose writings I have access agree that it is not a disease of 
 childhood. I have never seen a case in a patient under thirty. Bartels 
 records one case at eighteen years, and Dickinson one "between eleven and 
 twenty years." Suppurative interstitial nephritis, pyelo-nephritis, or " surgical 
 kidney," may occur in children, but it does not fall within the scope of this 
 work. It is of course possible that heredity or cardiac disease may cause con- 
 tracted kidney in childhood, but in clinical experience we rarely meet with such 
 cases. 
 
 Symptoms. — The following are the four classic symptoms of interstitial 
 nephritis, and I may mention them in the order of their occurrence : (1) increased 
 arterial tension, with a sharply accentuated second sound of the heart : the 
 increased arterial tension is easily recognized by examining the pulse ; (2) the 
 
 65 
 
1026 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 small amount of albumin present (rarely more than 1 to 2 per cent, by volume) 
 or its entire absence for considerable periods of time ; (3) the small number of 
 casts, their small size and structureless or hyaline appearance, and their form, 
 which is in many instances twisted or distorted; (4) the appearance of albumin- 
 uric retinitis, which is a late and very characteristic symptom. 
 
 These four symptoms are so nearly always present in interstitial nephritis, 
 and so uniformly absent in other forms of renal disease, that they may be 
 regarded as pathognomonic. Early in this disease the urine is pale and watery, 
 increased in quantity, and of low specific gravity (1005 to 1010). 
 
 Pathological Anatomy. — Chronic interstitial nephritis results in the pro- 
 duction of the " small red," u contracted," or " cirrhotic" kidney. The kid- 
 neys are contracted, atrophied, rough or nodulated, and dark red or brownish 
 red. The capsule is thickened, and when pulled off tears away portions of the 
 kidney with it. On section it is observed that the cortex is very much wasted, 
 and the medulla somewhat so. The arteries are enlarged, tortuous, prominent, 
 and unyielding or inelastic. The organ is indurated and condensed. Micro- 
 scopic sections show a great increase of the connective tissue, with wasting and 
 distortion of the tubules and the smaller blood-vessels. Broad bands of con- 
 nective tissue will be seen between the remaining tubules and surrounding the 
 Malpighian bodies. Many minute cysts will be seen which are due to dilata- 
 tions of the tubuli mainly, but partly to dilated Malpighian bodies. 
 
 Prognosis. — Chronic interstitial, nephritis is incurable. The damage done 
 by overgrowth of connective tissue cannot be repaired. Yet it is quite pos- 
 sible to arrest the further increase thereof, and thus practically arrest the 
 disease and prolong life indefinitely. Much depends upon the patient's habits, 
 environment, temperament, age, and social condition. Under favorable cir- 
 cumstances so much can be accomplished that, so far as the patient is concerned, 
 a practical cure may be expected. But the physician must not forget the 
 inveterate tendency of connective tissue toward mischief when once aroused, 
 and he must regard the disease, although latent, as still present and ready to 
 break forth at any unusual provocation. 
 
 Treatment. — I reaffirm and refer to all that I have said in the foregoing 
 pages regarding habits, dress, exercise, and food and drink, except that the 
 dietary may include a little fish or fowl or a small allowance of almost any 
 kind of game once a day. Medical treatment should be directed to the arrest 
 of the further development of pathological connective tissue in the kidney. 
 For this purpose the remedies most efficient in my experience are bichloride 
 of mercury, iodide of potassium, and chloride of gold and sodium, in small 
 doses long continued. I use but one of these remedies at a time, but alter- 
 nate them at intervals of two or three weeks. If the kidneys falter, diure- 
 tics are indicated, and I have found the lactate of strontium a prompt and 
 efficient diuretic in this form of Bright's disease. It may be given in doses of 
 5 grains three times a day to patients from six to eight years old. Diure- 
 tine sometimes answers very well, but is quite likely to fail altogether. Of 
 course the potash salts may be given with every expectation of good results. 
 Chalybeate tonics are indicated in most cases, and the tincture of the chloride 
 of iron is particularly adapted to our wants. If combined with syrup of 
 lemon (fy. Tr. ferri chloridi, fgj ; syr. limonis, adfgij. — M.) it makes a very 
 palatable mixture, and will be readily taken by children. Heart failure, 
 uraemia, and other complicating symptoms must be met and treated as already 
 indicated in the foregoing articles. 
 
TUMORS AND OTHER ENLARGEMENTS OF THE 
 
 KIDNEY. 
 
 By THOMAS R. NEILSON, M. D., 
 
 Philadelphia. 
 
 Tumors of the kidney are met with in infancy and childhood with suffi- 
 cient frequency to make the subject one of great importance from a clinical 
 point of view. In the allotted space the different varieties of these tumors, or 
 those diseases of the kidney which may constitute tumor, will of necessity be 
 considered somewhat briefly. But, while no extended discussion of the subject 
 can be attempted, the effort will be made to present as compactly as possible 
 the essential facts. 
 
 In addition to solid growths — neoplasms — certain other affections, cysts, 
 hydronephrosis, pyonephrosis, and perinephritic abscess, may give rise to 
 enlargement in the renal region. These will be first taken up. 
 
 Renal Cysts. 
 
 Congenital Cystic Degeneration of the Kidney. 
 
 This condition may cause tumors of considerable dimensions. It sometimes 
 results in destroying the life of the foetus or in premature birth, and so great 
 may be the size of the tumor that delivery is impossible and embryotomy is 
 required. In less-marked cases the child may live a few months or even a 
 year or two, and may not give evidence of the affection by the presence of 
 tumor, but sooner or later is likely to perish either from uraemia or from 
 exhaustion. In this disease the kidney is studded with or changed into. a con- 
 glomeration of cysts of varying sizes, filled with a fluid usually clear, but 
 sometimes turbid, and containing urea and urinary salts. Both kidneys are, 
 as a rule, affected. 
 
 The condition is generally accompanied by defects of development of the 
 urinary apparatus, such as absence of the pelvis of the kidney or the ureter, 
 exstrophy of the bladder, and malformations of the genitalia, as well as vices 
 of comformation of the extremities, hare-lip, cleft palate, etc. The origin 
 of the affection has been explained by Virchow as due to an imperforate con- 
 dition of the straight tubes of the papillae, resulting from a prenatal inflam- 
 mation caused by impaction of the ducts with uric acid and the urates, and 
 leading to retention of secreted urine and dilatation of the uriniferous tubules. 
 Another view of the etiology has been taken by Koster, who considers the 
 condition to be due to defective development. The accompanying abnormalities 
 of the urinary organs, as well as of other parts of the body, would seem to favor 
 this theory, at least in some cases. 
 
 Cystic degeneration is not likely to call for surgical treatment. Even 
 
 » ' 1027 
 
1028 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 though there should be marked symptoms caused by the dimensions of the 
 tumor, the strong probability of both kidneys being affected and the fatal tend- 
 ency of the disease would interdict any radical interference, and even aspira- 
 tion could offer but slight temporary relief, if any at all. 
 
 • Paranephric Cyst. 
 
 Another variety of renal cysts which may be met with in children is one 
 which grows in the cellulo-adipose tissue surrounding the kidney, the cyst not 
 being primarily connected with the kidney. Morris, in his work on Surgical 
 Diseases of the Kidney, mentions an interesting case of this kind reported by 
 Mr. Caesar Hawkins, observed in a boy six years old. In this instance the 
 cyst developed from an imperfect third kidney, and reached great proportions, 
 extending from the lower border of the thorax to Poupart's ligament. The 
 cyst seemed to be like the simple renal cysts met with in adults, and was filled 
 with a clear fluid which contained neither albumin nor urinary salts. 
 
 Paranephric cysts may be of congenital origin, as in the case just referred 
 to, and sometimes they may be due to traumatism. They may communicate 
 secondarily, by a fistulous tract, with the pelvis of the kidney or the ureter. 
 The diagnosis of the tumor from other forms of renal cyst and from hydrone- 
 phrosis must be difficult, if not sometimes impossible. 
 
 Treatment. — These cysts should be evacuated with the aspirator, and the 
 procedure repeated if the fluid should reaccumulate. If, after this has been 
 tried, the cyst should rapidly fill up again, it would be better to cut down upon 
 it and incise it, securing it to the margins of the wound in the integument, 
 thus maintaining drainage. 
 
 Hydatid Cysts of the Kidney. 
 
 The ova of the* taenia echinococcus, a diminutive species of tapeworm 
 infesting some of the lower animals, notably dogs, sheep, and swine, are some- 
 times transmitted to man in food and drinking water, and give rise to what are 
 known as hydatid cysts. In the kidney hydatids are not so frequent as in the 
 liver, the statistics of Davaine, quoted by Roberts, showing the proportion to 
 be 1 to about 5J. 
 
 Pathology and Symptoms. — Hydatid of the kidney may be met with at 
 any age, although less often in children than in adults, and is unilateral, 
 involving the left oftener than the right kidney. Palpable tumor is produced 
 in somewhat less than one-half of the cases. The cyst, surrounded by a capsule 
 of fibrous tissue and having in its interior the characteristic daughter cysts, 
 usually develops in the parenchyma of the kidney, but sometimes between the 
 organ and its capsule, and, as it grows, encroaches on the kidney tissue, causing 
 more or less atrophy. Sometimes several hydatids are found in the same kid- 
 ney. These cysts tend to rupture and discharge their contents, and this may 
 take place into the pelvis of the kidney, which is the usual place, into the 
 intestine, or into the lung. The peritoneum is generally pushed forward by the 
 tumor, and rupture into its cavity never occurs. 
 
 Unless the cyst has attained proportions sufficient to constitute a tumor, or 
 unless it should rupture and discharge its contents in the urine, there may be 
 no evidence of its presence. The tumor generally occupies the loin, is globular 
 in outline, and more or less fluctuating. The thrill or fremitus supposed to be 
 peculiar to hydatids is a very uncertain symptom of the disease in the kidney, 
 having seldom been observed in recorded cases. Rupture of the cyst into the 
 
TUMORS OF THE KIDNEY. 1029 
 
 pelvis or ureter is manifested by pain in the lumbar region, together with a 
 sensation of something having given way. Then, as the vesicles descend 
 through the ureter, symptoms similar to those caused by the passage of a renal 
 calculus will be provoked. The vesicles may become impacted and obstruct 
 the ureter, giving rise to distention of the kidney with urine; or, reaching the 
 bladder and escaping into the urethra, they may obstruct that channel and cause 
 retention of urine. The escape of the hydatid vesicles, or of portions of the 
 laminated cyst-wall, or of the peculiar booklets of the echinococcus in the 
 urine positively establishes the presence of the affection. In some cases pus 
 has been noticed in the urine during the discharge of the cyst. After once 
 evacuating itself the tumor may subside, or, on the other hand, it may fill 
 again and empty itself as before, and this may happen at greater or less inter- 
 vals for a long time, even many years. Should the cyst undergo suppuration, 
 fever and other evidences of constitutional disturbance will result. 
 
 Diagnosis. — A renal tumor is easily recognized as an hydatid cyst when 
 vesicles, particles of cyst- wall, or hooklets appear in the urine. In the absence 
 of this evidence the tumor may readily be mistaken for hydronephrosis, other 
 varieties of renal cyst, or pyonephrosis. Hydatids differ from malignant 
 tumors of the kidney in their slow development and the absence of constant 
 pain and cachexia. 
 
 Prognosis. — The disposition of these cysts to rupture and discharge their 
 contents by the urinary channels or to disappear without evacuation makes the 
 prognosis usually good. If, however, the tumor continues to increase in size, 
 it may lead to serious, sometimes fatal, results from destruction of the paren- 
 chyma of the kidney or from pressure upon other organs. Suppuration, either 
 in or about the cyst, is a grave complication, and death may follow rupture into 
 the pleural cavity or the bronchi. 
 
 Treatment. — With the object of destroying the life of the parasite certain 
 anthelmintics, such as oil of turpentine, male fern, and the like, have been 
 exhibited, but there is no evidence of their efficiency. When hydatids are dis- 
 charged in the urine, alkaline diluents should be freely given for the purpose 
 of increasing the secretion of urine, and thereby favoring the washing out 
 of the pelvis and ureters. Beraud is mentioned by Roberts as having had 
 a case in which the administration of nitre caused an increase in the discharge 
 of vesicles. Renal colic induced by the escape of hydatids into the pelvis and 
 ureter should be treated as when due to other causes. 
 
 If the cyst does not discharge, but continues to increase, or if it should sup- 
 purate, or if, from obstruction of the ureter, sudden distention of the kidney 
 should occur, surgical interference will be called for. Under these circumstances, 
 while aspiration may afford relief, the best prospect of success is offered by 
 cutting down to the tumor, opening the cyst, and suturing its edges to the 
 external wound. 
 
 Hydronephrosis. 
 
 The term " hydronephrosis " signifies dilatation of the kidney and the ureter 
 from some hindrance to the outflow of urine. The affection may be either 
 unilateral or bilateral. Its causes may be divided into congenital and acquired. 
 When the cause is congenital, it does not necessarily follow that the hydrone- 
 phrosis is present at birth ; it may not develop for some years later. In 
 extreme cases the condition has caused dystochia, necessitating embryotomy. 
 
 Etiology and Pathology. — The obstacle which leads to the formation of 
 hydronephrosis may be any one of several. Thus an excessive angulation of 
 
1030 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the junction of the ureter with the pelvis of the kidney, a twisting contrac- 
 tion, imperforate condition, or valvulation of the ureter, compression of that 
 duct by an abnormal supernumerary renal artery, and obstruction of the 
 urethra by a septum of mucous membrane, are all recognized causes, falling 
 under the congenital class. As acquired causes may be named obstruction of 
 ureter from injury due to the passage of a calculus or from traumatism from 
 without, stone in the bladder, vesical tumors, stricture of the urethra, phimosis, 
 and habitual frequent micturition. Floating or movable kidneys are sometimes 
 hydronephrotic. 
 
 The proportion of cases in which there is tumor is small, but the distention 
 sometimes reaches enormous dimensions. The appearance of the sac varies, 
 sometimes being quite thin and pellucid, while at others it is thick and opaque. 
 The accumulation of urine first distends the pelvis of the kidney ; then the 
 calyces becomes dilated, and by degrees the resulting compression causes absorp- 
 tion of the renal substance, until none, or but a mere trace, of it remains. 
 The tumor thus formed is a cyst, sometimes, but not always, subdivided by 
 fibrous septa. Its contents differ in the majority of instances from normal 
 urine. Often a fluid resembling water is found ; in other instances it may be 
 brownish ; and, again, colloid material may fill the sac. The fluid may contain 
 no salt but chloride of sodium ; or uric acid and its salts, oxalate of lime, and 
 the phosphates may be present, as may albumin, pus, muco-pus, and epi- 
 thelial cells in some cases. 
 
 Symptoms. — When the affection is limited to one kidney, and the sac so 
 small as not to produce tumor, it may give rise to no definite symptom ; on the 
 other hand, occasionally there may be lumbar pain, thirst, frequent micturition, 
 or intermittent anuria. When both kidneys are hydronephrotic, uraemia may 
 result. When tumor is present, it is situated in the first place in the loin or 
 flank ; later it becomes more prominent in the abdomen, and may even reach 
 such a size as to extend from the median line in front to the vertebral column 
 behind, and from the hypochondriac region above to the iliac region below. 
 A very large tumor will by its presence create considerable pain, and in those 
 cases in which the trouble results from an obstruction in itself painful there 
 will naturally be much suffering. The tumor on percussion is dull, and on 
 palpation is soft and fluctuating, and sometimes a lobulated condition of its out- 
 line may be noticed. The abdominal viscera may be variably displaced 
 according to the size as well as the direction in which the cyst extends, and 
 symptoms referable to its pressure on the different organs or the diaphragm 
 may result. Sudden subsidence of the tumor, either complete or partial, may 
 occur synchronously with the passage of a large amount of urine. The urine 
 under these circumstances is of a lower specific gravity than normal, and may 
 occasionally contain pus, muco-pus, or even blood. Hydronephrosis is some- 
 times intermittent. 
 
 Diagnosis. — In the few cases in which the abdominal tumor subsides 
 during the discharge of a large quantity of urine the diagnosis presents little 
 difficulty. Under other circumstances hydronephrosis may resemble renal, ova- 
 rian, hepatic, or splenic cysts, pyonephrosis, perinephritic abscess, and ascites. 
 There may be considerable difficulty in making the diagnosis from renal cysts, 
 except in the case of hydatids, when vesicles appear in the urine. Ovarian 
 cysts may be distinguished by their relation to the colon, which is generally 
 behind them, and by the absence of dulness on percussion of the loin. In 
 ascites the area of flatness on percussion changes on alteration of the patient's 
 position, while in hydronephrosis it remains fixed. Pyonephrosis and peri- 
 nephric abscess present a history of pyuria or the constitutional signs of sup- 
 
TUJIOBS OF THE KIDNEY. 1031 
 
 proration, and oedema and redness of the integument of the lumbar region not 
 characteristic of this affection. Hepatic and splenic cysts are affected by the 
 movements of respiration rather more than the hydronephrotic enlargement, 
 and tend to become prominent anteriorly rather than toward the loin. 
 
 Prognosis. — When the condition is unilateral, and the other kidney is 
 equal to carrying the burden of sufficient urinary excretion, there is no imme- 
 diate risk of life. Even if the cyst be large the prognosis is not unfavorable 
 if it be evacuated early. But if the tumor increase to a great extent, fatal 
 consequences may result from its pressure upon other organs, from rupture into 
 the peritoneal cavity, or from uraemia. In bilateral cases death will sooner or 
 later be caused by the diminution of kidney tissue induced by pressure of the 
 accumulated fluid. 
 
 Treatment. — When there is no trouble from the size of the tumor hydro- 
 nephrosis requires no treatment. Massage is sometimes recommended with the 
 idea of removing the cause of obstruction, but if practised the danger of rup- 
 turing the cyst should be borne in mind. Large tumors, accompanied by much 
 pain or by urgent pressure symptoms, call for evacuation of the fluid, which is 
 most easily accomplished by aspiration. This may be repeated if the sac fills 
 again. In inserting the trocar a spot should be chosen where there is no risk 
 of wounding the peritoneum, for if this should happen the escape of some of 
 the cyst fluid into the peritoneal cavity would be attended with great danger. 
 If after repeated aspirations the sac refills, lumbar nephrotomy should be per- 
 formed. The cyst, having been exposed and emptied, should be secured to 
 the margins of the wound, and after exploring with a probe for calculus in the 
 pelvis or ureter a large drainage-tube should be inserted. The after-treatment 
 consists in antiseptic irrigation of the cyst, for which purpose either boric-acid 
 solution or Thiersch's fluid may be used. If a persistent fistula should follow 
 this operation, and if it be known that the amount of renal tissue remaining is 
 insignificant, nephrectomy is to be recommended. 
 
 Pyonephrosis. 
 
 Distention of the kidney with pus or with urine and pus is called pyone- 
 phrosis. 
 
 Etiology and Pathology. — The condition may originate from any of the 
 causes which give rise to hydronephrosis, provided that pyelitis be developed. 
 Also it may result from injury, from tuberculosis, or from diphtheria and other 
 zymotic diseases. 
 
 Distention of the pelvis and calyces and wasting of the renal parenchyma 
 from pressure occur just as in hydronephrosis, and the kidney is eventually 
 replaced by a mere lobulated pouch. The tumor is whitish in color, with walls 
 of variable thickness, and the sac-contents are purulent urine or pus mixed 
 with blood and, in some cases, phosphatic material. The mucous membrane 
 of the pelvis is pale in color and much thickened. A large pyonephrotic kid- 
 ney causes displacement of other organs, and, especially if due to impacted 
 stone, may ulcerate, discharging its contents into one of the hollow abdominal 
 organs or into the peritoneal cavity, or, becoming adherent to the abdominal 
 wall, it may discharge externally, establishing a fistula. 
 
 Symptoms. — While in some cases there may be no perceptible swelling, 
 pyonephrosis usually gives rise to a fluctuating or elastic tumor in the renal 
 region. It is generally accompanied by pain, the character of which depends 
 on the cause of the obstruction. Sometimes it is very severe. It originates 
 in the lumbar region, and is increased by pressure from in front, but relieved 
 
1032 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 by pressure in the loin. Chills, fever, sweating, diarrhoea, and vomiting are 
 present, together with marked loss of flesh. In cases in which the obstruction 
 is not complete the urine voided, although containing pus, may be normal in 
 reaction, being mixed with that secreted by the sound kidney; later it is liable 
 to become alkaline. When the obstruction is complete, pyuria will not be 
 observed. In pyonephrosis resulting from stone there will be a history of 
 pyuria and hematuria extending over a considerable period. 
 
 Diagnosis. — Pyonephrosis may be confused with the same conditions as 
 hydronephrosis. The constitutional symptoms which, on the one hand, estab- 
 lish the diagnosis from hydronephrosis, on the other hand render the affection 
 liable to be mistaken for perinephritic abscess. 
 
 Prognosis. — The prognosis is more grave than in hydronephrosis, and is 
 manifestly more serious if the condition be bilateral than when only one kid- 
 ney is affected. The nature of the cause of the pyonephrosis, and whether the 
 accumulation has been gradual or sudden, materially influence the chances of 
 life. If it has been gradual, the opposite kidney may become hypertrophied 
 and do duty for the diseased one. Spontaneous removal of an obstructing 
 calculus is a favorable occurrence, as is the discharge of the cyst into some 
 part of the urinary organs below the seat of obstruction. A fatal termination 
 may be reached by the sac rupturing into the peritoneum, from the results of 
 pressure upon other organs, from pyaemia, septicemia, or amyloid disease 
 induced by prolonged suppuration, even though the pyonephrosis has dis- 
 charged its contents externally or into the intestines. 
 
 Treatment. — In cases where the obstruction is not complete the treatment 
 may be expectant. The patient should be kept at rest with warm applications 
 to the abdomen and lumbar region. The condition of the digestive organs 
 should be carefully seen to, and light, easily-assimilable nourishment given. 
 When obstruction is complete and the tumor rapidly increases in size, causing 
 marked pain, and the constitutional effects of the suppuration are severe, or 
 symptoms consequent upon pressure become urgent, interference is indicated 
 and lumbar nephrotomy should be performed. When the cyst has been open- 
 ed a finger should be inserted, not only to explore for a stone, but to feel for 
 and to break down any septa which may subdivide the sac, so that all parts of 
 it may be well drained. The cyst should be drawn up into the wound and 
 sutured to its edges, a drainage-tube left in, and the cavity washed out daily 
 with antiseptic fluids, as in hydronephrosis. 
 
 In cases where the kidney tissue is ascertained to be destroyed, or where 
 the health is seriously impaired, or where prolonged suppuration continues in 
 spite of thorough drainage, nephrectomy should be the operation selected. 
 
 Perinephritic Abscess. 
 
 Perinephritic abscess, resulting from inflammation of the fatty and areolar 
 tissue surrounding the kidney, may be met with at any age from the earliest 
 weeks of infancy. 
 
 Etiology and Pathology. — Perinephritis may be either a primary or a 
 secondary condition. Primarily, it may arise from traumatism, exposure to 
 cold, or as a sequela to the zymotic diseases ; secondarily, it may result from 
 renal calculus, pyelitis, pyelo-nephritis (or "surgical kidney," so called), pyo- 
 nephrosis, cysts, tumors, and tubercular disease of the kidney, vesical calcu- 
 lus, stricture of the urethra, and phimosis. Again, the suppuration may be 
 traced to disease of the vertebrae, to abscess resulting from perforative ulcer- 
 ation of the colon or ileum, or to retrocaecal abscess. In some instances, accord- 
 
TU3I0BS OF THE KIDNEY. 1033 
 
 log to Steven, infection from inflammation originating in the bladder may 
 extend by means of the lymphatics of the ureter to the capsule of the kidney 
 and the tissue surrounding it, the kidney itself escaping. In the same way it 
 is possible that the source of the inflammation might be traced to other remote 
 points. 
 
 When suppuration occurs the abscess is generally at first limited by a well- 
 defined wall of lymph, but the nature of the tissue, like that in the ischio- 
 rectal fossa, is such as to favor extension of the suppurative process, and the 
 pus soon works its way in various directions through the loose cellular and 
 fatty tissue. From its original situation it may burrow through the lumbar 
 muscles and point in the loin, or it may travel downward and appear in the 
 thigh, like a psoas abscess, or, getting beneath the pelvic fascia and passing 
 through the sacro-sciatic notch, it may point in the buttock. Extending 
 upward, the pus may pass through the diaphragm and cause pleurisy, empy- 
 ema, pneumonia, or may discharge into the bronchi. Again, the abscess may 
 rupture into the peritoneum, the colon, small intestine, stomach, bladder, or 
 prostatic urethra. 
 
 In the primary cases the kidney may be found macerated or broken down 
 by the action of the surrounding pus, while in secondary cases of renal origin 
 there will be found the special morbid conditions to which the abscess is due. 
 
 Symptoms. — The patient will usually first complain of pain in the lumbar 
 region, extending forward, generally severe, and aggravated by motion as well 
 as by pressure. At the same time it will be observed that the trunk is bent 
 toward the affected side, and the thigh is kept slightly flexed upon the abdo- 
 men and rotated outward. On assuming the erect posture the patient assists in 
 supporting his weight by bearing with his hand upon the thigh of the affected 
 side. Examination will reveal more or less fulness or prominence of the loin 
 instead of the normal concavity, and in marked cases palpation and percussion 
 will map out a well-defined tumor. This latter symptom may not be present 
 for any great length of time in consequence of the tendency of the pus to 
 burrow. The integument of the part is oedematous, waxy, red or congested, 
 and hot to the touch. 
 
 The constitutional symptoms are prominent, consisting of decided elevation 
 of temperature, reaching as high, perhaps, as 104° F., chills, sweating, ano- 
 rexia, and diarrhoea. Pressure of the abscess upon the lumbar plexus of 
 nerves excites pain in its various branches, which, together with the attitude 
 assumed, may lead to error in diagnosis. The urine, except in those cases in 
 which the abscess is the result of violence, and in which there may be hema- 
 turia or pyuria, presents no especial characteristics. In some primary cases 
 there may be a little albumin, resulting from high temperature, or, when the 
 abscess is large and produces congestion of the kidney from pressure, some 
 blood may be found. 
 
 Diagnosis. — The local and constitutional signs of a fully-developed peri- 
 nephritic abscess are generally sufficiently clear to leave little room for doubt as 
 to the diagnosis. It may, however, be confused with hydronephrosis, pyoneph- 
 rosis, cysts and tumors of the kidney, lumbago, disease of the vertebrae, 
 coxalgia, psoas abscess, and perityphlitic abscess. It is not possible here to 
 point out the distinguishing features of these affections. Careful and exact 
 examination, together with the accurate history of the case in question, will 
 usually easily remove any difficulty that may be in the way of establishing the 
 diagnosis. 
 
 Prognosis. — The prognosis depends upon the cause of the abscess, although 
 the condition should always be regarded as a serious one. When the abscess 
 
1034 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 results from pyonephrosis or from disease of some other organ, the outlook is 
 more grave than when it is primary. The prognosis is most favorable when 
 the pus is evacuated early, while in unrelieved cases a fatal termination is to 
 be apprehended from the discharge of the pus into other organs — into the 
 peritoneum, the pleural cavity, lungs, or bronchi. Amyloid disease is immi- 
 nent when the suppuration is long continued. 
 
 Treatment. — At the onset attempts may be made to induce resolution of 
 the perinephritis, for which purpose cupping or leeching of the loin and the 
 application of an ice poultice may be tried. The patient should be kept upon 
 a liquid diet, a simple fever mixture should be prescribed, the bowels kept 
 freely opened, and opium given for the relief of pain. If these measures fail 
 to ameliorate the local and constitutional symptoms, warm flaxseed poultices 
 should be applied, quinine added to the medicinal treatment, and the patient 
 closely watched. Increased elevation of temperature or the occurrence of chills 
 and sweating, being tokens of suppuration, call for prompt resort to the knife. 
 Delay is dangerous, since it renders possible burrowing of the pus. Therefore, 
 in spite of the absence of fluctuation, a free incision in the lumbar region 
 should at once be made down to the perirenal tissue. Then with the finger 
 this should be carefully explored or teased apart until the abscess, which is 
 sometimes deeply seated, is found. The opening made with the finger should 
 be enlarged by inserting a pair of long-bladed haemostatic forceps and sepa- 
 rating the blades. This being done, the abscess-cavity should be washed out 
 and a good-sized drainage-tube inserted. Later, strips of iodoform gauze may 
 be gently pushed into the cavity beside the tube, and the packing gradually- 
 lessened and the tube shortened as granulation progresses. 
 
 In cases in which the abscess is secondary to disease of the kidney, nephrot- 
 omy or nephrectomy may be called for, according to the condition found at the 
 time of operation. 
 
 Tumors op the Kidney. 
 
 New growths of the kidney, as met with in children, are for the most part, 
 if not entirely, of the malignant class. While it is possible that benign growths 
 may occur, investigation of statistics has failed to find any case which has been 
 the subject of surgical operation. Malignant tumors may involve the kidney 
 either primarily or secondarily, but it is only with the primary tumors that we 
 are here concerned. 
 
 Etiology and Pathology. — Some of these growths are congenital. In 
 other cases their origin is attributed either to the irritation of a renal calculus 
 or to injury, such as contusions or falls upon the loin, although it is not very 
 easy to understand how this latter cause can be operative. 
 
 Unlike similar formations elsewhere in the body, malignant tumors of the 
 kidney are met with more frequently in the first ten years of life than during 
 the period of life generally recognized as that of malignancy. They may occur 
 at any age in childhood, although the greater number of cases have been 
 observed in children under five. Thus, in 54 cases references to which the 
 writer has obtained, 9 were under one year old, 17 between the ages of one 
 and three, 18 between three and five, 6 between five and eight, and 4 between 
 eight and twelve years of age. As to sex, in 40 cases in which it was stated 
 22 were females and 18 were males. The tumor is unilateral as a rule. When 
 both organs are the seat of growths, except in cases of congenital myosarcoma, 
 the involvement of one organ is secondary to the disease in the other. Of 30 
 cases, the right kidney was the seat of the neoplasm in 14, the left in 12, and 
 both were involved in 4. 
 
TUMOBS OF THE KIDNEY. 1035 
 
 The great inaj ority of these renal tumors in children are sarcomata. Out of 
 52 cases, 43 were instances of sarcoma, while 9 were designated as encephaloid 
 carcinoma. The variety of sarcoma most often found is the round-celled, both 
 large and small, the spindle-celled variety being less frequent. These growths, 
 which are first usually encapsuled, but which, owing to their rapid develop- 
 ment, soon extend through their capsule, may begin at the hilum and either 
 spread around and envelop the kidney, or they may extend into the kidney, 
 which ultimately becomes stretched out as a thin layer over the tumor. More 
 often they originate in the cortex, being separated from the surrounding renal 
 tissue by a capsule until the latter gives way, when the sarcoma extends through- 
 out the kidney. In addition to the round-celled and spindle-celled, other 
 varieties of sarcoma which have been found are adenomo-sarcoma, in which the 
 sarcomatous tissue and that of the glandular substance of the kidney are com- 
 bined ; myxo-sarcoma, in which the elements of mucous tissue are combined 
 with sarcoma; alveolar sarcoma; and myo-sarcoma and rhabdo-myoma. Tumors 
 of the last-named kind are of congenital origin, and consist of a mixture of 
 striped muscle tissue and sarcoma tissue. They may be either unilateral or 
 bilateral, sometimes reach a very large size, and are rapidly fatal. Owing to 
 special characteristics, certain sarcomata have been described as fibrous and 
 fibro-fatty tumors. 
 
 Sarcomata of the kidney grow rapidly and are highly vascular, extravasa- 
 tions often taking place into them. They frequently break down in places 
 and form cysts containing blood and clots. 
 
 The variety of carcinoma which has been most frequently met with is the 
 encephaloid, although any of the varieties may be found. Encephaloid cancer 
 of the kidney has sometimes attained immense proportions. The growth may 
 invade the entire kidney, being disseminated throughout it and producing a 
 tumor possessing the general outline of the organ, or it may develop from one 
 part of the organ and have an irregular outline. The origin of the growth is 
 traced to the intertubular connective tissue, its epithelium being derived from 
 proliferation of the normal renal epithelium. Like sarcomata, carcinomata 
 grow rapidly. It is doubtful whether some of the tumors specified in the older 
 classification as encephaloid cancer would not now be placed under the heading 
 of sarcoma. 
 
 Lymphadenomata have been occasionally observed in the kidney, but are 
 secondary to disease in the lymphatic system. It is possible that a growth of 
 this kind might be mistaken for a round-celled sarcoma. 
 
 Malignant growths of the kidney spread by means of the lymphatics and 
 veins. Carcinomata are particularly apt to involve and extend by the veins. 
 Secondary formations soon take place. The lumbar glands are early infected. 
 The tumor may by pressure cause erosion of the vertebrae, and, opening the 
 spinal canal, involve the meninges, and even the cord itself, by direct extension. 
 
 Symptoms. — In addition to tumor, which is the symptom most invariably 
 present, malignant disease of the kidney causes pain, emaciation, cachexia, 
 frequent perhaps involuntary micturition, hematuria, and various symptoms 
 resulting from pressure of the growth. 
 
 The tumor, if detected early, will be found confined to the loin, where it 
 causes more or less fulness or prominence. In some recorded cases the growth 
 has attained an immense size, occupying the whole abdominal cavity, pressing 
 upward the diaphragm and embarrassing the thoracic organs. Again, in 
 other cases it may be very difficult, if not impossible, to detect a palpable 
 tumor, even though metastasis has taken place. Pain in the lumbar region is 
 an early indication, but while in older children, as in adults, it is an important 
 
1036 AMERICAN TEXT-BOOK OF DISEASES OF CHILD BEN. 
 
 sign, it is very doubtful if in very young subjects it could be relied upon, as it 
 is not likely that it would be intelligently located. It is dull in character and 
 usually constant, although occasionally paroxysmal, differing, however, from 
 the pain due to renal calculus in not being either aggravated by motion or 
 relieved by rest. Hematuria is not always noted as a symptom. When it 
 does occur it is constant, and although in some cases it may not be alarming, the 
 bleeding may, on the other hand, be very severe. Sometimes clots may obstruct 
 the urethra or may distend the bladder, or, again, may become wedged in the 
 urethra. The haemorrhage may be due to the calculus from which the tumor 
 may have arisen, or it may result from the neoplasm involving and extending 
 into the pelvis of the kidney and then ulcerating. 
 
 The tumor, as it grows, may encroach upon and compress the nerves of the 
 lumbar plexus, giving rise to pain, and even to paralysis in the parts supplied 
 by its branches. From pressure upon the veins within the abdomen oedema 
 of the lower extremities and engorgement of the superficial abdominal veins are 
 produced. Other symptoms due to the pressure of the tumor are constipation, 
 jaundice, anorexia, and vomiting. 
 
 The urine will be found normal unless the growth has involved the pelvis 
 of the kidney, when it may contain blood, blood-casts, albumin, epithelium, 
 pus, or portions of the ulcerating tumor. Although convulsions have taken 
 place in a few cases, uraemia rarely, if ever, occurs. 
 
 Diagnosis. — The salient symptoms of renal neoplasms are rapidly-increasing 
 tumor and pain. If to these haematuria be added, the diagnosis should not be 
 difficult. If the tumor be large, however, there may be some difficulty in 
 deciding whether on the right side it is not a cyst or enlargement of the liver, 
 or on the left whether it is not an enlarged spleen, particularly as renal tumors, 
 as well as those of the liver and spleen, are affected by the movements of respi- 
 ration. The examination will usually be more satisfactory if the child be 
 under ether or chloroform anaesthesia. The relation of the ascending colon on 
 the right side and the descending colon on the left to these tumors is an 
 important point. Unless the growth be very large or has extended in one 
 particular direction from the kidney, the colon should be found in front of it. 
 In cases where the tumor is very large the bowel may be pushed aside, either 
 inward or downward. Another point of distinction is that renal tumors can 
 usually be traced deeply into the loin. Other affections with which these 
 growths may be confounded are cysts of the ovary, faecal accumulations, and 
 perityphlitic abscess. Ovarian cysts should have the bowel behind them and 
 not in front, and are generally easily made out by rectal or vaginal exami- 
 nation ; and perityphlitic abscess will usually present constitutional symptoms, 
 which, together with the history, will clear up any doubts that may exist. 
 
 Prognosis. — Malignant disease of the kidney can of course terminate in 
 only one way. The child may live but a few weeks after the appearance of 
 the growth, or he may live a year perhaps, the average being six or seven 
 months. In children these neoplasms are usually softer, grow faster, and 
 exhibit their malignant nature more speedily than in adults. 
 
 Treatment. — The question as to whether operative treatment should be 
 resorted to in malignant renal growths is one that can be answered only after 
 considering the merits of each particular case. Nephrectomy is of course to 
 be thought of only in those cases in which, so far as examination can deter- 
 mine, the disease is in all probability confined to the kidney, under which cir- 
 cumstances there may be some possibility of the removal completely eradicating 
 it, or, if it fails in that, of somewhat prolonging life. 
 
 A review of the literature of the subject shows the results of nephrectomy 
 
TUMORS OF THE KIDNEY. 1037 
 
 for renal tumor in children to be not very flattering. The late Prof. S. W. 
 Gross collected 16 operations upon children between sixteen months and seven 
 years of age. Of these, 9 died and 7 recovered from the operation. Of 
 the latter. 5 were known to have died from recurrence of the disease at times 
 varying from five to sixteen months after the operation, while in the remaining 
 2 the result was not ascertained. Dr. Gross considered nephrectomy to be 
 positively contraindicated in sarcoma in children. 
 
 Dr. Marie B. Werner has tabulated 31 operations, including some of those 
 collected by Gross. An additional case is mentioned by Newman in the table 
 in his ' ; Lectures to Practitioners on the Surgical Diseases of the Kidney." Of 
 these 32 cases, 16 survived and 16 perished from the operation. Recurrence 
 is known to have taken place in 8 of the 16 cases which recovered from the 
 operation, the shortest time before death occurred being two months, and the 
 longest eight months. In the other eight cases the ultimate result was not 
 ascertained. One of them died a year and a half after the operation, but the 
 cause of death is not stated. 
 
 Butlin, in his work entitled " The Operative Surgery of Malignant Disease" 
 says of nephrectomy for sarcoma in children that " not one thoroughly success- 
 ful case can be claimed, and it is probable that the operation will fall into dis- 
 repute." 
 
 Judging by the ultimate result in those cases of operation in which it was 
 ascertained, there can be no doubt that the weight of evidence is unfavorable 
 to nephrectomy for malignant disease in children. If there be any hope of 
 success from the operation as a radical measure, it must be when it is performed 
 at a very early period of the disease. Each case, however, must be judged on 
 its own merits. If the operation is to be undertaken, there should be absence 
 of evidence of dissemination of the disease, and the general condition of the 
 child should warrant so severe a procedure. If resorted to, nephrectomy 
 should be performed by the abdominal incision, since the space in the loin in 
 children is insufficient to permit the safe removal of a tumor even if it be of 
 moderate size. The risks of the operation are very considerable, haemorrhage, 
 shock, collapse, and peritonitis being the imminent dangers encountered. 
 Owing to the high degree of vascularity of these growths the danger of pro- 
 fuse bleeding during their removal, especially if adhesions have to be broken 
 up, is very great. 
 
 In cases which do not permit of operation all that can be done is to attempt 
 to afford some palliation for the symptoms to which the tumor gives rise. Pain 
 should be subdued by the administration of opium and the local use of bella- 
 donna plaster, or opium, chloral, chloroform, aconite, and belladonna in lini- 
 ment. Haemorrhage will call for the employment of haemostatic remedies, 
 such as gallic acid and ergot. Morris speaks highly of ferric alum for this 
 purpose. 
 
VESICAL CALCULUS. 
 
 By J. WILLIAM WHITE, M. D., 
 
 Philadelphia. 
 
 Varieties of Calculus found in Children. — The uric-acid calculus is 
 by far the most common kind found in children. Statistics by different authors 
 variously place it from two-thirds to five-sixths of all stones. It was first 
 described by Scheele in 1776. It may be composed exclusively of uric acid, 
 or it may be mixed more or less with oxalate of lime and the urates of ammo- 
 nium and sodium either in its intimate structure or in alternating layers. It 
 is generally oval, rarely very large, and sometimes quite smooth, though more 
 often granular or slightly tuberculated. The color varies from a light fawn — 
 almost white — to a brownish or blackish red. There are two forms — the lami- 
 nated and the amorphous — although a stone may contain layers of both. The 
 laminated variety, when cut through the centre and polished, resembles an 
 agate ; but, besides the concentric curved lines, radiating lines may often be 
 seen extending from the centre to the periphery. This variety is very hard, 
 and when broken splits into angular and often sharp-pointed fragments. The 
 amorphous uric-acid calculus is structureless or sandy on section, and generally 
 of a dirty reddish-yellow color. It is sometimes quite soft and breaks into 
 irregular fragments. 
 
 Next in frequency to the uric-acid stone comes the oxalate-of-lime or mul- 
 berry calculus, first described by Wollaston in 1797. It is generally round, 
 covered with blunt points or spicules, very hard, and varies in color from a dark 
 gray to a brownish black. 
 
 Urate of ammonium occasionally occurs as a calculus, but is usually in 
 combination with uric acid. When it does occur it is flattened, oval, smooth, 
 or granular, brittle, and of a clay color. 
 
 The mixed or fusible phosphate, the ammoniaco-magnesian phosphate, 
 phosphate of calcium, carbonate of calcium, cystic oxide, xanthic oxide, fib- 
 rinous, fatty (urostealith), and indigo calculi are extremely rare, or never occur 
 in children as pure calculi, although some of them may enter into the composi- 
 tion of a stone with uric acid. 
 
 Stone in children may be small or large, from a few grains 1 to an ounce or 
 more ; soft or hard, depending upon its composition and the length of time it 
 has taken to form ; single or multiple ; free or attached to the bladder-walls, 
 either by a band of lymph or by being caught in one of the folds of mucous 
 membrane. It almost always has its origin in the kidney, unless it be formed 
 around some foreign body which has been introduced into the bladder. The 
 
 1 Sir Henry Thompson objects to giving a concretion of less than 20 grains in weight the 
 name of " calculus " or " stone." While there may be some practical advantage in this limitation 
 in the case of adults as regards especially the significance of statistics, there can be none in 
 children. 
 
 1038 
 
VESICAL CALCULUS. 1039 
 
 experiments of Rainey, Ord, Vandyke Carter, and others have shown that 
 % - urinary calculus is not an accidental agglomeration of solids, crystalline, and 
 amorphous, in a cement of mucus," but that it is a " massive crystallization of 
 urinary ingredients in a colloid substance," the formation of which occurs in 
 obedience to a fixed law. Although the frequency of the uric-acid calculus is 
 doubtless due to the excess of uric acid in the urine of children and to the 
 presence in the kidneys of infarctions which are almost entirely composed of 
 uric acid, and which Virchow has shown to be very common, almost constant, 
 during infancy, yet it must be remembered that some colloid substance, as 
 mucus, albumin, pus, etc., has to be present or no stone will be formed, and the 
 crystals will pass out with the urine in the well-known cayenne-pepper or brick- 
 dust deposit. 
 
 Etiology. — As just stated, the two chief causes of stone are crystals in 
 the urine and the presence of a colloid substance. How far the production 
 of these two causes is influenced by heredity it is very difficult to state. 
 
 That stone is occasionally found with exceptional frequency in certain 
 families there can be no doubt, but before its occurrence is assigned to heredity 
 it should be remembered that there may be some local cause equally affecting 
 all the members of a family and peculiar to their place of residence, not to their 
 physical condition. 
 
 Cadge, some years ago, made the following interesting remarks as to this 
 point : "In five instances I have operated on brothers, and in four other in- 
 stances I have operated on one brother, and other surgeons on another. Mr. 
 Clubbe of Lowestoft has given us a curious history of a stone-family : Three 
 brothers were cut for stone by Mr. Clubbe ; a fourth passed a stone ; a fifth 
 child died, aged three months, with every symptom of stone ; a female child 
 now has vesical irritation and bloody urine. The father and mother are con- 
 stantly passing large quantities of lithic acid ; the grandfather passed one stone, 
 and the grandmother seven ; a great-uncle was cut for stone, and six uncles 
 and four aunts all suffer either with fits of gravel or from lithic deposits ; and, 
 to finish, a cousin passes calculi. There is considerable historical testimony in 
 favor of this hypothesis. We know that Montaigne and his father both died 
 of stone in the bladder, and we remember how he moralizes on the incompre- 
 hensible wonders of the hereditary transmission of mental and bodily resem- 
 blances and infirmities. The celebrated minister Sir Robert Walpole and his 
 brother Horace (who once represented this city in Parliament) were both 
 afflicted with stone ; and their mother also had stone." 
 
 It is probable that gout and rheumatism increase any tendency to the for- 
 mation of stone, as they are usually accompanied by acid urine, with an increase 
 in uric acid and the urates. As gout is hereditary, the tendencies to stone, 
 which it produces, may also be hereditary. But gout, as a rule, is an inherit- 
 ance of the rich, brought on by generations of over-eating and drinking, and 
 yet it is a remarkable fact that the children of the rich are singularly free 
 from calculus, while the children of the poor make up more than one-half of 
 the cases of stone in the tables of statistics. Deschamps, at the close of the last 
 century, said that during the thirty years in which he treated people afflicted 
 with calculus, he had yet to see the child of a rich man affected with stone. 
 Sir William Fergusson is quoted as saying that he had but once received a fee 
 for operating on a child. Of the 863 cases of stone which Sir Henry Thomp- 
 son treated in private practice, but 3 were under sixteen years of age. and only 
 8 from sixteen to twenty-four. In explanation of this Sir Henry Thompson 
 says: "Insufficient food, clothing, and fresh air, the necessary accompaniments 
 of poverty, appear to encourage calculous formations among children, but not 
 
1040 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 among adults. Habits of self-indulgence, in relation chiefly to diet, and indo- 
 lence, encourage calculous formation in elderly adult males, but the children 
 of such parents are not so affected. Hard physical labor and a regimen which 
 necessarily contains simple diet, largely cereal, with animal food in small pro- 
 portion, even although often associated with intemperate habits and with un- 
 healthy dwellings, discourage calculous formations among all classes of the com- 
 munity alike." 
 
 It is a well-known fact that stone occurs much more frequently in certain 
 districts than in others, but a satisfactory explanation of this has not been 
 given. It is possible that climate may have some slight influence over the 
 production of these affections, as in very changeable regions calculous diseases 
 are more common than in those localities where the temperature is more uni- 
 form. This may be due to a lack of proper clothing and insufficient protection 
 of the skin, whereby its functions become disturbed and the kidneys are re- 
 quired to perform an excess of labor. In the United States stone is much 
 more common in Kentucky, Tennessee, Ohio, Virginia, and North Carolina 
 than in any other portions of the country, and yet we have a vast area of ter- 
 ritory which is similarly located, geographically, geologically, and climatically, 
 in which stone is rarely if ever encountered. In England calculus is common 
 around Norfolk and Manchester, while in other regions, which are in the same 
 latitude and subject to the same temperature, it is almost unknown. Neither 
 can it be attributed to hard water alone, as Mastin shows that in parts of Ken- 
 tucky and Tennessee, where the water is soft, calculous diseases are common, 
 and just as frequently met with as in the limestone districts. Again, Mr. Dud- 
 geon of Pekin informs us that at Canton in China stone is frequently met with, 
 while around Pekin it is hardly ever seen ; yet the water of Pekin is full of 
 lime, while the Canton water is soft. 
 
 It would seem that race has some influence over stone formation. The 
 negro in America is said to be remarkably free from calculus, and Rayer says 
 that in Egypt he escapes, while the Arab suffers. 
 
 Diet and regimen, at least in the cities, have much more to do with the pro- 
 duction of stone than heredity, climate, water, soil, etc. ; and I believe that 
 Mr. Cadge has come nearer the cause when he says that the frequency of 
 calculus in children will be found in strict accordance with the difficulty in 
 procuring milk. He adds: "A few years ago, after removing a stone from 
 a child of well-to-do parents, I was remarking to one of my assistants that this 
 was the first instance in my practice, and that I attributed the general absence 
 of stone in such persons to the free use of milk : the mother volunteered the 
 statement that in a large family this was her only child who never could take 
 milk, and who, therefore, never had any." 
 
 Sex undoubtedly has an influence upon the frequency of vesical but not of 
 renal calculus. There is no reason why the female is not as liable to the for- 
 mation of calculous concretions within the kidney as the male ; but, the nucleus 
 having once descended to the bladder, the large size and shortness of the urethra, 
 the absence of the prostate, and the comparative freedom from urethral diseases 
 and vesical catarrh are almost sufficient to secure immunity. Giraldes asserts 
 that vesical calculus happens twenty-four times more frequently in boys than in 
 girls, while Neubauer found but 5 girls in 100 cases. 
 
 Relative Frequency of Calculus. — Most of the statistics of cases of 
 calculus agree in that children make up one-half or a little more than one-half 
 of the number. In a collection of 1103 cases by Prout, 594 were under four- 
 teen years of age. In Cheselden's series of 213 cases, 115 were under ten 
 and 62 were from ten to twenty years old. Robert Smith's 543 cases from 
 
VESICAL CALCULUS. 1041 
 
 Leeds and Bristol show 253 to be under sixteen. Sir Henry Thompson's elab- 
 orate table of 1827 cases shows that 1001 were under sixteen years of age. In 
 Dolbeau's collection of 5376 cases, 2416 were under the age of puberty. No 
 period of life is exempt from the liability to stone. Langenbeck found a cal- 
 culus in the bladder of a male foetus of six months, and Jacobi has reported a 
 case in which the child was only ten days old when symptoms of difficult mic- 
 turition were noticed, and another case of an infant who passed blood soon after 
 birth, the first urine being voided forty-eight hours later, and a reddish, 
 gritty mass being found in the diapers. He has detected six cases of congenital 
 renal calculi in forty autopsies, and believes that many cases of so-called intes- 
 tinal colic occurring in children are in truth cases of renal colic. The passage 
 of a calculus is frequently accompanied by haemorrhage and followed by sec- 
 ondary nephritis. 
 
 In Thompson's table the frequency of stone rapidly increases from birth 
 to the fourth and fifth years of life, after which it gradually decreases to the 
 age of puberty. The fallacy of depending upon these figures has, however, 
 been shown by various writers, and Sir Henry Thompson says that after inves- 
 tigating the old statistics of stone and those collected prior to 1850, he found 
 them misleading. He adds: "So far from the stone being more common in 
 children than in adults, according to the universal belief at the period referred 
 to, justified as it was by the records of hospital practice, I was soon in a posi- 
 tion to affirm that stone was more common among men of sixty years of age 
 and upward than at any other period of life. For let it be remembered that 
 all existing records of practice, whether found in museums or reported by the 
 operators themselves, from all sources previous to the middle of the present 
 century, showed that half the total number of operations for calculus occurred 
 in childhood and youth. The truth, nevertheless, is that a very large majority 
 of calculous cases was then, as now. to be found in persons above fifty years of 
 age, but the fact was then unknown; the calculi were simply overlooked, not 
 being suspected to exist; and one obvious reason of the oversight is to be found 
 in the fact that the early symptoms in elderly subjects are extremely slight — 
 a rule with only few exceptions — contrasting strongly with the marked and 
 painful symptoms rarely absent in the young." 
 
 Agnew, after quoting the figures of Gross, Civiale, and Thompson, show- 
 ing 62.33 per cent, under twenty years of age, adds: "These estimates, how- 
 ever, are calculated to mislead, from the disparity which must necessarily exist 
 between the different classes of patients when the number of each is contrasted 
 with the entire population living at the same ages. Were the statistics based 
 on this principle, a result the reverse of that exhibited would be shown. In 
 other words, the tendency to calculous disorders would be found to increase 
 with advanced age. The inaccuracy of all statistics with regard to the age of 
 calculous patients will be further shown by the fact that the date has been 
 fixed at the time the patient was operated on, though the disease may have 
 existed several years previously." 
 
 Mr. Coulson has made a similar remark, viz. "that an error has crept in 
 from not using the proper precaution to distinguish between absolute and rela- 
 tive numbers. To determine liability the absolute numbers should be corrected 
 by the number of persons living at the several periods of life enumerated. 
 Thus, if all persons under twenty were affected with stone and all over seventy 
 were affected with the like complaint, it is evident that the liability would be 
 the same, though the absolute number of persons attacked would be very dif- 
 ferent." Mastin says : "To enable us to determine the liability of chil- 
 dren of a certain age to stone, we must correct the absolute numbers by the 
 
 66 
 
1042 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 numbers of persons of all ages living at the several periods of life enumerated. 
 Corrected in this manner statistics would most probably show that young per- 
 sons are much less liable to calculous affections than is generally believed." 
 
 Symptoms. — The symptoms of vesical calculus in children are for the 
 most part the same as in adults, but they present certain peculiarities due to the 
 age of the patient. If the child be not old enough to appreciate when he is 
 sick, and to describe the character and locality of the pain, the surgeon has to 
 rely almost entirely upon objective symptoms for his diagnosis. But if the child 
 be old enough, in many cases, before the development of vesical symptoms, the 
 descent of the nucleus from the kidney will be announced by a group of symp- 
 toms known as nephritic colic. While feeling perfectly well he is suddenly 
 seized with a violent pain, felt first in the lumbar or hypochondriac region, and 
 rapidly extending down the line of the ureter toward the scrotum and end of 
 the penis. The testicle is drawn upward by spasm of the cremaster muscle. 
 The pain follows the branches of the lumbar plexus into the groin, thigh, and 
 hypogastrium. Vesical irritation and tenesmus are frequent. Faintness, cold 
 sweating, convulsions, and even collapse, may be present. These symptoms 
 may cease as suddenly as they began, but the relief will not be permanent until 
 the stone has passed into the bladder. As long as the stone is in the ureter, the 
 attacks of colic succeed each other at intervals of a few minutes to an hour or 
 more. The urine is high-colored, scanty, and may even be almost suppressed. 
 A history of this kind is an important indication in cases of suspected stone, 
 and should lead the surgeon to make repeated examinations if the following 
 group of symptoms or the majority of them be present: 
 
 (1) Frequent micturition or incontinence of urine, more marked by day than 
 by night; also more marked if the stone has an irregular surface than if it is 
 smooth, and increased by active motion while at play or driving over rough roads. 
 This symptom is more marked and more common in children than in adults. 
 
 (2) Pain. — The characteristic pain of stone is darting and burning, and 
 is felt during urination, but is most severe at the termination of the act, when 
 the irritated mucous membrane of the empty bladder comes in contact with the 
 calculus. The pain is rarely referred to the bladder, but is felt on the under 
 surface of the penis a short distance behind the external meatus. It is so 
 severe as sometimes in children to cause convulsions, and often continues for a 
 long time or until sufficient urine has collected to remove the walls of the blad- 
 der from close contact with the stone. In cases of encysted stone pain may be 
 almost entirely absent. Handling of the penis and traction on the prepuce to 
 relieve the pain gradually stretch the foreskin until it becomes abnormally 
 long, and induce priapism, which, owing to the congestion of the vessels of the 
 prostato-vesical region, often leads in children to the habit of masturbation. 
 
 (3) Sudden Interruption of the Stream during Urination. — In the early 
 period of the stone, while the calculus is still small and movable, it is often 
 swept into the neck of the bladder and acts as a ball-valve, completely obstruct- 
 ing the vesical orifice of the urethra. The child soon learns the best method 
 of obviating this difficulty, and will assume some peculiar or unusual position 
 which experience has taught him will dislodge the stone and permit the com- 
 pletion of the act. 
 
 (4) Hematuria is rare as a symptom in children. It is due to the wounding 
 of the congested mucous membrane by contact with the calculus, hence it is 
 aggravated by exercise and is most noticeable at the end of urination. 
 
 (5) Evacuation of the bowels during urination, with prolapse of the rectum, 
 is a frequent symptom when the vesical tenesmus is great on account of the 
 violent straining to void the last few drops of urine. 
 
VESICAL CALCULUS. 1043 
 
 (6) The presence of muco-pus in the urine is a corroborative symptom due 
 to the concomitant cystitis, and is of no special diagnostic value. 
 
 (7) Reflex pains in different parts of the body are sometimes associated 
 with stone. In many cases the pains will be referred to the rectum or perineum, 
 but sometimes to portions of the body far removed from the seat of the trouble, 
 as in the upper extremities, the back, lungs, stomach, thighs, and feet. 
 
 The principal symptoms, then, are frequent desire to urinate, with incon- 
 tinence or very rarely retention ; pain referred to the end of the penis ; sudden 
 stoppage of the stream ; tenesmus ; prolapse of the rectum ; and priapism, with 
 occasionally more or less cystitis and hematuria. 
 
 But the existence of this group of symptoms cannot justify a positive diag- 
 nosis of stone unless further it is felt and heard by the surgeon with the aid of 
 the sound. The stone may be in the kidney or under the prepuce. Rectal trou- 
 bles, prolapse from various irritations, as worms, ulceration, etc., may, by reflex 
 irritation, affect the functions of the bladder apparently as seriously as though 
 it were the principal organ involved. Diseases of the kidneys, phimosis, 
 adherent prepuce, irritating smegma, etc. may also produce analogous symp- 
 toms, and, on the other hand, there is no ordinary symptom which may not be 
 absent in a case of stone. 
 
 Diagnosis. — The diagnosis of stone is therefore to be made with the sound. 
 Many different forms of vesical sound have been recommended, but the best 
 and simplest has a straight steel shaft with a short curve near the tip and a 
 smooth flattened handle. The tip should be blunt and of slightly larger calibre 
 than the shaft, so that the walls of the urethra may not grasp the shaft so tightly 
 as to interfere with the delicacy of the movements. The curve at the tip should 
 be shorter than in the adult sound, owing to the anatomical difference of the 
 parts in children. Sounding should always be done with the patient under 
 ether unless there is a good reason for not doing so in the special case. The 
 patient should be in a recumbent or semi-recumbent position, the abdominal 
 walls well relaxed by slight elevation of the shoulders, the knees drawn up, 
 and the thighs somewhat separated. During the exploration the bladder should 
 be moderately distended with water. The sound being warm and well oiled, it 
 is held lightly but securely by the handle, and the surgeon should allow it to 
 glide along the upper surface of the urethra, more by its own weight than by 
 using any pushing force. Once in the bladder, the cavity should be explored 
 in a systematic manner. The sound should be partially withdrawn and reinserted 
 in a straight line, the handle being slightly raised and depressed from time to 
 time. The beak of the sound should then be turned toward one side of the blad- 
 der, and should be made to traverse the arc of a circle, sweeping transversely 
 through the bladder from above downward. It should then be turned to the 
 opposite side, and the same manoeuvre repeated. If the stone is not found 
 in this manner, the searcher should again be introduced to its full length, and 
 the tip turned gently toward the floor of the bladder, and then rotated from 
 side to side, while the instrument is gradually withdrawn until it comes in con- 
 tact with the vesical neck. If the stone be of moderate size, in nine cases out 
 often it is struck and heard at once, and its mobility in the bladder is recognized. 
 So positive are these sensations that the nature of the case is determined even 
 by an inexperienced examiner. A few surgeons consider it sufficient to feel 
 the stone with the tip of the instrument, but the majority prefer to demonstrate 
 its presence by eliciting the characteristic click. The latter is certainly by 
 far the most definite and satisfactory symptom it is possible to obtain, and, 
 although even that does not entirely exclude the possibility of error, it reduces 
 
1044 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 it to a minimum, especially in children, where tumors with calcareous incrusta- 
 tions are exceedingly rare. 
 
 Among the sources of failure in the detection of stone are (1), the sound 
 may be pushed through the delicate urethra immediately anterior to its unde- 
 veloped prostate, when it would at once enter the ischio-rectal space, where, 
 in the very loose tissues of the child, it may be moved about almost as freely 
 as if it were in the bladder ; or (2), without breaking through the urethra, the 
 loosely-attached bladder may be pushed before the sound. This is especially 
 likely to occur in children as compared with adults. (3) A more or less com- 
 pletely encysted condition of the calculus, leaving little or nothing of its sur- 
 face exposed to immediate touch. This is exceedingly rare in young persons. 
 (4) The presence of a diverticulum containing a stone and communicating 
 with the bladder by a small aperture, the calculus in such a case being prac- 
 tically extra-vesical. This is a condition usually associated with long-continued 
 obstructive disease, and is almost never found in children. (5) The stone may 
 be suspended by a thread of lymph from the summit or the anterior wall of the 
 bladder. (6) The surface of the stone may be covered with a blood-clot or with 
 lymph, so as to prevent the characteristic sound from being elicited. 
 
 It is a curious fact in the history of stone in the child, as well as in the 
 adult, that one surgeon may detect the calculus and another of equal expe- 
 rience may miss it. 
 
 The examination for stone in female children does not differ materially from 
 the same procedure in the male. Owen quotes Holmes's remark : "I hope it 
 may not be impertinent to point out that at very early ages the vagina may be 
 mistaken for the urethra," and adds, " This caution is extremely pertinent: if 
 there be any doubt, a second sound may be deliberately passed into the vagina 
 to prove that the first has entered the bladder ; or the finger may be passed 
 into the rectum to show that the vagina is free ; or the beak of the sound may 
 be felt for above the pubes." 
 
 Preventive Treatment of Stone. — As we have seen, most of the cases 
 in children belong to the ignorant and poorer classes, subjects of improper diet 
 and unfavorable surroundings. If such cases could be treated in the early 
 formative stage, there is no doubt but that much might be done to prevent the 
 formation of stone. In the preventive treatment of calculus the avoidance of 
 catarrhal conditions of the urinary tract is of the greatest importance. The 
 main colloid for acid stone is probably mucus, and a little scratching of the 
 mucous membrane by the points of the crystals or irritation by concentrated 
 urine is sufficient to call out enough mucus to act as a colloid. Our object 
 should then be to make the urine as bland and abundant as possible, and 
 for this purpose there is nothing better than milk and the free use of water as 
 a beverage between meals. The particular kind of water to be used is of minor 
 importance, as the most noted waters in the treatment of stone seem to have 
 purity as their chief recommendation. A proper diet for such a case should be 
 chosen from the following articles : fish, poultry, bread, all cereals, green vege- 
 tables, salads, fruits, and eggs. Sugar and the different kinds of fats are harmful, 
 as is an excess of the dark meats. Over-eating is especially and particularly 
 to be avoided. Highly-seasoned articles of food are even more objectionable 
 with children than with adults, as they tend to excess in eating, and in addition 
 often cause acute indigestion or, worse still, a chronic acid dyspepsia. 
 
 The solvent treatment of stone has but little to recommend it. Brodie tried 
 injections of dilute nitric acid ; Roberts has experimented with potassium 
 citrate and acetate ; Garrod, with the lithia salts ; Vogt, with piperazine : 
 
VESICAL CALCULUS. 1045 
 
 Beale. with aininoniuin carbonate, etc. Electrolysis has also been tried even 
 more unsuccessfully. 
 
 All these procedures are more objectionable in children than in adults. 
 Vesical injections of all kinds are relatively more irritating on account of the 
 greater delicacy of the mucous membrane. The administration of large doses 
 of alkalies and diuretics by the mouth are almost certain to interfere with diges- 
 tion, and thus do more harm than good. In the presence of excess of uric acid 
 or urates or oxalates in the shape of crystals, the free use of water, and of 
 small doses of lithia with potassium carbonate, is of great value in prophylaxis ; 
 carbonated " lithiated Yichy " water, a commercial product, is often agree- 
 able and useful, but is sometimes disliked by children on account of its effer- 
 vescence. 
 
 Anatomy of the Urinary Organs in Children. — This may be briefly 
 alluded to before describing the operative treatment of stone. In the infant 
 the bladder is egg-shaped, having the larger end resting in the pelvis. There 
 is no marked fundus or base to the bladder in the young child, and it is situated 
 mainly in the abdomen. As the pelvic cavity increases in size the bladder 
 gradually descends into it, and the infant about this time assuming the perpen- 
 dicular attitude, it has been thought that the weight of the urine tends to make the 
 lower part more capacious. Observations upon the dimensions and position of 
 the bladder will naturally vary with the empty or distended state of the organ. 
 Through childhood until toward puberty, when the organs of generation are 
 developed and the neighboring parts assume their normal adult relations, the 
 urinary bladder is always so loosely attached to the pelvic walls that, although 
 it may have settled into the pelvis, it will require very little force to push it 
 upward into the abdomen. This lax condition of the bladder-attachments is 
 of great importance in the consideration of surgical interference in this region. 
 In the young child the anterior wall of the abdomen, from the symphysis pubis 
 almost to the umbilicus, is in close relation to the bladder, and the neck of the 
 bladder and urethral orifice are about on a level with the upper border of the 
 pubic symphysis. 
 
 The peritoneum is reflected entirely over the posterior surface of the blad- 
 der in the child. The recto-vesical pouch usually embraces the prostatic region 
 very closely, and is liable to injury in children during the operation of litho- 
 tomy, causing peritonitis, the most frequent fatal termination in that operation. 
 
 The anterior surface of the bladder is always uncovered by the peritoneum 
 in children. The capacity of the bladder in infancy is smaller than in after 
 years, and this may account for the frequency with which young children 
 micturate. 
 
 The prostate gland is very small in children. According to Sir Henry 
 Thompson, this gland " at the age of seven years weighs only about thirty 
 grains, and between eighteen and twenty years it weighs two hundred and fifty 
 grains, or nearly nine times as much." 
 
 The urethra, in males, appears to increase slowly in length from birth until 
 puberty is reached. Its canal is more dilatable than was formerly supposed in 
 both adults and children. The meatus is often constricted, so that only a small- 
 sized catheter or sound can be introduced, but if the orifice is incised quite a 
 large instrument will readily pass. The membranous part of the urethra in 
 children is relatively very long, owing to the smallness of the prostate gland at 
 that period of life. In sounding the bladder in a child it should be remem- 
 bered that the urethra lies close to the rectum, and that its walls are exceed- 
 ingly thin and delicate. 
 
 The degree of curvature of the urethra is greater in the child than in the 
 
1046 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 adult, but there are variations in this respect naturally following, as do those 
 pertaining to the contiguous parts, upon growth or immature development. 
 
 In the female the urethra is imbedded in the anterior wall of the vagina, 
 which is sometimes of large size in childhood, and corresponds to the upper 
 part of the prostatic portion of the male passage. It is very distensible. 1 
 
 The Operative Treatment of Stone. — Three methods for removal of 
 stone from the bladder of male children are open to the operator: 1. Supra- 
 pubic lithotomy ; 2. Perineal lithotomy ; 3. Litholapaxy. 
 
 The statistics of these operations (see next page) indicate unmistakably the 
 rejection of the first as a routine method in children. It should be reserved for 
 those calculi which are both too large for the perineal operation and too hard for 
 crushing — a very rare combination. 
 
 A comparison of the two other methods is, however, of much practical 
 importance at this time, the statistical evidence having only recently justified 
 positive conclusions. 2 
 
 Until comparatively recent times the very low mortality of perineal lith- 
 otomy in children in the hands of skilful operators made it seem a work of 
 supererogation to seek for a better method of operation. A safer could scarcely 
 be found. A high rate of mortality after lithotomy was almost always due to 
 deaths among elderly adults. Fergusson and Velpeau, and, later, Freyer, 
 Thompson, and others, objected to the crushing of stone in boys on account of 
 the undeveloped condition of the genito-urinary organs, the smallness of the 
 bladder, the narrowness of the urethra, and the liability to laceration of the 
 vesical and urethral mucous membrane. No instrument had been invented 
 by which litholapaxy could be performed with safety in male children. 
 
 Other objections were advanced from time to time, mainly, however, 
 relating to the same anatomical points, and (before the introduction of lith- 
 olapaxy) to the difficulty of getting rid of the fragments, but the majority of 
 them are now, in the light of the modern improvements in lithotrity, without 
 applicability. 
 
 Anaesthesia has made the "extreme sensibility" of the part and the "indo- 
 cility" of the patients of little moment. Otis has shown that in children, as 
 in adults, the "small diameter of the urethra" may be greatly increased with 
 entire safety. He says that the proportionate relation between the circumfer- 
 ence of the urethra and that of the penis, which he has already demonstrated 
 in adults, holds good in children. Thus, with a circumference of penis of one 
 and a half inches, as in a child from two to three years of age, the size of the 
 urethra would not be less than sixteen millimetres in circumference; and this 
 urethral calibre increases or diminishes about two millimetres for every quarter 
 inch added to or subtracted from the penile circumference. It is but fair to 
 mention that Morelli has called attention to a fact upon which some of the 
 success of the Indian surgeons may depend — viz. the very early age at which 
 the children of tropical and Eastern countries reach full sexual development. 
 This may permit the use of larger instruments on an average at a given age 
 than would be possible in Europe or America, and would facilitate and extend 
 the possibilities of litholapaxy. 
 
 Antisepsis during and after the operation has minimized the danger of 
 laceration of the mucous membrane ; instruments have been made which are at 
 the same time small enough to permit of their introduction into the urethra 
 
 x For further information I may refer to McClellan's Anatomy, from which the above 
 account has been condensed. 
 
 2 As my opinion, arrived at a few years ago {Medical News, May 17, 1890), remains 
 unchanged, and has indeed been strengthened by later experience, I may be excused for sum- 
 marizing here the views then expressed and making such additions as seem important. 
 
VESICAL CALCULUS. 1047 
 
 and bladder of young infants, and strong enough to deal with very large and 
 verv hard calculi : Bigelow has overcome the difficulty of getting rid of the frag- 
 ments : and the argument from statistics is at least neutralized by the records 
 of Keegan and Freyer. 
 
 Cabot has given the most recent statistics of the three operations, made up 
 from a series of published cases and from others obtained by him. As all 
 the cases were operated upon after 1878, and as they are classified according 
 to age, they are especially valuable for the purpose of this paper. They may 
 be compared as follows for children under fourteen: Suprapubic lithotomy, 
 591 cases; 74 deaths; 12.52 per cent, of mortality. Perineal lithotomy, 539 
 cases; 16 deaths; 2.96 per cent, of mortality. Litholapaxy, 241 cases; 4 
 deaths; 1.66 per cent, of mortality. 
 
 Recurrence. — In the face of these figures and of the foregoing facts. there 
 is but one argument remaining which, to my mind, has any weight as urged 
 against the operation of litholapaxy in children, and that is the alleged greater 
 probability of recurrence. 
 
 As regards the two great classes of operative procedures for the removal of 
 calculus — the cutting and the crushing operations — all forms of lithotomy as 
 compared with all forms of lithotrity and at all ages, there can be little doubt 
 that the statistical evidence in relation to recurrence is at present in favor of 
 lithotomy. But it should not be accepted without reservation. Many of the 
 tables, notably those of Sir Henry Thompson and of Mr. Cadge, are based on 
 an experience extending over many years and antedating the introduction of 
 litholapaxy. Those tables make the proportion of recurrence after lithotrity 
 about 1 in 7 or 1 in 8, and after lithotomy about 1 in 20; but, like so much 
 of the statistical matter which our text-books and journals contain, they are 
 useless or misleading at the present day. The two principal causes which lead 
 to recurrence are — a. The failure to remove every portion of stone at the first 
 operation ; b. The new formation of stone in the kidney and its descent into 
 the bladder. In the tables of Mr. Donald Day, based on the records of the 
 Norwich Hospital, the first class includes two-thirds of all the cases of recur- 
 rence. But circumstances have altered. The employment of a large-sized 
 evacuating- tube, the immediate and thorough emptying of the bladder, the 
 minute pulverization usually possible with completely fenestrated lithotrites, 
 the increased knowledge of the great tolerance # of the bladder to prolonged 
 manipulations if they are gentle and skilful, have all combined to place the 
 question of recurrence upon a very different level, and to make the collection 
 of a new set of statistics as to recurrence absolutely necessary before venturing 
 to draw any positive conclusions. 
 
 But if, for the sake of argument, we investigate existing statistics on this 
 subject, we find that the great majority of cases of relapse or recurrence have 
 taken place in patients past middle life, and especially in very old persons 
 with enlarged prostates and feeble or atonic bladders. It will be recognized 
 at once that these conditions do not prevail in children. The prostate is 
 undeveloped; the bladder is almost an abdominal organ; no pouch exists at 
 the fundus; sacculation is nearly or quite unknown; 1 cystitis is a compara- 
 tively manageable complication ; the expulsive power is proportionately greater 
 than in the male adult, in whom a "physiological atony" is not at all infre- 
 quent. In addition to the reasons above given for not anticipating the forma- 
 tion of new calculi in children around nuclei of vesical origin, it may be rea- 
 sonably expected that the conditions favoring the development of renal calculi 
 
 1 Fergusson said that even in adults " sacculated stones " were generally met with by young 
 lithotomists. 
 
1048 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 will be more easily treated and controlled in children than in adults. Cer- 
 tainly among well-to-do people who can carry out a proper system of diet and 
 medication it is fair to suppose that the lithic diathesis, of whatever variety, 
 will be more readily combated in children whose diet and drugs and mode of 
 life can be rigidly administered than in adults with fixed and often very pre- 
 judicial habits. Mr. Cadge expressly states that this was true in his own 
 cases, and adds that he has no personal experience of lithotrity in children. 
 
 Jacobson at one time asserted that this important matter — the percentage of 
 recurrences after litholapaxy — had been left undealt with by Keegan, then the 
 chief advocate of this operation in male children. 
 
 Keegan, in reply, says that in his monograph on the subject (1886) he 
 did not deal with this point, because then he had only had 58 cases in male 
 children and boys. Later (1890), the operation having been on trial for more 
 than seven years, and he having collected 145 cases, 110 of which he had per- 
 formed himself, he felt competent to consider the question, and said : " As to 
 the outcome of this practice and experience, I have arrived at the conclusion 
 that recurrence of stone does not follow litholapaxy in male children any oftener 
 than it does lateral lithotomy, provided that the former operation be skilfully 
 performed. It will be conceded that recurrence of stone after litholapaxy, 
 when performed on adult and aged male patients, is less than that which 
 in former days followed the now obsolete lithotrity of many sittings. But it 
 must be admitted that recurrence of stone does occasionally follow litholapaxy 
 in old patients. When, however, we come to investigate the causes of this 
 recurrence, we find that the main factors which bring it about in aged patients 
 do not exist in the case of male children and boys." He states that he began 
 in 1881 to use litholapaxy, and that of the 145 cases operated on since but one 
 boy has returned with a second calculus. 
 
 Freyer records 3 cases of recurrence in 65 children, the average age of 
 whom was seven and a half years. 
 
 For these reasons, while admitting that the question of recurrence is still 
 sub judice, I am distinctly of the opinion that there is little probability that 
 there will be enough difference between the proportions of relapses in children 
 after lithotomies and after litholapaxies to justify any decided preference on 
 that ground alone. 
 
 The position of litholapaxy in children is moreover strengthened by a review 
 of the history of lithotomy, which, unlike the operation with which we contrast 
 and compare it, has undergone but little change for many years. 
 
 The improvements in suprapubic lithotomy have, it is true, rendered it 
 applicable to a much wider range of cases, and it is equally true that its most 
 favorable results have been attained in children ; but thus far, as we have seen, 
 the statistics of suprapubic lithotomy in children do not compare favorably with 
 those of either litholapaxy or lateral lithotomy. This is probably due to the 
 fact that in a large proportion of cases the operation was selected only after 
 litholapaxy had been attempted and failed, or else was originally chosen on 
 account of the unusual character of the calculus. 
 
 It is true that MacCormac has reported 33 cases of suprapubic lithotomy 
 without a death, but they were from scattered sources and did not constitute a 
 consecutive series. There is no means of knowing how many unsuccessful, and 
 therefore unreported, cases occurred during the same period. 
 
 It will probably always be employed in preference to lateral or median lithot- 
 omy in cases of extremely large or exceptionally hard stones ; but when we 
 remember that Freyer has removed by litholapaxy a calculus weighing 808 
 grains from a boy of nine, and Keegan one of 700 grains (and of uric acid) 
 
VESICAL CALCULUS. 1049 
 
 from a boy nine and a half, it is evident that neither size nor hardness offers an 
 insuperable bar to the latter operation. 
 
 Median lithotomy in children, although advocated by some surgeons, is 
 objectionable on account of the greater danger of wounding the bulb or the 
 rectum, and the difficulties in obtaining space through which to pass the finger 
 into the urethra and the bladder. It is indeed true that the passage of the finger 
 is not absolutely necessary, although it has always been one of the time- 
 honored rules of lithotomy not to withdraw the staff until the finger is in con- 
 tact with the stone. I have, however, frequently seen Dr. Agnew, when 
 operating on young children, introduce a pair of very small lithotomy forceps 
 along the groove of the staff, separate them, and seize the stone, and then, after 
 the removal of the staff, extract the calculus, the finger never having been in 
 the bladder. I have used the same manoeuvre myself with success. I sup- 
 posed it was original with Dr. Agnew (and believe he was of the same opinion), 
 but I found that Mr. Cadge recommended almost precisely the same method as 
 both safe and efficient, adding, " I dare say it has been adopted by others, but 
 I do not find it alluded to in modern text-books." It must be remembered, 
 however, that its adoption places the surgeon in almost the same situation in 
 regard to the possibility of leaving de'bris or unnoticed stones in the bladder as 
 he occupies after a litholapaxy. If the stone is soft and breaks down under the 
 forceps, or if there are multiple calculi, he will be dependent on the touch and 
 sound elicited by the vesical explorer, just as after the other operation. 
 
 If, then, the introduction of the finger be dispensed with in either median 
 or lateral lithotomy in children, these operations lose one of their alleged advan- 
 tages — viz. the assurance of the absolute removal of all calculous fragments. 
 If it be insisted upon, it constitutes in a small proportion of cases an unavoid- 
 able source of both difficulty and danger. Sir William Fergusson, Keith, 
 Thompson, Cadge, and many others have recorded occasional trouble with this 
 step of the operation. The latter surgeon remarks, apropos of Fergusson's 
 case : " He was a master of the art of operative surgery ; if the difficulty 
 occurred to him, we may conclude that it is not unlikely to occur to any 
 of us." 
 
 Lateral lithotomy in children, in addition to the special difficulty due to the 
 smallness of the parts, the high position of the bladder above the pelvis, the 
 delicacy and mobility of the deep urethra and the vesical neck, has one pos- 
 sible contra-indication which should not be lost sight of. If the incision be 
 prolonged a little too far backward, the left ejaculatory duct can hardly escape 
 division and subsequent obliteration ; and although this may not be a serious 
 accident in cases in which the integrity of the opposite half of the genitals, the 
 testicle, duct, etc., is unimpaired, yet it leaves the patient entirely dependent 
 on that one side for fertility if not for potency. Mr. Teevan has reported four 
 cases of sterile husbands among lithotomized patients. Langenbeck and Sir 
 William MacCormac have called attention to the same danger, and Keegan 
 believes the lateral operation to be frequently followed by emasculation. 
 Dennis quotes Dr. Charles Leale in relation to several cases coming under his 
 own observation, in which such patients grew up with shrill voices, atrophied 
 testicles, absence of hair upon the face, etc. ; in fact, with all the character- 
 istics of eunuchs. The evidence as to this point is as yet fragmentary and 
 inconclusive, but is of sufficient importance to deserve careful consideration, 
 although Ehrmann characterizes the fear of sterility as a "bugbear." 
 
 The objections to perineal lithotomy in children are, however, at least as 
 weighty as any that have been urged against litholapaxy. 
 
 The ease and satisfaction to both patient and surgeon with which the latter 
 
1050 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 operation may be performed I can best illustrate by a brief abstract of one of 
 the earliest of my own cases : 
 
 C. W , a" small boy, aged five and a half, was brought to me by his 
 
 father in October, 1889, on account of nocturnal incontinence of urine. He 
 had a long, tightly-adherent prepuce with pin-point aperture. It " ballooned " 
 at each act of urination. I circumcised him, gave small doses of belladonna 
 and bromide of sodium, and dismissed him, apparently cured, in November. 
 
 In January he was brought to me again by his nurse, who told me that his 
 symptoms had returned. I then sounded him for stone, but failed to find it. 
 Insisting (according to my invariable rule in such cases) upon a second exami- 
 nation before giving a positive opinion, I easily found a calculus. I recom- 
 mended crushing, and after a little delay the parents consented. On February 
 20th, the child being etherized, I drew oif the urine and injected three ounces 
 of warm boric-acid solution (fifteen grains to the ounce) into the bladder. I 
 then enlarged the meatus l and introduced a Weiss fenestrated lithotrite, No. 16 
 French. This went in with ease. The stone was readily seized and broken. 
 I spent twenty-five minutes in pulverizing it, paying especial attention to gen- 
 tleness of movement and to the avoidance of rude or unnecessarily wide sepa- 
 ration of the jaws of the instrument. A No. 16 tube was then introduced and 
 a Bigelow evacuator employed. In about eighteen minutes, 2 as no more frag- 
 ments or dust could be perceived, the tube was withdrawn and the bladder 
 carefully explored with a vesical sound. Nothing was discoverable. 
 
 The time of operation was forty-three minutes ; weight of dried calculus, 
 170 grains. The child was sitting up in bed on February 22d, and was out of 
 bed, playing about the room, on February 25th. The nocturnal incontinence 
 persisted for a week or ten days, and then disappeared entirely. There was no 
 fever, bleeding, chill, or other alarming symptoms. 
 
 The parents were nervous, consented reluctantly to this operation, and 
 would certainly have postponed a lithotomy for a long time, much to the child's 
 detriment. 
 
 This is a typical case of litholapaxy in a young boy. I have now had 
 many such cases, and have never had a moment's anxiety about the little 
 patients. It can scarcely be wondered at that after his experience Keegan 
 writes that he would as soon think of cutting an old man for the removal of a 
 small stone as of performing lateral lithotomy on a boy whose urethra would 
 readily admit the passage of a No. 8 (No. 15 French) lithotrite, and whose 
 stone was neither abnormally large nor hard. Nor is it surprising that Freyer 
 says that, lithotomy in the adult having been practically blotted out of his 
 practice, he looks forward confidently to lithotomy in children meeting with a 
 similar fate. Freyer says: "When, in 1885, Keegan first showed that Bige- 
 low's operation was capable of successful extension to the case of male children, 
 I lost no time in procuring the necessary instruments and applying the opera- 
 tion to such cases. In two papers I placed before the profession full details of 
 
 1 Otis recommends performing the meatotomy long enough before the litholapaxy to allow 
 the parts to heal. This is certainly desirable for some reasons, but in nervous children its advan- 
 tages are counterbalanced by the need for two fixed appointments, two operations, etc. I have 
 never found any harm resulting from the plan I here followed. 
 
 2 The pressure on the rubber bulb during the process of evacuation should be slight and 
 frequent rather than slow and vigorous. Prof. Bigelow himself called my attention to the much 
 greater value of the former method, and I have repeatedly verified the correctness of the state- 
 ment. Not only is the danger of driving back into the bladder sharp fragments of stone mate- 
 rially lessened, but the swiftness and effectiveness of the outward current are much increased. 
 I so often see an entirely unnecessary degree of force expended in the working of the bulb during 
 this stage of a litholapaxy, even by expert operators, that it seems worth while to make this 
 note. 
 
VESICAL CALCULUS, 1051 
 
 49 cases of litholapaxy undertaken by me in male children or boys below the 
 age of puberty. Since then 67 males of fifteen years and under, suffering from 
 stone, have come under treatment, and in 66 of these I have performed litho- 
 lapaxv — in all with complete success. In only one instance was it necessary 
 to have recourse to lithotomy (suprapubic). The greater my experience of 
 litholapaxy amongst male children becomes, the more I am fascinated by this 
 operation. Though the average number of days such cases were kept in hos- 
 pital was five and a half as a rule, these little patients may be seen playing 
 about the day after the operation, perfectly happy and untroubled by urinary 
 symptoms of any kind." 
 
 Cadge, MacCormac, Jacobson, Kingston, Keyes, Hunt — indeed, most recent 
 writers — press the conviction, though in less sweeping terms, that the field of 
 litholapaxy in children is likely to be considerably enlarged in the near 
 future. 
 
 I have once, in a patient of Dr. E. L. Duer's, been compelled to abandon 
 the operation on account of the impossibility of inserting the evacuator, 
 although a lithotrite of equal calibre had gone in easily. Walsh am and Mar- 
 shall have called attention to the necessity of having a number of sizes 
 of lithotrites and evacuating tubes, as they had both found great difficulty 
 toward the end of the operation in children in introducing an instrument which 
 had passed easily at its commencement. This is the only experience of the sort 
 I have had in a child. The patient, aet. ten years, passed 40 grains of detritus, 
 and a few weeks later I removed a calculus weighing 240 grains by the lateral 
 operation. Convalescence was then uninterrupted. 
 
 Basing my opinion on the facts mentioned in this paper and on my personal 
 experience, I believe the following conclusions to be justifiable : 
 
 1. In every case of calculus in male children 1 litholapaxy, on account of 
 ease of performance, low mortality, speedy recovery, and absence of danger 
 of emasculation, should be the operation of predilection, division of the meatus 
 being freely resorted to if that portion of the urethra offers an obstacle to the 
 introduction of instruments. 
 
 2. The lithotrite and evacuating-tube should be of a size which can be 
 inserted into the bladder without much effort or over-distention, and great 
 gentleness should be observed in passing these instruments. Keegan says : 
 " When I advocate litholapaxy as being the best operation, in my opinion, for 
 the great majority of stones occurring in male children and boys, I do so 
 with a very important reservation — viz. that no one should attempt to per- 
 form it in boys until he has first gained some practical experience of 
 it in adult males. The surgeon who meets with cases of stone only at rare 
 intervals during his career will be acting more wisely if he adheres to lateral 
 lithotomy or suprapubic cystotomy. It is his misfortune, and not his fault, that 
 he has not been afforded many opportunities of gaining a practical familiarity 
 with the use of the lithotrite." 
 
 3. The instruments should be withdrawn and reintroduced as seldom as pos- 
 sible, the stone being finely pulverized before the lithotrite is taken out at all. 
 In seeking for or attempting to seize the stone care should be taken to avoid 
 such wide separation of the blades as will bring the male blade in frequent 
 contact with the vesical neck. The crushing should invariably be done only 
 after rotating the blades into the centre of the bladder. Every particle of 
 the calculous dust should be evacuated. 
 
 4. Rest in bed, milk diet, and sterilization of the urine by boric acid or 
 
 1 These remarks apply almost as well to adults. 
 
1052 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. 
 
 salol given internally, both before and after the operation, are valuable adju- 
 vants. During the operation every antiseptic precaution should be observed. 
 
 Southam very properly emphasizes the importance — «, of this preliminary 
 sterilization of the urine by the administration of salol and boric acid, and if 
 need be by irrigation of the bladder ; and b, the avoidance of shock by 
 thorough protection of the patient against surface chilling. 
 
 5. The exceptional cases of calculi which are both large and hard may be 
 best treated by suprapubic lithotomy, but neither unusual size nor a moderate 
 degree of density should of itself alone be thought positively to contraindicate 
 litholapaxy. 
 
 6. Perineal lithotomy has now a very limited field, and should be employed 
 chiefly in those cases of stone thought to be of small or medium size, in which 
 no lithotrite, however small, can be introduced with safety. 1 
 
 Operative Treatment for Stone in Female Children. — Surgical opinion 
 in regard to the choice of operation in female children has not as yet become 
 so definitely established. The possible methods are — 
 
 a. Vaginal Lithotomy, which is attended with much disturbance of the parts, 
 requires over-stretching of the vagina, section of the fourchette, destruction of 
 the hymen, etc., and which, even in good hands, has not infrequently been fol- 
 lowed by a permanent vesico-vaginal fistula. 
 
 b. Dilatation of the Urethra. — This is easy and safe in the case of small 
 stones, but in larger ones, and especially if incision of the urethra is required, 
 is extremely liable to be followed by incontinence. 
 
 c. Suprapubic Lithotomy. — This is at present the operation of choice with 
 many surgeons. Jacobson thinks it would be wiser to make use of it in all 
 but the very smallest stones. He adds : "I would refer my readers to a case 
 of suprapubic operation by Mr. Barwell in a child aged nine, from whom a stone 
 weighing two and a half ounces was successfully removed. It is interesting to 
 note that Mr. Barwell was led to adopt the suprapubic operation from his 
 having had within seven months no less than three cases of vesico-vaginal 
 fistula originating in the extraction of calculi during infancy and youth by 
 different surgeons." 
 
 d. Litholapaxy. — The statistics which are slowly accumulating (chiefly from 
 Indian sources) tend to show that this will be the operation of the future, but 
 cases of stone in female children are so rare comparatively that the figures thus 
 far available cannot be regarded as conclusive. The difficulty of crushing in 
 such small bladders has been alluded to, but it is usually not greater than in the 
 case of males. If a lithotrite and a fair-size evacuating-tube can be inserted 
 without over-distention of the urethra, there would seem to be no a-priori rea- 
 son why the operation should not be as successful in females as in males. 
 
 The details of the performance of the various operations in both male 
 and female children belong to the systematic works on general and operative 
 surgery, and need not here be considered. 
 
 It may be remarked, finally, however, that an improvement in results 
 scarcely less than that found in other branches of surgery has followed the in- 
 troduction of antisepsis into genito-urinary work, and that, whichever operation 
 is selected in a given case of vesical calculus in a child, the little patient is on 
 the average safer to-day than he was in the hands of even the most skilful 
 operator twenty-five years ago. 2 
 
 l An American Text-Book of Surgery, 1892. 
 
 2 1 desire to acknowledge my obligation to Dr. Robert G. Le Conte for the collection of 
 much statistical matter upon which some of the above statements are based and for further aid 
 in the preparation of this article. 
 
GONORRHCEA AND VULVOVAGINITIS. 
 
 By J. WILLIAM WHITE, M. D., 
 
 Philadelphia. 
 
 I. Gonorrhoea in Male Children. 
 
 In male children specific urethritis does not differ materially in its course, 
 symptoms, and complications from the same disease in the adult. The cause 
 is often some sexual relation established between the child and an adult female 
 for purposes of sexual gratification of the latter, even though the boy may be 
 so young that intromission is impossible. In other cases mediate contagion has 
 occurred by means of dirty clothing, towels, or cloths used by older persons of 
 the same household, etc. In others, chiefly in boys near the age of puberty, 
 the disease is acquired in the customary manner — i. e. during actual or at- 
 tempted intercourse. 
 
 Symptoms. — The usual symptoms, purulent discharge, ardor urinse, 
 chordee, frequent urination, etc., are present. Of the complications, phimosis 
 and balano-posthitis are more common than in the adult, owing to the rela- 
 tively excessive length of the prepuce and to the delicate character of the 
 mucous membrane lining it and covering the glans. Cystitis is not uncom- 
 mon; epididymitis is more so. Prostatitis, as might be expected, is almost 
 unknown, or at least cannot be differentiated from vesical inflammation. The 
 intensity of the urethritis and the severity of the symptoms are both rather 
 greater than in the average case in the adult, and the accompanying constitu- 
 tional disturbance is much more marked. 
 
 Diagnosis. — As such cases are not infrequently the basis of legal pro- 
 ceedings, the physician should be especially guarded in pronouncing upon the 
 character of the disease in any given instance. While specific urethritis can 
 usually be traced to one or the other of the causes above named, there are 
 many cases of simple urethritis which are clinically indistinguishable, and the 
 non-specific nature of which can only be recognized by the absence of a his- 
 tory of infection on the one hand, and by the existence of a sufficient trau- 
 matism, such as the passage of instruments, the ejection of a calculus, etc., on 
 the other. I have seen severe urethral inflammation follow retention and decom- 
 position of smegma beneath a long, tight prepuce, the orifice of which was so 
 small that "ballooning" occurred with each act of urination. In such cases a 
 small quantity of urine is always retained beneath the foreskin, and cleanliness 
 is impossible. In comparison, however, with the number of cases in which 
 this condition exists in children the frequency of occurrence of urethritis as a 
 result is extremely small, and caution should be observed in attributing a par- 
 ticular urethritis to this cause. 
 
 While bacteriological investigation will throw much light upon the etiology 
 of a case of this kind, our information is not yet definite enough to enable us 
 to predicate absolutely upon the presence of the gonococcus the specific char- 
 
 1053 
 
1054 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 acter of the inflammation. It renders it highly probable that the disease is 
 the result of infection, direct or indirect, from another person having the same 
 disease, but it is not yet safe to say more than that. Competent observers, such 
 as Bumm, assert that in the normal urethra a diplococcus is found having all 
 the peculiarities of the gonococcus. If this be true, even if it occurs with 
 great rarity, it is apparent that it destroys the diagnostic value of the gonococ- 
 cus in medico-legal cases. A knowledge of its presence is, however, of use 
 clinically, as indicating an inflammation of more severe type than the simple 
 urethritis in which the infection has been exclusively with staphylococci or 
 streptococci. 
 
 Treatment. — The child should be kept in bed. If there is marked phi- 
 mosis, the prepuce should be slit up the dorsum, or, if the oedema and inflam- 
 matory exudate are not too extensive, a formal circumcision should be per- 
 formed. The organ should be wrapped in cloths wet with lead-water and 
 laudanum, and the constitutional disturbance controlled by mild laxatives, 
 small doses of aconite, and full doses of potassium bromide. An excellent 
 formula is the following, the doses of which are proper for a child five years 
 of age: 
 
 Ify. Potassii bromidi 3j. 
 
 Acid, borici gr. xlviij. 
 
 Tinct. aconiti filiij- 
 
 Tinct. belladonnae . TTLxij. 
 
 Spts. aetheris nitrosi f ^iij . 
 
 Mist, potassii citrat q. s. adfgvj. — M. 
 
 Sig. Dessertspoonful in water every two hours. 
 
 The diet should consist almost exclusively of milk. 
 
 When the inflammatory symptoms have subsided the use of injections may 
 be begun. They should be from one-half to two-thirds of the strength required 
 for the adult, and the excellent rule applicable to the latter should not be 
 deviated from — viz. to avoid the production of pain by the free dilution of the 
 injection to any necessary extent. 
 
 It is often well to begin with a lead-and-laudanum injection, substituting 
 the extract of opium for the tincture: 
 
 3^. Ext. opii aq g r - v j- 
 
 Liq. plumbi subacetat. dil fgvj. — M. 
 
 Sig. Use locally. 
 
 Later, an antiseptic and astringent injection like the following may be 
 employed with advantage : 
 
 fy. Hydrarg. chlorid. corros . gr. JU 
 
 Acid, boric 3j. 
 
 Zinci sulpho-carbolat. gr. xij. 
 
 Liq. hydrogen peroxid fgss. 
 
 Aquae rosae fgvss.— M. 
 
 Sig. Use locally. 
 
 These injections should be given by a nurse immediately after the child has 
 urinated. From half a drachm to a drachm is a sufficient quantity to throw in 
 at one time. 
 
GONOBBHCEA AND VULVO- VAGINITIS. 1055 
 
 During the subsiding stage the internal administration of salol will be of 
 use. and if an irregular febrile movement persists, as is sometimes the case, full 
 doses of quinine night and morning will be of great value. 
 
 II. VULVO-VAGINITIS. 
 
 The vulvo-vaginitis of children may be — a, Catarrhal or irritative ; b, 
 Gonorrhoea!. 
 
 a. The catarrhal form is caused by any simple irritant, the commonest 
 causes being the prolonged contact of the parts with filthy diapers, the retention 
 of urinous and sometimes of fsecal matter between the labia, all forms of 
 dirt, seat-worms, etc. It may be excited by any traumatism or by an attempt 
 at rape. It is an almost pure vulvitis, the vagina being but slightly involved 
 and the urethra very rarely. 
 
 It is characterized by the ordinary symptoms of inflammation, heat, swell- 
 ing, redness, pain or itching, and sometimes by extensive excoriation or actual 
 ulceration. 
 
 b. The gonorrhoeal form is much more severe. There is free purulent dis- 
 charge, much swelling of the external genitalia, intense hyperemia of the 
 mucous surfaces, which bleed readily when touched, ardor urinae, pelvic and 
 abdominal pain, and often some endometritis, with tenderness and swelling 
 of the uterus. 
 
 The constitutional symptoms are quite marked. The fever often has a high 
 range and is very persistent. The local conditions are apt to be rebellious to 
 treatment. 
 
 Diagnosis. — The diagnosis between these two conditions is often a matter 
 of the gravest importance, not so much perhaps to the little patient as to others 
 who may be suspected of being the source of infection. 
 
 The clinical diagnosis will be based upon the presence or absence of the 
 causes of catarrhal vulvitis enumerated above, and upon the extent and charac- 
 ter of the symptoms. The catarrhal variety is not markedly contagious, does 
 not give rise to purulent ophthalmia, and yields readily to treatment. The 
 reverse is true of the gonorrhoeal variety. The former occurs most frequently 
 during the first two years of life ; the latter, from the third to the seventh year. 
 
 The bacteriological diagnosis is open to the same uncertainties as have been 
 mentioned in relation to urethritis in male children. 
 
 One of the most carefully observed cases which has been recorded is 
 reported by Dr. Edward Martin, 1 and appears to show that the discharge from 
 a case of vulvo-vaginitis acquired in an entirely non-venereal manner, appa- 
 rently originating de novo, is capable of exciting a severe attack of typical 
 gonorrhoea when inoculated in a healthy urethra. In 5 of 9 cases he made 
 careful microscopic examinations, and found gonococci present in all. In all 
 but one the possibility of contagion was positively denied. 
 
 The general evidence shows a remarkable difference between the histories 
 of some of the cases and their bacteriology, as in the above instances, and also 
 between the results arrived at by different observers. Vibert and Bordas 
 in six cases of purely traumatic vulvo-vaginitis found diplococci absolutely 
 identical with the gonococci. On the other hand, Martin failed to find gono- 
 cocci in a single case of irritative vulvo-vaginitis, although he examined a con- 
 siderable number. It is apparent, therefore, that the mere presence of the 
 
 l Jour. of Cut. and Gen. JJrin. Dis., November, 1892. Dr. Martin's excellent article con- 
 tains a resume of the latest observations on this subject, and may be referred to with advantage. 
 I have used it in the preparation of this paper. 
 
1056 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 gonococcus does not justify the unreserved diagnosis of specific infection, 
 although it may be said strongly to favor that view and practically to establish 
 it when the clinical symptoms coincide. 
 
 When the disease appears at a very early age, it is almost always the result 
 of infection from a gonorrheal inflammation of some portion of the generative 
 tract of the mother. Later, especially if there is an accusation of rape directed 
 against any one, it is well to remember that the same liability exists, and that 
 the disease may have been carried by the fingers or garments of the mother. 
 
 Treatment. — In the catarrhal variety absolute cleanliness, obtained by 
 frequent bathing in warm water and soap and favored by first pouring carbol- 
 ized oil (1 : 60) over the region, dryness of the parts produced by the gentle 
 use of absorbent cotton, separation of the labia by portions of cotton or gauze, 
 and the use of some dusting powder, such as that given below, are the essentials 
 of treatment : 
 
 1^. Pulv. zinci oxidi, 
 
 Pulv. acid, boric ■ . . da. 3ss. 
 
 Pulv. amyli Ij. 
 
 In the gonorrheal form a little more active treatment is required. Vaginal 
 douches of hot soda solution or of soapsuds, followed by antiseptic irrigation, 
 are to be employed two or three times daily ; the soda may be of the strength 
 of 1 per cent ; the antiseptic solution should contain bichloride of mercury 
 (1 : 4000), or carbolic acid (1 : 100), or boric and salicylic acids (10 gr. of the 
 former and 5 gr. of the latter to f §j), or silver nitrate (1 : 5000). It is 
 important after each irrigation to dry the parts carefully but gently, and then 
 to use a dusting powder, keeping the labia separated. 
 
 If the urethra is involved, and especially if there are evidences of cystitis, 
 the internal administration of boric acid and salol, or of some such mixture as 
 that previously given for the same disease in boys, will be found useful. 
 
 In all varieties of this disease the general health of the little patient should 
 be scrupulously looked after, as struma, anaemia, and digestive derangements are 
 frequently found associated with local causes in producing the symptoms or 
 favoring their continuance. 
 
PHIMOSIS, ADHERENT PREPUCE, PARA- 
 PHIMOSIS. 
 
 By HENRY R. WHARTON, M. D., 
 
 Philadelphia. 
 
 I. Phimosis and Adherent Prepuce. 
 
 Phimosis consists in a contraction of the orifice of the prepuce, which is 
 frequently associated with elongation of the prepuce, preventing the exposure 
 of the glans penis. The condition may be either congenital or acquired. In 
 congenital cases the contraction is much more marked in the inner or mucous 
 layer of the prepuce, which adheres closely to the glans penis. Acquired 
 phimosis is usually seen in children who have suffered from balanitis, and is 
 not common in very young children. Adherent prepuce is a very common 
 condition during early infancy, and is often associated with phimosis : this 
 adhesion by pressure tends to dwarf the growth of the glans penis, and causes 
 accumulation of smegma, which may harden and act as a foreign body. I 
 have frequently seen in cases of adherent prepuce a complete cast of hard- 
 ened smegma filling up the groove behind the corona. 
 
 Phimosis with adherent prepuce, as has been stated before, is almost always 
 present in male infants at birth, but as the child develops the condition 
 usually disappears, and in many cases no symptoms are developed referable 
 to it ; on the other hand, there are often mechanical irritations and reflex 
 nervous disturbances which can be traced to the presence of phimosis, such as 
 malnutrition, choreic movements, paralysis, convulsions, nocturnal incontinence 
 of urine, dysuria, prolapsus of the rectum, and hernia, the latter conditions being 
 most frequently seen where there is marked contraction of the preputial orifice 
 and severe straining efforts are made during micturition. Adherent prepuce 
 with retained smegma in young infants frequently produces priapism, vesical 
 irritation, defective nutrition, and restlessness at night, which conditions are 
 usually relieved by exposure of the glans. In older children the condition of 
 phimosis with adhesions is apt to give rise to priapism, and is unquestionably 
 the cause of the habit of masturbation in young boys. Bearing in mind these 
 facts, it seems the part of wisdom for the physician to investigate the condi- 
 tion of the genital organs in all male infants, to ascertain the fact that the 
 prepuce and the glans are separable ; and it is especially important in any 
 obscure diseases developing in infancy and childhood that this examination 
 should not be neglected. 
 
 In cases where the preputial orifice is very small, as in Fig. 2 (Plate XXII.), 
 the adhesion of the mucous layer of the prepuce to the glans penis is usually 
 very firm, and as the glans cannot be exposed, the adhesion becomes firmer as 
 the patient increases in age, so that to expose the glans it is often necessary to 
 dissect the mucous layer of the prepuce from the glans. 
 
 It is an unquestionable fact that preputial adhesions are separated spon- 
 
 67 1057 
 
1058 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 taneously, and that the condition of phimosis is outgrown, and that many cases 
 reach adult life without presenting any symptoms due to the condition described. 
 But when we consider that a very trivial operation in infancy will relieve the 
 condition which may later gives rise to serious symptoms, it seems to me to be 
 wise to stretch the prepuce and separate the adhesions in all cases. If phimosis 
 still exists and symptoms are present, it can be relieved later by operative 
 interference. 
 
 Treatment of Adherent Prepuce. — This condition is best relieved by 
 stripping the glans, which is accomplished as follows : The foreskin should be 
 drawn slowly backward until the point of adhesion is reached, by grasping the 
 penis between the finger and thumb and making traction upon the margin of 
 the ring in this way : by passing the end of a silver probe around the adhesions 
 between the mucous membrane and the glans, they can usually be separated 
 without difficulty. When all adhesions have been separated and any collec- 
 tions of smegma about the corona have been removed, which is best accom- 
 plished with the end of a probe, the foreskin should be movable upon the glans. 
 The exposed surface of the glans should then be anointed with carbolized oil 
 or boracic-acid ointment, and the prepuce again brought forward, care being 
 taken not to keep the foreskin back for any considerable time, as the condition 
 of paraphimosis soon develops, and much difficulty may be experienced in its 
 reduction. This manipulation should be repeated at intervals of a few days, 
 and in ten days or two weeks it will be found that no tendency to readhesion 
 exists. When there is very marked contraction of the preputial orifice, so that 
 the glans cannot be exposed, it is necessary to resort to dilatation or stretching, 
 excision, or circumcision of the prepuce. 
 
 Dilatation. — This method of relieving phimosis is accomplished by intro- 
 ducing into the preputial orifice the blades of a pair of dressing or dissecting 
 forceps, or forceps specially devised for the purpose, and separating the blades, 
 thus stretching or rupturing the mucous membrane until the glans can be freely 
 exposed ; when this is accomplished, it should be covered with carbolized oil or 
 boracic-acid ointment, and the foreskin should again be brought forward. The 
 manipulation should be repeated at intervals of two or three days for several 
 weeks, until the glans can be exposed without difficulty. The disadvantage of 
 forcible dilatation of the prepuce lies in the fact that there is often a consider- 
 able amount of inflammatory induration of the mucous membrane following the 
 procedure, and forcible dilatation has been followed by gangrene of the pre- 
 puce. I have knowledge of one case in which this unfortunate complication 
 resulted. Therefore, the procedure is, I think, not to be generally recom- 
 mended, but, judiciously employed in connection with stripping of the glans, 
 it is often of advantage ; but in severe cases it is better to resort to excision or 
 circumcision. 
 
 Excision.— This procedure for the relief of phimosis consists in first incis- 
 ing the foreskin on the dorsum of the glans from the preputial opening to the 
 corona glandis ; the flaps thus made, consisting of skin and mucous membrane, 
 are seized with forceps and trimmed off with scissors, so as to make an oval 
 wound. In performing this operation it is well to introduce the end of a 
 grooved director into the preputial orifice and pass it backward over the dor- 
 sum of the glans penis to the corona glandis ; the tissues upon the director are 
 next divided with a bistoury or scissors to the corona glandis ; the flaps result- 
 ing are seized with forceps and trimmed off with a scalpel or scissors, so as to 
 make an oval wound, the fraenum being left intact ; a few stitches of catgut or 
 fine silk are next introduced to hold the skin and mucous membrane together, 
 and the wound is dressed with boracic-acid ointment spread on lint. The result 
 

 
 ,. ' _J 
 
PHIMOSIS AJ\ r D PARAPHIMOSIS. 1059 
 
 following this operation is usually very satisfactory, and it will be found most 
 serviceable in cases where the prepuce is indurated or oedematous as a result of 
 balanitis. 
 
 CIRCUMCISION. — This operation in most cases of phimosis, and particularly 
 in congenital cases, is the one which is to be selected as securing the most satis- 
 factory removal of the redundant prepuce and the freest exposure of the glans 
 penis. In performing the operation of circumcision the foreskin should be 
 drawn slightly forward and the blades of a pair of forceps, preferably Ricord's 
 fenestrated forceps, or a modification of this instrument, fenestrated spring 
 forceps (Fig. 1), should be placed obliquely upon the foreskin, so that more 
 
 Fig. 1. 
 
 Fenestrated Spring Forceps. 
 
 tissue is included in the region of the corona glandis than in the region of the 
 fraenum, care being taken to see that a sufficient quantity of skin is removed, 
 and that no portion of the glans is included in the grasp of the forceps. 
 Neglect of the former precaution often leads to the production of a secondary 
 phimosis after healing has taken place, and a subsequent operation is required 
 to expose the glans. I have been called upon to do a number of secondary 
 circumcisions which were necessitated by the operators having failed to remove 
 a sufficient quantity of the foreskin to expose the glans completely ; it is an 
 error which inexperienced operators are apt to commit. The forceps being 
 placed as above ^described, a narrow bistoury is passed into the fenestra, 
 and the tissues between the blades are divided; or the same purpose may be 
 attained by cutting with scissors close to the forceps. The forceps are then 
 removed and the skin retracts. It will often be found that the mucous mem- 
 brane has not been divided or has only been slightly removed. If this be the 
 case, it should be divided upon the dorsal surface of the glans and corona by 
 introducing a director and dividing the mucous membrane with bistoury or 
 scissors; any adhesions to the glans should be separated with the end of the 
 director. The triangular flaps of mucous membrane thus resulting should 
 next be seized with forceps, and trimmed off with scissors to correspond to 
 the line of the skin incision. There is usually little hemorrhage, but occasion- 
 ally the arteries of the frgenum or a dorsal artery or vein bleed freely, in 
 which case they should be secured by means of fine catgut ligatures. To 
 secure prompt healing of the wound the haemorrhage should be perfectly con- 
 trolled before the skin and mucous membrane are sutured together. I have 
 seen neglect to control the bleeding at the time of operation give rise to trouble- 
 some consecutive haemorrhage, resulting in great swelling of the penis as the 
 blood escaped into the loose cellular tissue ; and I have also seen a child almost 
 exsanguinated by slow consecutive haemorrhage from the artery of the fraenum 
 which had gone on for hours after circumcision. To avoid this complication, 
 I think it is a matter of the first importance to check all bleeding, even if 
 insignificant, at the time of operation, and not to depend upon controlling a 
 haemorrhage by the final suturing of the wound, as is often recommended. After 
 the mucous membrane has been trimmed, the edges of skin and mucous mem- 
 brane should next be brought in apposition by introducing fine silk or catgut 
 sutures. I usually employ a fine chromicized catgut suture, as it does not 
 require subsequent removal. The first two sutures are introduced, one at the 
 fraenum and the other at the middle line of the dorsum ; two more sutures on 
 
1060 A MEBICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 each side are usually sufficient. The appearance of the parts immediately 
 after circumcision in the case already depicted, in which there were firm ad- 
 hesions between the mucous membrane and glans, is seen in the accompanying 
 plate. (Plate XXIII.) 
 
 The surface of the glans and the sulcus behind the corona should be dressed 
 with boracic-acid ointment or carbolized zinc ointment, and a dry dressing of 
 sterilized or carbolized gauze may be wrapped around the penis to cover the 
 wound, or a wet dressing, consisting of boracic acid, glycerin, and water, may 
 be employed in the same manner. The dressing may be held in place by the 
 turns of a narrow roller bandage or by the T bandage or by the child's nap- 
 kin. Subsequent dressings are made daily, and at the end of a week the union 
 is generally complete in the line of incision. Some oedema of the mucous mem- 
 brane may persist for weeks, but it usually disappears in a short time. 
 
 Paraphimosis. 
 
 II. Paraphimosis. 
 
 This name is given to the condition in which an abnormally narrow pre- 
 puce has been drawn up above the corona glandis and remains irreducible. 
 When this accident happens the glans soon becomes swollen 
 and cedematous from the constriction exercised by the 
 edges of the preputial orifice, and, if the condition is not 
 promptly relieved, ulceration or gangrene may occur. 
 Paraphimosis is usually met with in boys who retract the 
 prepuce and fail to replace it promptly, or may result from 
 the trick of tying strings or bands around the root of the 
 penis. One of the most aggravating cases I have ever 
 seen was caused by an ignorant nurse tying a string around 
 a boy's penis to control nocturnal enuresis. I have also 
 seen the condition resulting in young children from the 
 bites of insects. When paraphimosis has existed for some 
 time, the swelling and oedema of the glans and mucous 
 membrane become so marked that the greatest distortion 
 of the organ occurs; the appearance is well presented in Fig. 2. 
 
 Treatment. — When seen early these cases 
 can be quickly relieved by grasping the lateral 
 folds of skin between the thumb and finger 
 of the left hand, and drawing the foreskin for- 
 ward at the same time as the thumb and fore- 
 finger of the right hand compress the glans and 
 push it backward within the advancing ring 
 (Fig. 3). In cases where this manipulation does 
 not succeed minute punctures of the cedematous 
 mucous membrane with a sharp-pointed bistoury 
 will often cause a decided diminution in its bulk 
 by the escaped serum, so that the above manip- 
 ulation will then often be followed by success. 
 Should this procedure fail, it is better to anaes- 
 thetize the patient and resort to operative 
 measures. The operative treatment to effect the 
 reduction of the paraphimosis consists in intro- 
 ducing the end of a blunt-pointed bistoury under 
 the edge of the prepuce and dividing it freely Reduction of paraphimosis. 
 
 Fig. 3. 
 
PHI3I0SIS AND PARAPHIMOSIS. 1061 
 
 on the dorsum of the glans, or the constricting tissue may be divided at two 
 or three points. After this has been done the glans can usually be reduced 
 without trouble. The after-treatment consists in the application for a few days 
 of a lotion of carbolic acid, chloride of ammonium, glycerin, and water until 
 all swelling has disappeared. When paraphimosis has once occurred, it is 
 better, after the parts have resumed their normal condition, to circumcise the 
 patient and prevent the possibility of a repetition of the accident. 
 
PART XI 
 
 ORTHOPAEDICS. 
 
 By JAMES E. MOOBE, M. D., 
 
 MINNEAPOLIS. 
 
 Fig. 1. 
 
 Wry Neck, or Torticollis. 
 
 Torticollis is a deformity of the neck in which the head is drawn down 
 toward the shoulder and the face turned in the opposite direction. It may 
 be either congenital or acquired. The congenital cases are generally due to 
 injuries to muscles or nerves occurring at birth. Acquired cases may be 
 
 either traumatic, paralytic, compensa- 
 tory, cicatricial, spasmodic, or idiopathic 
 in origin. The traumatic variety is due 
 to injuries to the muscles, nerves, or 
 nerve-centres, and the rare paralytic 
 cases are similar in character, but lack 
 the element of traumatism. Compensa- 
 tory torticollis may be due to curvature 
 of the spine or to defects in the eyes ; 
 and burns or scalds of the neck severe 
 enough to leave cicatrices may produce 
 this deformity. Many cases are classed 
 as idiopathic because their cause is not 
 known. 
 
 Wry neck is therefore only a symp- 
 tom of many different conditions. The 
 anatomical changes are chiefly in the 
 muscles to which the spinal accessory 
 nerve is distributed, the sterno-cleido- 
 mastoid being the one usually affected. 
 While the condition may be either acute 
 or chronic, the acute variety may be- 
 come chronic. In chronic cases the 
 face becomes atrophied on the affected 
 side and the angle of the nose with the 
 eyes is changed. Pain and elevation 
 of temperature do not occur except in 
 acute cases due to inflammation of the muscle. 
 
 Diagnosis. — The diagnosis of this deformity can usually be made from 
 inspection, the appearance being quite characteristic (Fig. 1). Cervical 
 Pott's disease and cervical abscess should be excluded. In Pott's disease 
 
 1062 
 
 Congenital torticollis. 
 
ORTHOPAEDICS. 
 
 1063 
 
 Fig. 2. 
 
 the patient usually suffers, pain can always be elicited by manipulation, 
 motion is restricted in all directions, and the face is turned toward the 
 affected muscles. In wry neck the face is turned away from the affected 
 muscle. 
 
 Cervical abscess will be accompanied by fever and pain, and can be 
 detected by deep palpation. 
 
 Prognosis. — The prognosis is favorable under proper treatment, but 
 otherwise there is little tendency to recovery. Acute cases due to inflam- 
 mation, however, may recover promptly without 
 treatment. 
 
 Treatment. — The treatment of torticollis is ope- 
 rative and mechanical. In a very mild and com- 
 paratively recent case mechanical treatment alone 
 may suffice, but in severe chronic cases it will fail 
 unless preceded by an operation. In paralytic cases 
 mechanical treatment alone is indicated. 
 
 Operative treatment of wry neck consists in cut- 
 ting the contractured muscles. In the vast majority 
 of cases the sterno-cleido-mastoid is the only one re- 
 quiring an operation. This muscle may be cut either 
 by tenotomy or through an open incision. With 
 proper antiseptic precautions the latter is preferable, 
 because the former has been followed by serious haem- 
 orrhage. 
 
 After the operation the head must be forced into 
 an over-corrected position and held there by a plas- 
 ter-of-Paris dressing or some other appliance. 
 
 The most convenient way to hold the head in the 
 over-corrected position is by means of a plaster cast 
 over the head and extending well down over the 
 shoulders. This dressing should be worn for from 
 
 two to six weeks, according to the severity of the case. In mild cases this 
 will end the treatment, but in severe or very chronic cases this same or some 
 more elegant support must be worn until all tendency to relapse has disap- 
 peared. What is known among instrument-makers as Markoe's wry-neck 
 brace is a very good apparatus (Fig. 2). 
 
 Markoe 
 
 brace for torti- 
 collis. 
 
 Lateral Curvature of the Spine, or Scoliosis. 
 
 Scoliosis is a deformity of the spine characterized by a lateral deviation. 
 It is very uncommon in early childhood, occurring most frequently between 
 the ages of eight and fifteen. It is rarely congenital, most of the early 
 curvatures of the spine being of rachitic origin. The curve is usually in 
 the upper dorsal region and toward the right side (Fig. 3). 
 
 Etiology. — The causes of lateral curvature are not well understood. No 
 inflammation or other pathological condition is known to belong to this 
 deformity. In old cases the shape of the bodies of the vertebra is changed 
 by pressure. In severe cases the worst part of the deformity is due to a 
 rotation of the vertebrae upon each other. 
 
 Diagnosis. — Aside from the curvature, there are no subjective or objective 
 symptoms. The diagnosis must be made from the character of the deformity, 
 from the absence of symptoms, and by excluding other conditions. There is 
 no pain or tenderness, and the child is usually in good health. In early child- 
 
1064 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 3. 
 
 hood the spine is quite flexible. The child should be stripped and directed 
 to stand with its back toward the physician, with the arms hanging down. 
 
 The ilio-costal space on the affected side 
 will be found larger and of a different shape 
 from that of the opposite side. Rachitic 
 curves are usually antero-posterior, and are 
 jfe. accompanied by other characteristic symp- 
 
 toms of rickets. Curvature due to Pott's 
 disease is usually antero-posterior, but when 
 it is lateral is accompanied by the peculiar 
 gait, the inability to stoop, the pain, and 
 other characteristic symptoms. 
 
 Prognosis. — The prognosis of lateral 
 curvature is good so far as life is concerned, 
 but otherwise it is bad. There is a per- 
 sistent tendency to an increase of the de- 
 Pformity, which is very difficult to overcome 
 ■ by any known method of treatment. 
 Treatment. — In the early stage, while 
 the spine is still flexible, treatment is most 
 likely to be beneficial, but it is far from 
 satisfactory at any stage. Mechanical sup- 
 port is rarely helpful in these cases ; on the 
 contrary, it is likely to do more harm than 
 good. In a few exceptional instances, where 
 the deformity is increasing very rapidly, a 
 plaster or paper jacket will be beneficial. 
 In the vast majority of cases, however, the 
 greatest benefit is to be derived from intel- 
 ligent gymnastic exercises and massage. 
 
 A child can be taught at a very early 
 age to swing by his hands and to bend the 
 spine in the opposite direction from the 
 curvature or in such a manner as to unbend it. If a skilled masseur is not 
 at hand, the physician or parents should unbend the spine daily. The child 
 should be undressed and placed in such attitudes by the hands of the attend- 
 ant as will have a tendency to overcome the deformity. This exercise should 
 be kept up for at least fifteen minutes every day. By persistent effort in 
 this direction the deformity may be overcome in a mild case, and in every 
 case it may be prevented from becoming as severe as it otherwise would. 
 The child should be taught to avoid those attitudes that would naturally have 
 a tendency to increase the curvature. 
 
 Left scoliosis. 
 
 Pott's Disease, or Tuberculosis op the Spine. 
 
 Pott's disease is a destructive disease of the bodies of the vertebrae, and 
 is tuberculous in character. It was first clearly described by Percival Pott 
 in 1779. J 
 
 Etiology. — This disease occurs, in the vast majority of cases, in childhood. 
 The writer's experience leads him to discredit the popular belief that heredity 
 is a prominent cause, for the disease occurs very commonly in healthy chil- 
 dren of healthy parents. The parents usually ascribe it to some real or 
 imaginary injury. While it can rarely be traced directly to an injury, every 
 
ORTHOPEDICS. 
 
 1065 
 
 experienced orthopedist has met with some cases that evidently originated 
 in this way. It occurs frequently as a sequel of the exanthemata and other 
 diseases of childhood. In the writer's experience measles is the most fre- 
 quent forerunner. The disease usually begins in one small spot near the 
 anterior part of the body of the vertebra, but it may begin in more than one 
 vertebra at the same time. 
 
 Pathology. — The bodies of the vertebrae become gradually softened and 
 break down in cheesy debris ; this allows the spine to bend forward, caus- 
 ing the characteristic deformity, which is usually antero-posterior, with 
 
 the convexity backward. When only 
 one vertebral body is affected the angle 
 of deformity is quite sharp, but is more 
 
 Fig. 5. 
 
 Fig. 4. 
 
 Dorsal Pott's disease. 
 
 Characteristic position in dorsal Pott's disease. 
 
 obtuse when a number are involved. In either case, however, the angle is 
 more acute than that in any other spinal disease. The intervertebral disks 
 are destroyed by the granulation-tissue, but are probably never the original 
 seat of disease, as was once believed. When the disease is in the lower dorsal 
 or lumbar region, an abscess may form and follow the psoas tendon, pointing 
 just below Poupart's ligament. In the cervical region a retropharyngeal 
 abscess may form. Paralysis may occur as a result of pressure due, as a rule, 
 to thickening of the meninges by inflammatory deposits. The bone does not 
 press upon the cord even when the deformity is marked, and the cord rarely 
 becomes diseased. When recovery takes place the debris is absorbed, and the 
 vertebrae are joined together by bony formation, causing complete ankylosis. 
 Symptoms. — Generally the first symptom of Pott's disease is a disposition 
 upon the part of the child to lie down instead of playing about as usual. He 
 
1066 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 is restless at night, and after a time complains of pain, particularly at night. 
 The pain is usually located in the abdomen, and is often accompanied by 
 symptoms of indigestion that may be very misleading. The gait becomes 
 peculiar and characteristic, so much so that one accustomed to observe these 
 cases will readily recognize one on the street. The child holds his spine 
 rigid and walks with great care, often keeping the knees slightly flexed to 
 lessen the jar. This restriction of motion or rigidity of the spine is not alto- 
 gether voluntary, but is largely due to involuntary muscular spasm — a symp- 
 tom common to all tuberculous bone-lesions near joints. Deformity comes on 
 quite early ; it is often the first, and may be the only, symptom noticed before 
 
 bringing the child to the physician. It usually 
 appears as a sharp projection or knuckle com- 
 posed of one or more spinous processes. 
 
 This disease occurs most frequently in the 
 dorsal region, next in the lumbar, and least 
 often in the cervical region. When it occurs 
 in the cervical region the chin is thrown for- 
 ward in a characteristic manner ; the patient 
 may have a choking sensation and experience 
 difficulty in swallowing; at times there is an 
 irritating cough and pain in the chest; when 
 sitting the elbows are rested on the arms of the 
 chair and the head supported in the hands. 
 
 If the disease is in the dorsal region the 
 shoulders are elevated and the neck seems short 
 (Fig. 4). There is pain in the abdomen, which 
 becomes distended, and symptoms of indigestion 
 are prominent. The patient supports his weight 
 upon his elbows when sitting, and rests his 
 hands upon his thighs when standing (Fig. 5). 
 "When the lumbar region is affected the de- 
 formity is a lordosis or bending forward, and is 
 caused by contraction of the psoas muscles. The 
 patient throws his shoulders back in order to 
 keep his equilibrium (Fig. 6). The pain may 
 be in the abdomen, but is more likely to be in 
 the lower extremities. The bladder and rectum 
 may be irritable. 
 
 Complications. — The important complica- 
 tions of Pott's disease are paralysis, abscess, 
 amyloid changes in the liver and kidneys, and 
 tuberculosis of the lungs and cerebral meninges. 
 Paralysis is of rare occurrence except in untreated cases. It may affect 
 both the upper and lower extremities, but is usually confined to the latter. 
 It occurs most frequently with dorsal Pott's disease and* rarely affects the 
 sensory nerves. Since the paralysis is due to pressure from inflammatory 
 deposits, and not to bony pressure, the danger of this complication does 
 not increase with great deformity. It may occur when the deformity is very 
 slight. With this form of paralysis the knee-jerk is exaggerated and ankle- 
 clonus is marked. The bladder and rectum become affected when the lumbar 
 enlargement of the cord is involved. The muscles usually become soft and 
 flabby from disuse. Rigidity of the muscles is a grave symptom, since it 
 indicates disease of the spinal cord. 
 
 Lumbar Pott's disease : lordosis. 
 
ORTHOPAEDICS. 1067 
 
 Abscess may occur in any region, but is most common when the disease is 
 in the lumbar region. A psoas abscess is rarely due to any other cause, 
 so it may be considered as almost conclusive evidence of Pott's disease. 
 Lumbar and retropharyngeal abscesses occur, but not nearly so frequently 
 as psoas abscess. The complication is not nearly so common in children 
 as in adults, because in the latter the disease is more frequently located 
 on or near the surface of the bodies of the vertebrae. It is usually a late 
 symptom of the disease, and is apt to be preceded by increased pain and 
 other evidences of poor health, but occasionally it comes on so insidiously 
 that it is the first symptom noticed. These so-called abscesses are, in reality, 
 rarely true abscesses, because they, as a rule, contain neither pus nor pyo- 
 genic germs, but they were given the name of cold abscess before their 
 pathology was understood : and the name is so well established that it would 
 be difficult to change it. The contents vary from a thin, watery fluid to a 
 thick, cheesy mass. If at any time pyogenic germs are introduced into a 
 cold abscess, it at once becomes a true abscess. 
 
 Amyloid changes of the kidneys and liver are liable to occur as a compli- 
 cation in old cases of Pott's disease where there have been discharging 
 sinuses. They do not differ in any way from the changes following prolonged 
 suppuration from any cause. 
 
 Pulmonary tuberculosis occurs as a complication, but less frequently in 
 children than in adults. 
 
 Tuberculous meningitis has been, in the writer's experience, the most com- 
 mon cause of death in Pott's disease. It comes on late, beginning with very 
 severe headache, high temperature, delirium, and other symptoms character- 
 istic of meningitis, and ends fatally in ten days or two weeks. 
 
 Diagnosis. — It is important to make an early diagnosis of Pott's disease, 
 in order to begin intelligent treatment and to prevent deformity. When a 
 child develops a peculiar gait, shows a disposition to lie about, or complains 
 of persistent pain in the abdomen, its spine should be examined. It should 
 be stripped and made to walk up and down the room. If it holds its head, 
 shoulders, or arms in a peculiar manner, and walks as if it were afraid to 
 move, Pott's disease should be suspected. Place the child prone upon a 
 table, flex the knees so that the soles are turned upward, grasp the ankles 
 alternately, and make an effort to over-extend the thighs. If disease is 
 present in the lower dorsal or lumbar region, this effort at over-extension 
 will cause a spasmodic jerking of one or both thighs forward toward the table. 
 This symptom is known among orthopaedists as psoas spasm, and is consid- 
 ered a valuable aid in diagnosis. Turn the child upon its back, flex its 
 hips so as to relax the abdominal muscles, and make deep palpation over 
 the abdomen with the points of the fingers. In this way a psoas abscess may 
 be felt long before it can be seen. Have the child stand up, drop an object 
 upon the floor, and ask him to pick it up : if Pott's disease is present, he will 
 not bend the spine and pick it up as a healthy child would, but will bend his 
 knees and hips and crouch down, keeping the spine rigid. This is quite 
 characteristic of Pott's disease. 
 
 Pain is usually a prominent symptom, beginning quite early. It is felt 
 at the distribution of the spinal nerves coming from the seat of the disease 
 more than in the spine. In cervical and upper dorsal disease the pain is 
 often accompanied by a peculiar grunting respiration that is very distinctive. 
 The pain from dorsal disease is in the abdomen, and often leads to mistakes 
 in diagnosis, for there are usually other symptoms pointing to the digestive 
 tract as the seat of disease. When in the cervical region this disease may be 
 
1068 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 mistaken for wry neck. In Pott's disease the face is turned toward the 
 affected muscles, while in wry neck it is turned away from them, and the 
 condition is not a painful one. 
 
 Deformity is the most characteristic symptom of a well-established Pott's 
 disease. In all but the lumbar region it is backward. Nothing is to be 
 learned by palpation, for there is not even sensitiveness. It is to be differ- 
 entiated from the deformity of rickets. In Pott's disease the angle is sharp 
 and cannot be straightened out, while in rickets the deformity is more of a 
 curve, and will partly or entirely disappear when the child is laid upon its 
 face. With a rachitic curve the other symptoms of rickets are present. 
 
 Paralysis of Pott's disease is to be recognized by the exaggerated reflexes 
 and by the presence of the deformity and other symptoms of this disease. 
 The peculiar attitudes the child assumes in attempting to lift the weight 
 from the sore spine should be remembered. He holds his head with his 
 hands in cervical disease, and supports his weight on his elbows in dorsal dis- 
 ease. Hip-joint disease may be suspected when psoas contraction is present. 
 In hip-joint disease, however, there is tenderness about the joint, and motion 
 is restricted in every direction, while in psoas contraction from Pott's disease 
 the joint is not tender and motion is restricted in extension only. In the 
 few cases in which abscess is an early symptom it may aid in diagnosis. 
 Psoas abscess should not be mistaken for hernia or appendicitis. 
 
 Prognosis. — This disease is decidedly chronic, the average duration being 
 about three years. The natural tendency, however, is toward arrest. Prob- 
 ably 25 per cent, of the cases terminate fatally. Few die from the disease 
 per se, but from complications, such as tuberculous meningitis, phthisis, 
 abscess, and amyloid disease of the liver and kidneys. 
 
 The deformity of Pott's disease has a persistent tendency to increase. 
 Even with the best of treatment existing deformity cannot be overcome, and 
 an increase cannot always be prevented. 
 
 Abscess often runs a remarkably benign course, but it necessarily adds 
 to the gravity of the disease. 
 
 The paralysis of Pott's disease ends in recovery, in the vast majority of 
 cases, within one year. Some recover even after three years. 
 
 Treatment. — The great principle in the treatment of this disease is rest. 
 In tuberculous disease of bone, nature will bring about a cure in the major- 
 ity of cases, aided by rest alone. Under its influence abscesses often dis- 
 appear and paralyzed muscles regain their strength. There is little to be 
 gained by the administration of drugs, save to meet indications as they arise. 
 Pain is best relieved by rest secured by a proper mechanical appliance. 
 Opiates are to be avoided in this as in any other chronic disease, because 
 they usually do more harm than good, and are very liable in the end to add 
 to the patient's suffering. In many cases of Pott's disease the patient's gen- 
 eral health is good. Drugs are to be avoided under such conditions. The 
 bowels should be kept regular, and disturbances of digestion met just as if 
 Pott's disease did not exist. When the strength is failing, beef peptonoids 
 and plenty of good rich milk should be given, and if at all practicable the 
 child should be taken out of doors and kept out as many hours as possible. 
 In some very severe cases the best treatment is prolonged rest in bed, sup- 
 plemented always by a proper spinal support. It is really surprising to 
 see how well and strong these little sufferers become under this treatment, 
 but it is only recommended when ambulatory treatment cannot be employed. 
 The best means of carrying out this plan is by a piece of canvas stretched 
 over a light iron frame (Fig. 7). The canvas must have an opening through 
 
ORTHOPEDICS. 
 
 1069 
 
 which a bed-pan can be used, and the whole frame may be taken up and the 
 child carried out of doors if desired. 
 
 Various materials are employed for mechanical support in Pott's disease. 
 The general practitioner can meet every indication with the above-mentioned 
 
 Fig. 7. 
 
 The stretcher bed. 
 
 stretcher splint, by plaster of Paris, or some form of steel brace. A plaster- 
 of-Paris jacket meets the indications admirably in the lumbar and lower 
 dorsal regions. Objections are made to it only by those who do not know 
 how to use it. For the upper dorsal and cervical regions a steel brace, with 
 proper head-piece, is the best appliance. A 
 plaster cast with a jury mast can be used in 
 
 these 
 
 regions, 
 
 but 
 
 the writer has found that 
 practitioners with limited experience in this 
 direction find it difficult to apply the jury mast 
 properly. A plaster cast should never be ap- 
 plied when sinuses are present, because it is 
 impossible to keep it clean (Fig. 8). 
 
 The mistake made by inexperienced persons 
 in applying a jacket is that they get it too 
 bulky. It should not be any heavier than thick 
 pasteboard. For a child, from four to six plas- 
 ter bandages, four inches wide and six yards 
 long, are sufficient. Before applying the plas- 
 ter a close-fitting, armless knit shirt should be 
 put on the child. The anterior superior spinous 
 processes of the ilium and the prominent spinous 
 processes of the vertebrae should be surrounded 
 by rings of cotton or felt, so that the cast will 
 not touch them. The child's arms should be 
 lifted up and enough extension applied to its 
 head to make the spine as straight as possible. 
 It is a mistake to lift the child off its feet. The 
 ordinary extension apparatus sold by all instru- 
 ment-makers is the best appliance, but a very 
 satisfactory one can be improvised by an in- 
 genious practitioner. The . plaster bandages 
 should be made of the best dental plaster and 
 crinoline ; commercial plaster and cheese-cloth 
 are not suitable materials. An ordinary wash- 
 basin will not hold enough water to properly 
 moisten the bandages ; a larger vessel should be 
 filled with warm water and the bandages placed in it, one at a time, a sec- 
 ond one being put in just as the first is taken out. The roller should 
 be placed on end in the water, and as soon as bubbles cease to rise it should 
 be taken out and gently squeezed between the hands to remove the sur- 
 
 Plaster jacket. 
 
1070 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 plus water. Beginning well down on the pelvis, the bandage is applied 
 around the body, with just sufficient tension to make it fit comfortably and 
 without wrinkles. About three turns should be placed directly over one 
 another to form the lower end of the cast. After this each succeeding turn 
 should lap over about half the width of the last one, until the jacket reaches 
 well up under the arms, where about three turns should be applied directly 
 over one another. A sufficient number of bandages are applied in this 
 systematic manner to make the jacket of the desired strength, remembering 
 that the tendency is to make it too heavy. At the lower end the jacket 
 should reach as far down as possible without interfering with the flexion of 
 the thighs ; at the upper end it should not be so tight under the arms as to 
 be uncomfortable. It is not expected that the jacket will afford support by 
 pressure under the arms, but by supporting the body as a whole. The ends 
 should be trimmed off to the desired length before the jacket is entirely 
 hardened. A common pocket-knife is the best instrument for this purpose. 
 
 Fig. 9. 
 
 Fig. 10. 
 
 The Washburn spine-brace. 
 
 The modified Taylor brace, with head-piece. 
 
 When good plaster is used the jacket will be solid enough to support the 
 child by the time the trimming is done. Each jacket can be worn from one 
 to three months, when it should be replaced by a new one. 
 
 In all cases of Pott's disease above the seventh dorsal vertebra a head- 
 support should be applied, and this is best accomplished by means of a steel 
 brace. A steel brace can be employed with great satisfaction for disease in 
 any part of the spine, but it is specially well adapted to the upper end. The 
 general practitioner will find that the variety of brace known and illustrated 
 in surgical-instrument catalogues as "Washburn's brace" will give satisfac- 
 tion (Fig. 9). Braces with crutches under the arms are to be avoided, because 
 the patient cannot bear sufiicient weight upon the axilla to be of any service ; 
 they also cause the patient much unnecessary pain, and are altogether unsat- 
 isfactory (Fig. 10). 
 
 The Washburn brace acts upon the principle of a lever, the weight being 
 at the pelvis, the fulcrum at the deformity, and the power at the shoulders. 
 
OBTHOP^JDICS. 1071 
 
 It consists of a padded steel pelvic band, to which are attached two steel 
 uprights, one on either side of the spines of the vertebrae, and a cloth apron, 
 which is spread over the front of the body, holding the uprights close 
 against the back. To the upper end of the uprights are attached padded 
 strips of webbing which pass around under the arms and buckle to a cross- 
 piece over the scapulae, holding the shoulders back. The uprights are 
 padded opposite the deformity. The pelvic band acts as a fixed point ; the 
 uprights make pressure upon the transverse processes of the diseased ver- 
 tebrae, and the straps over the shoulders, with the aid of the spring in the 
 steel uprights, pull the shoulders back, thus lifting the weight from the 
 diseased bodies of the vertebrae and throwing it upon the healthy parts. 
 The brace acts as a splint does to a broken leg, holding the whole spinal 
 column as one piece, thus securing the desired rest for the diseased part. 
 
 Should an abscess appear, so long as it is not large and is causing no 
 symptoms it should be let alone. If, however, it is increasing rapidly in 
 size, if it is causing symptoms from pressure, or if the patient's health is 
 failing, it should be operated upon. It is far better in any case to let a cold 
 abscess alone than simply to open it and leave it to itself. 
 
 The writer has obtained the best results by evacuating the abscess with a 
 trocar and cannula, washing out with bichloride solution and injecting iodo- 
 form emulsion. Every antiseptic precaution must be employed in this 
 operation, because the introduction of pyogenic germs into these cavities, 
 causing a mixed infection, is a very serious matter. The iodoform emulsion 
 should.be 10 per cent., and from two drachms to two ounces may be injected. 
 A second operation any time after two weeks may be necessary. 
 
 The paralysis of Pott's disease requires the same care as paraplegia from 
 any other cause. The bladder and bowels must be cared for and bed-sores 
 avoided. The mechanical support must be continued. These cases usually 
 recover in about a year, and, in the writer's experience, get well just as 
 promptly without special medication. 
 
 Chronic Joint Disease. 
 
 It is now well understood that chronic joint diseases are generally tuber- 
 culous. They are always liable to be followed by deformity and permanent 
 disability, and require mechanical treatment. They are therefore classified 
 under the head of orthopaedic surgery. The greatest advance made in this 
 department of surgery is the establishment of the fact that tuberculosis of 
 bones and joints is essentially a local disease, and should.be treated as such. 
 They very rarely prove fatal, except when they become complicated by a 
 general tuberculosis or a tuberculosis of the brain, lungs, or some other vital 
 organ. The natural tendency of tuberculous joint disease is toward recovery, 
 and when assisted by proper mechanical or operative treatment the prognosis 
 is favorable in from 90 to 95 per cent, of the cases. The old idea was that 
 this disease is constitutional in character, and it was treated accordingly. 
 The belief still prevails that the disease is hereditary, but the facts do not 
 support this belief, for the children of healthy parents as well as those of 
 diseased ones are subject to the affection. The family history will not help 
 establish the diagnosis, and may even be misleading, because the mere fact 
 that some ancestor of the child had tuberculosis does not prove that an arthritis 
 occurring in the child is tuberculous. On the other hand, the fact that the 
 child's ancestors were free from tuberculosis does not enable us to exclude 
 this affection in the child. 
 
1072 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Tuberculous joint disease may begin either as a synovitis or an osteitis, and 
 it is often difficult to differentiate between them. Fortunately, the treat- 
 ment is the same in either case. In children the majority of cases begin as 
 an osteitis, and the tendency is for the disease to extend to all the tissues of a 
 joint, so that it becomes a tuberculous arthritis. The great principle of treat- 
 ment is prolonged rest, which is best secured by some mechanical device. 
 Usually when the joint is kept perfectly quiet for a sufficient length of time 
 nature will bring about a cure. There is no special medication for this dis- 
 ease. Local applications may, at times, help to relieve pain, but they have 
 no curative effect. 
 
 Hip- joint Disease. 
 
 The hip is the most frequent seat of chronic joint disease. It is tuber- 
 culous in character, and generally begins in the head of the femur near the 
 epiphyseal line. 
 
 Etiology. — Usually the exciting cause is not known, but it is certain 
 that in some cases it is traumatism. As a rule, it is not the puny, delicate 
 child of the family who develops hip-joint disease, but the active, stirring 
 one — the one, in short, who is most subject to traumatism. Injury thus 
 causes a locus minoris resistentice which affords a culture-field for the tubercle 
 bacillus. 
 
 Symptoms. — Generally the first symptom is a limp. The child will be 
 noticed to limp when it first gets about in the morning, and to get better as 
 the day advances. Deformity appears early, and is usually flexion with 
 adduction and apparent shortening, but it may be flexion with abduction 
 and apparent lengthening (Figs. 11 and 12). Atrophy is an early and con- 
 stant symptom. Pain is apt to be present early. It is most marked on the 
 inner side of the knee or on the anterior surface of the thigh. It is quite 
 exceptional that it is referred to the joint itself. Limitation of motion is 
 the symptom most depended upon by orthopaedists in making the diagnosis. 
 By proper examination it may be found at a very early period. Involun- 
 tary muscular spasm is an important symptom found upon manipulating the 
 joint. 
 
 The general health of the child is often fairly good, but there may be 
 emaciation from persistent pain and loss of sleep. There is no marked febrile 
 reaction, although a temperature of 99° or 100° F. is not uncommon. Later 
 in the disease an abscess may form, and may appear at any point about the 
 joint, but is seen most frequently in front. It is generally preceded or 
 accompanied by an unusual amount of pain, but sometimes comes on so 
 insidiously that it becomes quite large before it is noticed. 
 
 Pathology. — If treatment is begun early enough, it is possible to pre- 
 vent the disease from breaking into the joint, and thus save the motion in 
 the limb. In many cases, unfortunately, this has happened before the child 
 is brought under treatment, and the bone and other joint-structures are 
 breaking down. The disease, unless prevented by proper treatment, extends 
 to all of the structures of the joint. 
 
 Diagnosis. — When a child limps and complains of pain about the knee 
 or hip a careful examination of both the joints should be made. It is un- 
 fortunately a very common experience of every surgeon to have a child 
 
 Lght to him with well-advanced hip disease which has been diagnosticated 
 treated for rheumatism. This mistake should never be made, because 
 .amatism is an acute febrile disease usually affecting several joints at 
 once. 
 
ORTHOPEDICS. 
 
 1073 
 
 For examination the child must be stripped of all clothing, and made 
 to walk back and forth before the examiner, that he may locate the limp. If 
 the hip is affected, the patient swings the body when stepping forward 
 with the affected limb, making as little motion at that joint as possible. The 
 thighs should next be measured. If hip-joint disease is present, the thigh 
 on the diseased side is from half an inch to an inch smaller than the other, 
 and the gluteal fold is usually absent as a result of atrophy of the muscles. 
 Older writers placed much value upon deformity as a characteristic symp- 
 
 Fig. 11. 
 
 Fig. 12. 
 
 Hip-joint disease just beginning, showing slight flex- 
 ion and disappearance of gluteal fold. 
 
 Abduction and apparent lengthening. 
 
 torn, but it is very important to make a diagnosis before marked deformity 
 is present. 
 
 The child should next be laid upon its back upon a table (a bed is too 
 soft). Try to bring the popliteal space of the affected side and the lumbar 
 spine in contact with the table at the same time. If this can be accom- 
 plished with ease, hip-joint disease can be excluded, because even at an 
 early stage some flexion is present, although it may not be noticed when the 
 child is standing; and when it is present the popliteal space and lumbar 
 spine cannot be made to touch the table at the same time. Place the r)a*m 
 of the hand first upon the sound limb and gently roll it on the table, ther- 11 
 the lame limb in the same manner. If hip-joint disease is present, i '] 
 require more force to roll the afflicted limb, and the limb will not roll so < r 
 on account of the restriction of motion in the hip-joint. Next grasp the 
 
1074 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 ankle of the sound limb and flex the leg on the thigh and the thigh upon 
 the body, noting the natural resistance; the hip-joint should then be put 
 through all its natural motions to note the amount of normal resistance and 
 to gain the confidence of the child. The lame leg should now be taken and 
 put through the same motions, and if hip-joint disease is present, it will re- 
 quire more force to flex and rotate the hip, and there will be involuntary 
 spasm of the muscles about the hip. There is, in short, restriction of motion 
 and spasm. When this examination is made with care and gentleness, these 
 signs can be found at a very early stage, and are quite characteristic, since 
 no other disease will cause spasm and limitation of motion in every direction. 
 Rough manipulations must always be avoided, because they obscure the symp- 
 toms and may do harm. 
 
 Prognosis. — From 90 to 95 per cent, of cases of this affection will 
 recover under treatment, and the majority will have a useful amount of 
 motion in the joint. By recovery we mean that the disease will disappear. 
 Very rarely the joint is left in an almost perfect condition. Usually, how- 
 ever, there is some shortening and deformity, with more or less permanent 
 limitation of motion. In untreated cases the deformity is apt to be great, 
 and complete ankylosis is not infrequent. Abscesses add to the gravity of 
 the case, but do not make recovery with a satisfactory result impossible. The 
 length of time required to bring about a cure varies greatly in different sub- 
 jects'; a very few will recover in one year, many in two and three years, and 
 some continue for five years. 
 
 Treatment. — When the diagnosis is made there must be no delay in 
 beginning treatment, for it is only by early detection and prompt treatment 
 that the best results are obtained. Medicine is of little or no value for the 
 disease per se, but may be necessary to meet indications as they arise. The 
 great point is to secure perfect rest for the diseased joint : it must neither 
 move nor bear weight : this is best accomplished by some mechanical device. 
 Pain is best relieved by securing perfect rest; opiates 
 are to be avoided. An effort should be made when the 
 case is not too chronic to overcome some of the de- 
 formity. 
 
 When the child is suffering severely a very excel- 
 lent way to begin treatment is to put it in bed and 
 apply extension by means of a weight and pulley until 
 the acute pain has subsided ; then some mechanical de- 
 vice should be substituted and the confinement to bed 
 discontinued. The amount of weight required in ex- 
 tension varies from two to six pounds, or from half a 
 brick to two bricks, according to the age of the child, 
 the object being to secure continuous extension. The 
 relief afforded is another good gauge of the w T eight to 
 be employed, most surgeons erring in using too much. 
 The weight is best applied by means of an ordinary 
 Buck's extension, as pictured in all works on surgery. 
 The adhesive straps should always extend above the 
 knee, and the child must not be allowed to slide down 
 so as to come in contact with the foot of the bed. Some 
 Taylor's long hip-splint. patients do best if extension is kept up by means of an 
 extension-brace throughout the treatment, but most cases 
 do equally well if the joint is simply fixed without extension. The best exten- 
 sion-brace is the long hip-splint consisting of a padded steel waistband and a 
 
 
ORTHOPEDICS. 
 
 1075 
 
 long steel bar, capable of being lengthened or shortened, extending from the 
 waistband to a point just below the sole of the shoe (Fig. 13). Two perineal 
 straps are attached to the waistband upon which the patient sits instead of 
 stepping on the foot of the diseased side. The lower end of the brace is 
 attached to the leg by means of adhesive straps which have buckles attached 
 to them, and straps attached to the horizontal part of the brace which passes 
 under the foot. These straps are buckled into the buckles, and the length of 
 the bar made such that, when the child stands upon the brace, the foot will 
 
 Fig. 14. Fig. 15. 
 
 Taylor's long hip-splint applied. 
 
 Plaster-of-Paris splint for hip-joint disease. 
 
 swing clear of the cross-piece and of the floor. The shoe on the sound side 
 must be elevated so as to make the length of the leg equal to the length of 
 the brace. The perineal straps must be so adjusted that the waistband rests 
 between the trochanter and the crest of the ilium, and so that there is a 
 gentle pull upon the leg all the while, forcing the head of the femur away 
 from the acetabulum. A child can walk very comfortably upon a brace of 
 this kind without the aid of crutches (Fig. 14). 
 
 A very convenient and efficient method of treating hip-joint disease is to 
 
1076 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 apply a plaster-of-Paris splint from the ribs to the knee (Fig. 15). The shoe 
 on the unaffected side should be elevated at least two and a half inches, and 
 the child should walk with crutches. The elevation of the shoe should 
 always be sufficient to prevent the patient from bearing weight upon the lame 
 limb, as he is very prone to do as soon as it gets a little better. The plaster 
 will last longer if it is reinforced by light strips of wood over the fold of the 
 groin, where it is most likely to break. The splint should not be heavy, and 
 should be changed every three or six weeks, according to circumstances. 
 Sole leather softened in cold water and fitted to the body from the ribs to 
 the knee makes a good splint. A paper pattern may first be fitted and the 
 leather cut by this. The softened leather can then be fitted to the body arid 
 held there by plaster bandages until it is perfectly dry and hard. Particular 
 care must be exercised in every case that weight is not borne upon the 
 diseased limb, for a splint of any kind would be of little value were the 
 patient allowed to use the joint. It will be necessary to continue treatment 
 for from one to three years, or for six months after all pain and spasm have 
 disappeared. The parents should be informed from the first that the treat- 
 ment will necessarily be long, and that even w T hen the case is doing well 
 there will be acute exacerbations, continuing from a few days to as many 
 weeks, during which the child will suffer more and in every way seem worse. 
 During- these exacerbations the treatment should be in no way changed, save 
 that the patient should be kept as quiet as possible. 
 
 An abscess may appear at any time after the first feAv months, and always 
 adds to the gravity of the disease, but it does not follow that a good, useful 
 joint may not be secured. As long as an abscess is small and is causing no 
 symptoms it should be let alone, for it will do no harm and may disappear 
 entirely. Should it increase rapidly, should the child's general health begin 
 to fail, or should it give rise to any decided symptoms, it must be evacu- 
 ated. Some very good authorities advise aspiration, but the writer has not 
 been satisfied with this. It is better to empty it through a good-sized cannula, 
 and after washing thoroughly with a bichloride solution to inject from two 
 drachms to two ounces of a 10 per cent, emulsion of iodoform. It is not 
 good surgery to open these cold abscesses and drain with rubber tubes. 
 
 In a very few instances the disease will grow worse in spite of the best 
 treatment. In these and in some cases that first come under treatment after 
 the disease is well advanced the joint should be excised. This operation is 
 indicated when the disease grows rapidly worse in spite of proper treatment, 
 when the child's health is failing rapidly, and when there are sinuses and 
 other evidences of extensive disease of bone. The operation is not a very 
 dangerous one, and yields good and at times brilliant results, for, as a rule, 
 in a few weeks or months the child recovers. Unfortunately, however, the 
 ultimate results are not nearly so good as in cases treated mechanically, and 
 the writer, while approving highly of this operation under proper circum- 
 stances, only recommends it when mechanical treatment has failed or cannot 
 be applied. 
 
 Knee-joint Disease. 
 
 This disease, also called white swelling of the knee, is a chronic tuberculous 
 inflammation, beginning, in the majority of cases, as an osteitis of the femur or 
 tibia. It begins more frequently as a synovitis than does hip-joint disease. 
 
 Etiology. — The causes are the same as hip-joint and other tuberculous 
 joint diseases. A traumatism is frequently the excitant, but in many cases 
 no such history can be obtained. 
 
OR THOPjEDICS. 
 
 1077 
 
 Pathology. — The tubercle bacillus can usually be found in these cases. 
 No matter what tissue may be first attacked, the tendency is to extend to all 
 the tissues, causing greater or less destruction of the joint. When treat- 
 ment is established at an early date the focus of disease may become encap- 
 sulated. At a later date very extensive disease may entirely disappear by 
 absorption under rest treatment. The peculiar characteristic white swelling 
 is due to infiltration of the soft tissues about the joint with a gelatinous 
 substance, which is not tuberculous, since no bacilli can be found in it, but 
 which is evidently a product of tuberculosis. 
 
 Symptoms. — This disease begins, as a rule, quite insidiously. The first 
 symptoms are usually a limp and slight pain. The joint soon loses its 
 normal appearance from filling up of the depressions on either side of 
 the patella. The swelling gradually increases and the knee becomes flexed, 
 giving to the joint a very characteristic appearance (Fig. 16). At a later 
 
 Fig. 16. 
 
 Fig. 17. 
 
 Tuberculous knee. 
 
 Plaster cast properly applied to knee. 
 
 date the tibia, unless prevented by treatment, becomes subluxated back- 
 ward. The pain may at times become very severe, and is usually worse at 
 night. Night-cries frequently occur. Atrophy of the limb above and below 
 the knee is an early symptom. Limitation of movement and involuntary 
 muscular spasm are always present. There is, a's a rule, little if any general 
 rise of temperature, but the diseased knee is perceptibly warmer than the 
 other one. Abscesses may form, generally appearing on the anterior inner 
 aspect of the knee. 
 
 Diagnosis. — When a child limps and complains of pain in the knee he 
 should be carefully examined. It is well to remember that in hip-joint dis- 
 ease the pain is often felt in or near the knee, but then the knee is not 
 swollen and its motion is unrestricted. It is well to always examine both 
 joints carefully. Place one hand on each knee, and when knee-joint disease 
 is present a practised hand will feel an increase of heat on the affected side. 
 
1078 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 18. 
 
 Thomas's knee- 
 splint. 
 
 Fig. 19. 
 
 Gently flex and extend the knee, and if disease is present there will be 
 
 limitation of motion and spasmodic jerking of the muscles. Upon measure- 
 ment the affected knee will be found larger than the other, 
 and the limb, above and below, will be smaller than its fel- 
 low. These symptoms, together with the history and cha- 
 racteristic appearance, will be sufficient evidence upon which 
 to base a diagnosis of tuberculosis of the knee. This dis- 
 ease should never be mistaken for rheumatism, because it is 
 mono-articular ; it comes on slowly and is not accompanied 
 by fever. 
 
 Prognosis. — With proper treatment, instituted early, the 
 prognosis is good. Fully 90 per cent, recover with some 
 motion and little deformity. In neglected cases the knee 
 becomes ankylosed in a flexed position and the tibia is sub- 
 luxated backward. 
 
 Treatment. — The treatment of this, as of other tuber- 
 culous bone disease, is prolonged rest. Medicines either 
 internally or locally are of little if any value. It is desir- 
 able to overcome existing deformity as early as possible. 
 When this is not very marked the appliances used to secure 
 rest will also straighten the knee, but when it is well marked 
 these will not suffice. When the joint is not disorganized, 
 and when there are no sinuses or abscesses, the quickest and 
 best way is to administer an 
 anaesthetic and straighten 
 
 the limb by manual force. Care must be 
 
 exercised not to cause a subluxation of 
 
 the tibia backward or a separation of the 
 
 epiphysis of either the femur or tibia. 
 
 Force must not be used in old cases with 
 
 abscesses and sinuses. When the limb is 
 
 straight a plaster cast should be applied, 
 
 extending from the malleoli well up to the 
 
 body (Fig. 17). A short cast extending 
 
 only part way up the thigh or down the 
 
 leg is worse than useless. The cast should 
 
 be applied next the skin or over a very 
 
 light roller bandage, and should never be 
 
 heavier than pasteboard. The shoe on the 
 
 sound side should be elevated two and a 
 
 half or three inches, and crutches used. 
 
 The plaster should be changed every ten 
 
 days or two weeks until the deformity is 
 
 overcome, and after that about once a 
 
 month. A good splint can be made of 
 
 sole leather. It should be soaked in cold 
 
 water until soft, and then moulded to the 
 
 limb by applying a bandage over it. After 
 
 it dries it will keep its shape indefinitely, 
 
 and is light and clean. Leather is not as 
 
 suitable as plaster before the deformity is 
 
 overcome. After many years of experience with all sorts of apparatus the 
 
 writer prefers plaster of Paris for knee-joint cases. 
 
 Thomas's knee-splint applied. 
 
ORTHOPAEDICS. 1079 
 
 A very good knee-splint is that of Hugh Owen Thomas, which does away 
 with crutches (Fig. 18). It consists of a padded steel ring which surrounds 
 the thigh, and two steel uprights extending from the ring down to a point 
 two or three inches below the bottom of the foot, where they are united by a 
 smaller ring. The outer upright is longer than the inner one, so the upper 
 ring rests against the perineum on the inner side and passes above the great 
 trochanter on the outer side. When the child walks its weight on the affected 
 side is sustained by the ring, and thus taken from the joint (Fig. 19). The 
 limb is fixed between the uprights by straps or bandages. The shoe on the 
 unaffected side must be elevated so that this leg is as long as the brace. The 
 apparatus must be worn for a number of months after all symptoms of inflam- 
 mation have disappeared. The treatment usually lasts from one to three years. 
 When abscesses appear they are to be treated as in hip-joint disease. 
 
 In the few cases that do not yield to the above treatment and in neglected 
 cases it will be necessary to resort to operative treatment. Excision of the 
 knee is not to be recommended in children, because it interferes with the 
 growth of both the femur and the tibia, and the result is a very short, stiff 
 leg and one that is very prone to become deformed. Erasion, or scraping 
 out, is the better operation. The joint should be opened freely on*both sides 
 of the patella, and all diseased tissue removed with a bone-scoop and scissors. 
 If the operator is assured that he has removed all of the diseased tissue, and 
 that the wound is aseptic, after thoroughly iodoformizing the joint he should 
 close the wounds and apply a surgical dressing and a plaster cast. If, how- 
 ever, he is not thoroughly satisfied that he has removed all of the disease, or 
 if the knee is suppurating to begin with, he should wash out thoroughly 
 with bichloride solution and pack with iodoform gauze. The packing should 
 be kept up until the wound closes by granulation. When the structures are 
 not too badly diseased the joint may recover with some motion after erasion. 
 
 Disease of the Ankle and Tarsus. 
 
 Chronic inflammation of the ankle and tarsus is tuberculous in character, 
 and is due to the same causes and has the same pathology as hip- and knee- 
 joint disease. It begins either in the bones or synovial membrane, most 
 frequently in the former, the astragalus being the most common location. 
 Disease is much less frequent in the ankle than in the hip and knee. 
 
 Symptoms. — This disease is not, as a rule, as painful as hip disease, 
 although it is occasionally very painful. The child is first noticed to limp, 
 and upon examination limitation of motion, muscular spasm, local heat, 
 swelling of the part, and atrophy of the calf are found. The calf muscles 
 soon contract, drawing the heel up and producing deformity. Enlarged 
 veins can be seen over the swelling. 
 
 Diagnosis. — The ankle limp is peculiar. The child turns his toes out, 
 so as to avoid flexion of the joint, as he steps forward, and advances the 
 inner side of the foot, throwing as little weight upon the ball of the foot as 
 possible. Limitation of movement and spasm can be demonstrated by flex- 
 ing and extending the joint. These symptoms, with those mentioned above, 
 should establish the diagnosis. 
 
 Prognosis. — In children the prospect of recovery is good. Cases brought 
 promptly under treatment frequently get well in from six to nine months. 
 
 Treatment. — The proper treatment is prolonged and complete rest. This 
 is best secured by a plaster cast extending from the points of the toes to the 
 knee. Crutches must be used, and if the child persists in bearing weight 
 
1080 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 upon the foot, the sound foot must be elevated by a high-soled shoe. It is 
 of little value to apply a plaster cast and allow the patient to walk upon it. 
 The plaster should be changed every three or four weeks, and constant care 
 exercised to prevent the heel from drawing up. Cases treated in this manner 
 usually recover with a useful joint. Treatment must be continued for some 
 time after all pain, heat, and muscular spasm have disappeared. The Thomas 
 knee-splint is a very good instrument for treating ankle-joint disease. 
 
 Operation is rarely satisfactory. When the disease is confined to one 
 bone, the removal of that bone will yield a good result, but when it is more 
 extensive, as is usually the case, operation will not yield as good results as 
 rest treatment. In very extensive disease amputation is conservative, for in 
 such cases there is imminent danger of tuberculous meningitis or pulmonary 
 tuberculosis. 
 
 Wrist-joint Disease. 
 
 Chronic inflammation of the wrist and carpus is a tuberculosis beginning, 
 in the majority of cases, in the radius. It is quite a rare disease. 
 
 The causes and pathology are the same as in hip-joint disease. 
 
 Symptoms. — This is not a very painful affection, as a rule, but the joint 
 is quite sensitive to touch and motion. There are local heat and swelling, the 
 latter being usually most marked on the dorsal surface. The arm becomes 
 atrophied, and the thumb lies parallel with the fingers in quite a character- 
 istic manner. The joint usually becomes flexed and motion is restricted. 
 The tendon-sheaths are very liable to become involved, adding to the gravity 
 of the disease. 
 
 Diagnosis. — The above-mentioned features should establish the diag- 
 nosis, since no other disease gives rise to like symptoms. 
 
 Prognosis. — The prognosis in wrist-joint tuberculosis is always grave, 
 because of the marked tendency to pulmonary involvement. The wrist dis- 
 ease in a child usually recovers promptly with a good, movable joint, but 
 the patient rarely lives out his expectancy. 
 
 Treatment. — The treatment is rest, and this is best secured by a plaster 
 cast extending from the knuckles nearly to the elbow. The plaster should 
 be applied close to the skin, and should be changed every three or four 
 weeks. The hand must be carried in a sling and held halfway between 
 pronation and supination. Operations in this disease are very disappointing, 
 and do not yield nearly so good results as the rest treatment. Gouging and 
 scraping are not to be recommended. 
 
 Elbow- joint Disease. 
 
 Tuberculosis of the elbow is quite a rare disease. Its causes and path- 
 ology are the same as hip-joint disease. 
 
 Symptoms. — This disease is not usually painful, but the joint is sensi- 
 tive to motion. The first symptoms are generally flexion and limitation of 
 motion. Swelling comes on gradually, being first noticed on either side of 
 the olecranon process. The veins become enlarged and the elbow gradually 
 assumes a spindle shape. The arm above and below the joint becomes 
 atrophied. The disease begins most frequently in the olecranon, and next 
 in the humerus. 
 
 Diagnosis. — Recognition of the disease is based upon the limitation of 
 motion, the peculiar shape, and the local heat. 
 
 Prognosis. — For recovery the prognosis is good, but the joint is very 
 
ORTHOPEDICS. 1081 
 
 liable to ankylosis on account of its peculiar shape. Pulmonary tuber- 
 culosis occurs with this less frequently than with wrist-joint disease, but 
 more frequently than with hip- or knee-joint disease. 
 
 Treatment. — The joint should be flexed to a right angle and the hand 
 placed halfway between pronation and supination, and held there by a 
 plaster cast extending from the wrist to the shoulder. The forearm should 
 be carried in a sling. The above-mentioned position is the one in which the 
 arm would be the most useful should ankylosis occur. The plaster must 
 be changed every three or four weeks, and continued for some months after 
 all symptoms of disease have disappeared. 
 
 When the rest treatment fails, the joint should be opened and the dis- 
 eased tissue scraped out. The after-treatment is the same as after erasion 
 of the knee. There are the same objections to excising a child's elbow that 
 there are to excising its knee. 
 
 Shoulder-joint Disease. 
 
 Tuberculosis of the shoulder is rare, especially so in childhood. It has 
 the same causes and pathology as hip-joint disease. 
 
 The symptoms are the same as in tuberculosis of the knee — viz. heat, 
 swelling, limitation of motion, and atrophy of neighboring muscles. The 
 swelling may be obscured by the atrophy of the deltoid, and the limitation 
 of motion will not be so noticeable on account of the mobility of the scapula. 
 
 The prognosis is fairly good. 
 
 The treatment is rest. This is best secured by binding the arm to the 
 body by adhesive strips or bandages. In cases that do not yield to rest 
 treatment the joint should be excised. Excision is followed by very satis- 
 factory results. 
 
 Old Deformities. 
 
 Untreated cases of joint disease almost invariably result in deformity. At 
 the hip and knee the deformity may be so great as to interfere with the useful- 
 ness of the limb. These patients need not be condemned to the use of crutches 
 all their lives, for, no matter how severe the deformity, it can be remedied 
 in some way. When ankylosis follows a tuberculous disease, an effort to 
 restore motion in the joint is unwise, on account of the danger of lighting up 
 the disease again. When the knee is ankylosed in a straight position it should 
 not be disturbed, but when it is decidedly flexed the deformity should be over- 
 come. If the disease is well and there is motion in the joint, the limb can 
 usually be straightened by force and held there until the tendency to relapse 
 has disappeared. The greatest difficulty is to overcome the subluxation back- 
 ward, but this can be done by mechanical appliances made for the purpose. 
 When the knee is firmly ankylosed in a flexed position, it is best straightened 
 by performing an osteotomy just above the condyles of the femur. The limb 
 should be put in as straight a position as possible, and held there by a plaster 
 cast or other splint until the fracture is united. In extreme cases it may be 
 necessary to break the tibia also just below the epiphysis ; this, however, is 
 very rarely necessary. 
 
 In neglected cases of hip-joint disease there is apt to be severe flexion 
 with adduction and practical shortening. When the disease is well and there 
 is motion in the joint, it may be possible, by cutting the resisting muscles sub- 
 cutaneously, to overcome a greater part of the deformity. In very severe 
 
1082 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 deformity or when ankylosis exists the deformity is best overcome by perform- 
 ing an osteotomy just below the trochanters. It may be necessary to cut some 
 of the muscles, even when an osteotomy is performed, before the limb can be 
 brought into the desired position. The thigh should be brought down parallel 
 with its fellow and held there by a plaster-of-Paris cast extending from the 
 toes well up on the ribs, or by means of Buck's extension. After about six 
 weeks the child can begin to walk on crutches, and will soon be able to use the 
 afflicted limb. It should be remembered that none of these cases need go un- 
 relieved, for the treatment is not dangerous and is very satisfactory. 
 
 Ankylosis following tuberculous disease is not due to keeping the joint in 
 one position so long by means of apparatus, but to the ravages of the disease. 
 Nature, in her effort to bring about a cure, sometimes finds it necessary to 
 unite the joint surfaces by bone to secure a strong limb. When joints suffer- 
 ing from disease are not kept at rest by apparatus, they are most likely to 
 become ankylosed, while a healthy joint may be kept at rest indefinitely with- 
 out being thus affected. 
 
 Congenital Dislocation of the Hip. 
 
 Fig. 20. 
 
 Double congenital dislocation of hip, showing 
 extreme lordosis. 
 
 This is not a very common affection, 
 but one that is pretty certain to come 
 under the observation of every practi- 
 tioner. The dislocation is usually upon 
 the dorsum of the ilium, but a few cases 
 have been reported in which it was for- 
 ward. It is usually on but one side, but 
 may be double. 
 
 Etiology. — There are two classes of 
 cases — one in which the dislocation is due 
 to a traumatism at or before birth, and 
 the other in which there is a lack of de- 
 velopment of the acetabulum. Heredity 
 seems to have some bearing, because nu- 
 merous instances are on record in which 
 mother and child were both afflicted in 
 this way. It is more common in girls. 
 
 Symptoms. — The deformity is very 
 liable to be overlooked until the child 
 begins to walk, when it will be noticed 
 that it has a peculiar wabbling gait. 
 Upon examination the limb is found 
 short, adducted, and flexed, just as in a 
 dislocation occurring later in life. When 
 the deformity is double there is marked 
 lordosis (Fig. 20). The trochanter is 
 above Nelaton's line. The movement is 
 free in every direction except abduction. 
 There is no pain, but the child tires easily 
 and the joint may be sore after severe 
 exercise. 
 
 Diagnosis. — The diagnosis is easy 
 when the examiner knows that there is 
 such a thing as a congenital dislocation. 
 
ORTHOPEDICS. 1083 
 
 It is often mistaken for hip-joint disease. This should not occur, because 
 atrophy, pain, and muscular spasm are absent. There is, as a rule, limitation 
 of motion in but one direction — abduction. The crucial test for dislocation is 
 made by placing the child upon its unaffected side and drawing Nekton's line 
 from the tuberosity of the ischium to the anterior superior spine of the ilium. 
 This line passes just above the great trochanter in a normal joint, but when 
 dislocation is present the trochanter is some distance above the line. 
 
 Prognosis. — As a rule, the deformity continues about the same through 
 life ; it never improves ; occasionally it grows progressively worse. Parents 
 should be advised that the child will not be able to do heavy work or to be 
 much on its feet. 
 
 Treatment. — Mechanical treatment is not to be recommended, because it 
 has been faithfully tried by competent men and has failed to cure or afford 
 material benefit. The majority of cases are better off without treatment. In 
 exceptional instances, when the limb is too weak or too badly deformed to ren- 
 der good service, an operation is indicated. This consists in scooping out the 
 rudimentary acetabulum, which always exists, trimming the head of the bone 
 to the proper shape, and reducing the dislocation. The operation should only 
 be undertaken by an experienced surgeon, because of the dangers from sepsis 
 and shock. An expert reduces the danger of the former to the minimum by 
 his technique, and of the latter by his speed. 
 
 Club-foot. 
 
 There are four principal varieties of club-foot — talipes varus, in which the 
 bottom of the foot is turned inward ; talipes valgus, in which the bottom of 
 the foot is turned outward ; talipes equinus, in which the toes point down- 
 ward ; and talipes calcaneus, in which the heel points downward. As a rule, 
 two forms are associated, when the deformity is indicated by combining the 
 names of the varieties entering into it. Equino- varus is by far the most 
 common form. Club-foot is usually congenital, but may be acquired. 
 
 Etiology. — Acquired talipes is caused by traumatisms, burns, bone disease, 
 or paralysis. Paralysis due to poliomyelitis produces the majority of cases 
 of acquired talipes. 
 
 Many theories have been advanced as to the origin of congenital club-foot, 
 but none have been proven. The laity believe in maternal impressions as a 
 cause, but the majority of the profession place little value upon this theory. 
 In short, the etiology is undetermined. 
 
 Pathological Anatomy.— All of the tissues take part in the malforma- 
 tion. Bones are misshapen, ligaments are shortened, and muscles contracted, 
 and it is impossible to say which is the primary lesion. 
 
 Symptoms and Diagnosis. — The diagnosis is self-evident, and the symp- 
 toms are the peculiarity in appearance and gait. 
 
 Prognosis. — The prognosis of acquired talipes depends upon the cause. 
 Those cases due to paralysis are the least promising, but even in these some 
 good can be accomplished. Almost, if not quite, all cases of congenital club- 
 foot can be cured by proper treatment. 
 
 Treatment. — The time to begin treatment is as soon as the child is born. 
 At this very early date the foot must be repeatedly forced into as nearly the 
 normal position as possible with the hands. The nurse should be instructed 
 to repeat this many times a day. After four or six weeks the radical treat- 
 ment should begin. 
 
 When the deformity is double, as is very often the case, both feet should 
 
1084 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 be treated at once. There are two prime indications to be met ; first, to 
 overcome the deformity, and, second, to hold the foot in the corrected position. 
 There are many ways of meeting these indications, but in this brief article the 
 writer will describe only those that have been most satisfactory in his expe- 
 rience. 
 
 The deformity should be overcome as quickly as possible without resorting 
 to undue violence. In very young patients this can be accomplished in the 
 majority of cases by the surgeon's hands alone. Later it may be necessary 
 to cut tendons and fascia, and in exceptional cases to remove portions of bone, 
 but it is very rarely indeed that bone operations are required in children. 
 
 In order to decide upon the treatment of a given case the foot should be 
 grasped by the hands of the surgeon and an effort made to overcome the 
 deformity. If the foot can be brought into the normal position without much 
 force, no operation is needed, since a cure can be accomplished by holding the 
 foot in the corrected position by some mechanical appliance. 
 
 When the foot cannot be placed in the normal position, on account of bands 
 of fascia or shortened tendons, these must be cut subcutaneously. A very 
 common mistake made in treating club-foot is to perform tenotomies and then 
 apply some form of club-foot shoe. This almost invariably results in failure. 
 The operation should simply be looked upon as the preliminary treatment, for 
 it is only by persistent and long-continued care that satisfactory results can 
 be obtained. A club-foot shoe can be used to advantage to prevent a relapse 
 after the deformity has been overcome, but as a means of treatment it will 
 lead to disappointment. 
 
 To overcome the deformity the patient should be anaesthetized and an effort 
 made to force the foot into the desired position by the surgeon's hands. It is 
 always necessary to over-correct the deformity. If the foot can be forced into 
 an over-corrected position and held there by very slight pressure, no cutting 
 will be necessary. If it is found to be impossible to overcome the deformity, 
 or, having overcome it, to hold it there by light pressure, the tendons or fascia 
 offering the resistance should be cut subcutaneously. After the cutting the 
 foot should be forced into the over-corrected position and held there. In 
 some cases considerable pressure is required. Many machines have been in- 
 vented for the purpose, but the writer has been able to accomplish the desired 
 end with his hands alone. It may be necessary to use all the strength in one's 
 hands, but this can be done with perfect safety so long as the pressure is made 
 upon the foot. Care must be exercised not to apply too much force to the 
 lower end of the leg, lest it be broken. In some cases it will be found impos- 
 sible to overcome all of the deformity at one sitting. In these the foot should 
 be held in the best attainable position for a few days, when another effort 
 should be made to straighten it. 
 
 The most convenient method of holding the foot in the corrected position 
 is by means of a plaster-of-Paris bandage. One experienced in the use of 
 plaster may apply it directly to the skin, but one with limited experience 
 should apply it over a stocking or roller bandage. The plaster should be 
 light and smoothly applied. The foot should be held in the corrected position 
 while the plaster is being applied and until it is well hardened. It is a grave 
 error to apply plaster and make pressure while it is setting, for sloughing is 
 liable to follow. It should always be remembered that the plaster is to meet 
 the second indication, and not the first. Only the best bandages, made from 
 the finest dental plaster, should be used, the poorer grades being so slow setting 
 that they will cause great annoyance and sometimes failure. When the de- 
 formity has been over-corrected the plaster may be left on for a month before 
 
ORTHOPEDICS. 
 
 1085 
 
 changing. It should be reapplied until all tendency to relapse has disap- 
 peared, a period usually of several months. After a time a heavier cast may 
 be applied and the child allowed to walk upon it. When the deformity is 
 thoroughly overcome, and not till then, a club-foot shoe or walking shoe 
 
 Fig. 21. 
 
 Fig. 22. 
 
 Retention shoe for preventing relapse in club-foot. 
 
 Walking shoe for equino-varus. 
 
 should be used. Fig. 21 shows a retention shoe, which answers an excellent 
 purpose applied over an ordinary baby shoe. It is not intended for a walking 
 shoe, but is to be worn after the plaster has been removed and before the 
 child has learned to walk. In an older child it may be used at night only. 
 
 Fig. 23. 
 
 Talipes equino-varus. 
 
 Fig. 22 shows a walking brace to be attached to a heavy-soled, close-fitting laced 
 shoe. It should be made to lock at the joint, so that the toes cannot drop. 
 
 A child is not free from danger of relapse until it is walking fairly upon 
 the bottom of its foot. " Half cures are no cures ;" and always relapse. 
 
1086 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Talipes Equino-varus. — Of the special varieties, equino-varus, a combi- 
 nation of varus and equinus, is by far the most common (Fig. 23). It, in fact, 
 comprises the vast majority of cases of club-foot. In this variety the tibialis 
 anticus, tibialis posticus, tendo Achillis, and plantar fascia may require cutting. 
 The tendo Achillis should not be cut until the varus is overcome, as it fixes 
 the heel while the foot is being straightened. In severe cases that will not 
 yield to the above-outlined treatment it may be necessary to resort to open 
 incision or Phelps's operation. 
 
 Open Incision. — This operation must be done under the strictest aseptic 
 conditions. After applying an Esmarch's bandage an incision is made extend- 
 ing from just in front of the inner malleolus well across the bottom of the foot, 
 down to the bone, cutting everything that prevents the foot from straightening. 
 The foot is now forced into an over-corrected position, a piece of rubber tissue 
 placed over the wound, and a surgical dressing and plaster cast applied. 
 This dressing should remain for a month unless change is indicated by a rise 
 of temperature. When the wound is healed a walking shoe (Fig. 22) should 
 be applied. The same care to prevent a relapse is required after this as after 
 other methods of treatment. 
 
 Other special varieties of club-foot are to be treated upon the principles 
 above laid down. 
 
 Paralytic Deformities. 
 
 The most common paralytic deformities are those resulting from an attack 
 of poliomyelitis or infantile spinal paralysis. These cases can be diagnosed 
 from the blue atrophied appearance of the limb and from the history. Both 
 upper and lower extremities may be involved, but those of the lower are the 
 only ones for which much can be done. Several forms of club-foot, due to 
 paralysis, are met with. The treatment of these cases is not nearly so satis- 
 factory as that of congenital club-foot, because certain groups of muscles are 
 hopelessly paralyzed. Sometimes one muscle of a group may be quite strong, 
 while the others are functionless. In some of these cases tendon anastomosis 
 may be performed, and the tendons of the paralyzed muscles united to the 
 tendon of the healthy one, making it do the work of all. When all the mus- 
 cles in front of the leg are powerless, the tendons may all be shortened and 
 the joint stiffened by removing the joint-cartilages, thus making a useful 
 stiff foot. 
 
 When the extensors of the leg are paralyzed, making the knee-joint limp 
 and useless, the knee may be excised and a useful, stiff leg procured. The 
 only hope of relief in some cases in which the paralysis is about the hip-joint 
 is from mechanical support, and that is not very encouraging. No case of 
 this kind should be given up as hopeless, however, until it has been carefully 
 examined by an expert orthopaedist. 
 
 Another class of paralytic deformities are those resulting from infantile 
 cerebral paralysis or spastic palsy. These children do not walk at the usual 
 age, and have a spasmodic jerking of many of the muscles. In many cases 
 there is also a lack of mental development. By judicious tenotomies and me- 
 chanical supports some of these cases can be greatly benefited, although, as a 
 class, the outlook is discouraging. They also should have the benefit of skilled 
 attention, for some of them can be straightened and taught to walk, notwith- 
 standing the fact that they have gone several years past the age when chil- 
 dren usually gain the power of locomotion. 
 
ORTHOPAEDICS. 
 
 1087 
 
 Rachitic Deformities. 
 
 Every bone in the body may become deformed from rickets, but the spine 
 and the bones of the lower extremities are the only ones of interest from an 
 orthopaedic standpoint. Rachitic curvatures of the spine are usually antero- 
 posterior, and are to be diiferentiated from other curvatures by the fact that 
 when the child lies down all or a greater part of the deformity disappears, and 
 by the presence of other characteristic symptoms of rickets. A rachitic curve 
 of the spine is usually a long, even curve, offering quite a contrast to the 
 sharp, angular curve of Pott's disease (Fig. 24). 
 
 Fig. 24. 
 
 Rachitic spine. 
 
 The prognosis in these cases is usually good. The spine should be 
 straightened and held, until the bones have become hardened, by some of 
 the appliances recommended for Pott's disease. 
 
 Bow-legs is one of the most common rachitic deformities (Fig. 25). In 
 children under four years of age the legs can be gradually straightened by braces 
 (Fig. 27) ; after this age the bones are usually too hard to be so influenced. 
 When the deformity is very slight, interference is unnecessary, since the nat- 
 ural tendency is to grow straighter ; when well marked and the child's bones 
 are hardened, it is necessary to break the bones to straighten them. This can 
 be easily and safely done by means of an osteoclast. The limbs are then put 
 up in plaster of Paris, just as for a simple fracture, and after five or six weeks 
 the child will be well. The bones may also be broken by means of hammer 
 
1088 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 and chisel, but it is not so safe as osteoclasis. In practised hands, however, it 
 
 is good treatment. 
 
 6 Fig. 25. 
 
 Mild knock-knee. 
 
 Knock-knee, or genu valgum, is characterized by an undue prominence 
 
ORTHOPEDICS. 
 
 1089 
 
 of the inner condyle of the femur (Fig. 26). It may be single or double. 
 When the knees are brought together the inner malleoli of the ankle-joints 
 will not touch, as they should. In severe cases there is usually some lateral 
 motion in the knee-joint due to the stretching of the internal lateral ligaments. 
 In young children, before the bones have hardened, this deformity may be en- 
 
 Fig. 28. 
 
 Bow-leg braces. 
 
 Knock-knee braces. 
 
 tirely overcome by means of braces (Fig. 28), but in older children the femur 
 should be broken just above the condyles by means of a mallet and osteotome, 
 and the limbs put up straight in plaster of Paris. After six weeks the bone 
 will be firm. Done under proper aseptic precautions, this is a safe and satis- 
 factory operation. 
 
 69 
 
PART XII. 
 
 DISEASES OF THE SKIN. 
 
 By W. A. HARDAWAY, A. M., M. D., 
 
 St. Louis. 
 
 In a general way it may be said that the child and the adult are subject to 
 very nearly the same diseases of the skin ; nevertheless, a close scrutiny will 
 show that certain differences exist, both of kind and degree, that are worth 
 attentive consideration. 1 
 
 In the first place, owing to the greater vulnerability of the skin in children, 
 inflammatory disorders of all sorts take on a more acute aspect than with the 
 grown person, and, for the same reason, mechanical irritants are more apt to 
 be productive of mischief. Then, again, the frequent gastro-intestinal dis- 
 orders of infancy increase, in an indirect way, the tendency to inflammatory 
 and erythematous cutaneous processes. Although the influence of dentition 
 is much overrated as an etiological factor, it remains true that the nervous 
 erethism set up by the eruption of teeth may be regarded as a complicating 
 agency of importance in certain cases. As regards special diseases, Diday shows 
 that congenital syphilis develops generally in the first three months of life ; , 
 ichthyosis may be congenital or show itself between the ages of three and six ; 
 eczema is more common during the first five years than at any other period ; 
 impetigo contagiosa is a disorder of childhood ; ringworm of the scalp is essen- 
 tially a disease of the young, and so is pediculosis capillitii ; pemphigus is not 
 infrequently encountered in children ; and lupus vulgaris usually begins early in 
 life. On the other hand, by way of contrast, it may be stated that acne is 
 rare before puberty ; tinea versicolor is an affection of the adult ; epithelioma 
 is uncommon before the fortieth year, and children rarely have essential 
 pruritus. These comparisons might be much extended, but enough has been 
 shown for practical purposes. 2 
 
 In this article, owing to necessary limitations of space, only those disorders 
 of the skin most common to children will be considered at any length ; rare 
 diseases, or those whose nosological positions are still uncertain, will not be 
 noticed at all or only in the briefest manner. 
 
 1 In the preparation of this article the writer is under especial obligations to the papers on 
 dermatology by various authors in Keating's Cyclopaedia of the Diseases of Children, and to 
 Crocker's Text-book of Skin Diseases. Thanks are also due Dr. C. F. Hersman for much valuable 
 assistance. 
 
 2 See writer's article, " Locality and Age in the Diagnosis of Skin Diseases," St. Louis Clini- 
 cal Record, Nov., 1875. 
 
 1090 
 
DISEASES OF THE SKIN. 1091 
 
 DISORDERS OF THE GLANDS. 
 
 SEBACEOUS GLANDS. 
 Seborrhcea. 
 
 Seborrhea is a functional disease of the sebaceous glands, characterized 
 by excessive secretion, which is discharged upon the integument in the form 
 •of oily, scaly, or crusted material. There are two varieties — viz. seborrhoea 
 oleosa and seborrhoea sicca ; in the first condition the secretion is fluid or oily, 
 .and in the second it is dry and scaly. As the vernix caseosa of the new-born 
 it may be regarded as physiological. Both forms of seborrhoea may be present 
 in the same patient, or, on the other hand, the distinction between them may 
 be hard to define. The disease may be present on any part of the body save 
 the palms and soles. A slight amount of seborrhoea of the scalp is often seen 
 during the first month of infancy, and the frantic efforts to get rid of this 
 -almost normal secretion frequently leads to an annoying and rebellious eczema. 
 Sometimes the secretion forms a thick crust and extends over the forehead and 
 adjacent parts. Unless the skin has become irritated by the decomposition of 
 the secretion, it will be found cool and even paler than normal. In older 
 children both the dry form, the so-called pityriasis capitis, and the oily variety 
 -are not infrequently observed, and, as in the adult, give rise to a dry, lack- 
 lustre state of the hair or comparative baldness. 
 
 According to Crocker, the disease is often seen in strumous children in the 
 form of small shining scales situated upon the trunk and limbs, and generally 
 coexisting with lichen scrofulosis. Excessive secretion of sebum at the 
 umbilicus, on the glans penis, the inner surface of the prepuce, and the sulcus 
 in the male, and about the labia and clitoris in the female, is common in ill- 
 cared-for children, and as a consequence of decomposition produces a most 
 sickening odor and sets up an acute dermatitis. Hebra and others regard ich- 
 thyosis congenita as a seborrhoea. 
 
 Under the term seborrheal eczema Unna includes not only the dry sebor- 
 rhoea of the body (lichen circumscripta) common to adults, but those forms of 
 eczema in children situated upon the eyelashes and other regions. This 
 question cannot be discussed here, but it is proper to remark, as long since 
 pointed out by Kaposi, that seborrhoea is a very common provocative of eczema, 
 -and that, therefore, the latter disorder is often encountered in regions richly 
 supplied with oil-glands. 
 
 Etiology. — Among the common causes of seborrhoea in children may be 
 mentioned various disorders of nutrition arising from struma, anaemia, gastric 
 and intestinal disorders, and, more directly, inattention to personal hygiene. 
 Unna regards seborrhoea as an inflammatory affection of the sweat-glands, and 
 Brooke thinks it is of parasitic origin. 
 
 If long continued, the glands are apt to undergo atrophy, but in the begin- 
 ning the disorder is purely functional. The secretion, examined microscopic- 
 ally, is seen to consist of epithelial scales, amorphous granular material, and 
 free oil-globules and fat. 
 
 Diagnosis.— This offers few difficulties. On the scalp the disease is differ- 
 entiated from eczema by the absence of marked itching and infiltration of the 
 skin and by the greasy character of the scales. The scales in psoriasis are not 
 greasy, but dry, and are arranged in more or less isolated mortar-like heaps 
 scattered over the scalp. Oily seborrhoea of the body is easily recognized : 
 the dry form should be differentiated from eczema, psoriasis, ringworm, and 
 pityriasis rosea. (See articles on these diseases.) 
 
1092 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Prognosis. — Infantile seborrhoea is usually very amenable to proper treat- 
 ment. 
 
 Treatment. — The internal treatment is entirely symptomatic, and consists 
 in the removal of any apparent derangement of the health. Minute doses of 
 sulphide of calcium have been recommended, but the writer has seen no benefit 
 from its use. Mothers should be warned against the fine-toothed comb and 
 other harsh measures in their efforts to cleanse the heads of their babies. 
 Instead, the crusts should be soaked off with free applications of olive oil, 
 and then kept clean with Eichoff's superfatted thymol soap; but if the skin is 
 at all tender, it is better to keep the parts anointed with a little vaseline for a 
 short while. Seborrhoea of the body is managed in the same general way, but 
 if the secretion is persistent — and this holds equally good for the scalp — it is 
 well to apply once or twice daily the following ointment : 
 
 I$5. Sulphuris praecip gr. x-xx. 
 
 Acidi salicylici . . . . gr. v-x. 
 
 Yaselini §j. — M. 
 
 Sic. Local use. To be further diluted if too active. 
 
 Resorcin, carbolic acid, white precipitate, and tannin are also good remedies. 
 
 Seborrhoea of the umbilicus and of the genitals requires absolute cleanli- 
 ness and the local application of alum or tannin washes. In all cases, if the 
 disease has set up much dermatitis, soothing and antipruritic treatment will 
 be required. (See Eczema.) 
 
 Comedo. 
 
 Comedo is a disorder of the sebaceous glands in which their excretory ducts 
 are plugged with inspissated sebum mixed with epithelial cells. These so-called 
 flesh- worms or black-heads are generally slightly elevated, pinpoint to pinhead 
 in size, and can be expressed as a filiform mass when pressure is made at the 
 sides of the lesions. Sometimes the comedo is slightly depressed, and, instead 
 of the usual black color, may have a yellowish or even bluish tint. The usual 
 seats of comedones are the face, neck, chest, and back. 
 
 Ordinarily, comedones are not seen before puberty ; but some years ago 
 Crocker called attention to cases occurring in the children of the poor in sum- 
 mer. According to this observer, they appear on the upper part of the fore- 
 head and corresponding parts of the occiput in boys above three years, on the 
 temples in girls, and on the cheeks in infants. They are densely packed and 
 often grouped, and accompanied by seborrhoea of the scalp. Warmth and 
 moisture seem to be the exciting causes. T. C. Fox has made similar obser- 
 vations. 
 
 Treatment. — Cleanliness and the free use of soap and water are all that is 
 required in the way of preventive treatment. To remove the comedones when 
 present, friction with a green-soap lather is usually efficacious : 
 
 1^. Saponis olivae prsep., vel saponis viridis . . . 3j. 
 
 Alcoholis fgj. 
 
 Aquae q.s. adfgiv. — M. 
 
 Sig. Apply with flannel rag. 
 
 In some cases it may be necessary to express the plugs with a comedo- 
 extractor. 
 
DISEASES OF THE SKIN. 1093 
 
 Acne. 
 
 Although Chambord and others have reported a few cases of acne in young 
 children, practically the disorder does not make its appearance until puberty. 
 The acne due to the ingestion of the iodides and bromides and to the use of tar 
 is not a true form of the disease. 
 
 Milium. 
 
 Milia are small white or yellowish papules, varying in size from a pinhead 
 to a split pea, that occur for the most part under the eyes, on the forehead, and 
 over the cheeks. It is a tolerably common affection in infants, and constitutes 
 the strophulus albidus of Willan. 
 
 Etiology. — The etiology is not always clear when occurring in infancy. 
 Milia are often congenital. They also follow in the wake of other diseases — 
 namely, pemphigus, lupus, erysipelas, etc. They are usually regarded as due 
 to retention in one or several of the acini of an oil-gland, but Robinson thinks 
 that two causes may be operative in their production : in one instance " it is a 
 case of miscarried embryonic epithelium from a hair-follicle or from the rete," 
 while in milia following pemphigus, lupus, etc., the contents consist of fatty 
 epithelium and cholesterin, the epithelium being often arranged in concentric 
 layers around a central fat-nucleus. 
 
 Prognosis. — Favorable. 
 
 Treatment. — The electrolytic puncture, as originally suggested by the 
 writer, is not demanded, nor would it be tolerated, in infantile cases. More or 
 less vigorous friction with soap and water is all that is needed. 
 
 SWEAT GLANDS. 
 
 Hyperidrosis. 
 
 Hyperidrosis is a functional affection of the sweat-glands, giving rise to 
 hypersecretion of their contents. It may be acute or chronic, general or local, 
 limited or excessive in amount. Universal hyperidrosis is usually symptomatic, 
 occurring in connection with acute febrile states or dependent upon general 
 diseases of a debilitating character, such as phthisis, rickets, etc. In the last- 
 named disease, however, the sweating is most abundant about the head. Gen- 
 erally in babies the profuse local and general sweating is induced by injudicious 
 clothing and excessive heating of living apartments, and when these unhygienic 
 conditions are kept up, intertrigo and eczema are not infrequent sequelae about 
 the genitals and between the folds of the skin. Generalized eruptions of 
 sudamina from the same causes are also encountered. 
 
 Hyperidrosis of the palms and soles and axillae often develops during child- 
 hood, and sometimes is clearly congenital and occasionally hereditary ; but it 
 does not follow that all of these localities are involved at the same time, for 
 usually the disorder is limited to one region or the other, the palms and soles 
 being more apt to suffer together. When the palms and soles are affected — 
 that is, if the sweating be at all abundant — the skin becomes sodden and 
 macerated, and from the feet the odor is often disgusting. This condition, 
 known as bromidrosis, is more frequent, however, in the adult. 
 
 Etiology. — Aside from the more or less physiological sweating due to high 
 temperature, faulty innervation apparently plays the chief role in hyperidrosis. 
 Cutler regards it as a functional affection of the sympathetic system. Foetid 
 perspiration is due to the presence, according to Thin, of the bacterium 
 fcetidum. 
 
1094 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Prognosis. — Sweating of the feet is more controllable than that of other 
 parts. Upon the whole, the prognosis of hyperidrosis should be guarded. 
 
 Treatment. — The treatment of general sweating is based upon the causal 
 indications, and need not be dwelt upon here. The debilitating sweating about 
 the head in children may be much mitigated by directing them to lie on hair 
 pillows instead of the usual feathers. Among specific remedies may be men- 
 tioned belladonna, atropine, agaricin, and ergot ; but their effect at best is only 
 temporary. Crocker highly extols precipitated sulphur, given in milk, twice a 
 day. If it proves too laxative, it may be combined with the compound chalk- 
 and-cinnamon powders. 
 
 The local applications are numerous. Among the most satisfactory are a 
 1 per cent, solution of quinine in alcohol, belladonna salve or liniment, tannin 
 dissolved in bay rum (gr. viij to f giv), salicylic acid in alcohol (sj-fliv), and 
 various dusting powders, composed of zinc, starch, boracic and salicylic acids. 
 For sweating of the hands Pringle recommends pure silicic acid (terra silicea). 
 For foul-smelling perspiration of the feet dusting the stockings with boracic 
 acid is valuable. The following powder, as suggested by Van Harlingen, is 
 to be commended : 
 
 Ify. Pulv. acidi salicylic . 3ij. 
 
 Pulv. zinci carb. praecip 3ij. 
 
 Pulv. magnesiae ustae 3ij- 
 
 Pulv. amyli Svijss. 
 
 Pulv. talci . . 3x. — M. 
 
 Sig. Dusting powder. 
 
 Hebra's plan, although troublesome, is eminently successful. Briefly, it 
 consists in wrapping the feet and toes, the latter separately, in cloths spread 
 with diachylon ointment, which should be changed twice daily, and the parts 
 rubbed dry before each reapplication. This should be kept up for two weeks, 
 water being absolutely interdicted during the treatment. Strapping the parts 
 evenly and firmly with soap or lead plaster often suffices. 
 
 Miliaria. 
 
 Miliaria, lichen tropicus, or prickly heat, is an acute inflammatory affection 
 of the sweat-glands, resulting in papular, vesico-papular, vesicular, and even 
 pustular, lesions. It is a very common disorder in young children, and is 
 usually seated upon the trunk, although the face and other parts of the body 
 are also attacked. The subjective symptoms are very annoying, and consist 
 of sensations of intolerable burning and stinging. The rash comes out sud- 
 denly, often after profuse sweating, and generally subsides in a few days with 
 slight desquamation ; but if the cause is kept up successive crops will appear. 
 According to the lesion present — and this apparently depends upon the inten- 
 sity of the process — the eruption has been variously designated — viz. m. vesic- 
 ulosa or rubra (the " red gum " of the nursery), m. papulosa or prickly heat, 
 etc. The non-inflammatory variety is m. crystallina or sudamina. Furuncu- 
 losis and eczema are not infrequent sequelae of neglected or ill-treated cases. 
 
 Etiology. — Intense heat is the common factor, and therefore miliaria is 
 most frequently encountered in summer. Sudamina are noted in connection 
 with states of general debility and in febrile disorders, but also as a consequence 
 of excessive sweating. In sudamina the sweat collects between the deepest 
 laminae of the horny layer ; the sweat-duct is obstructed, with consequent 
 
DISEASES OF THE SKIN. 1095 
 
 rupture of the wall and formation of a vesicle. In miliaria there is vascular 
 congestion about the ducts, increased secretion, and more or less effusion into 
 and about the sudoriparous organs. 
 
 Diagnosis. — Sudamina are non-inflammatory in character ; which fact, 
 taken in connection with the history of the case, will be sufficient for their 
 differentiation from varicella. The lesions of eczema papulosum are larger 
 than those of miliaria papulosa, are more persistent, and the pruritus is more 
 intense. The vesicles of vesicular eczema are more closely set than those of 
 vesicular miliaria : they rupture readily (in miliaria the vesicular contents 
 usually dry up without rupture) and give rise to the peculiar sticky discharge. 
 
 Treatment. — In relapsing cases tonics are sometimes demanded, and more 
 especially change of climate. Ordinarily, attention to diet, which should be of a 
 plain, non-stimulating sort, with proper clothing and, at the height of the attack, 
 some mild refrigerant mixture, is all that is required in a general way. 
 Children in summer should be kept well powdered with borated talcum or 
 similar preparation as a preventive measure. During the outbreak the speed- 
 iest relief is secured from the use of the calamine-and-zinc lotion : 
 
 1^. Zinci oxidi gss. 
 
 Pulv. calaminae prsep Biv. 
 
 Glycerini f^j. 
 
 Liq. calcis f §vij . — M. 
 
 Sig. Shake and mop on freely. 
 
 If the itching be intense, from two to five minims of carbolic acid may be added 
 to each ounce of the mixture. 
 
 Anderson's dusting powder is useful : 
 
 1^. Pulv. amyli £vj. 
 
 Zinci oxidi giss. 
 
 Pulv. camphorse 3ss. — M. 
 
 Sig. Dusting powder. 
 
 INFLAMMATIONS. 
 
 Erythema Simplex. 
 
 In simple erythema the skin presents variously-sized, diffused or circum- 
 scribed, hypersemic lesions that fade temporarily upon pressure, and are usually 
 without sensible elevation above the surrounding surface. Subjective symp- 
 toms are trivial, and consist for the most part of slight burning and tingling, 
 or they may be absent entirely. An altogether unnecessary confusion has 
 enveloped this subject, owing largely, perhaps, to errors in diagnosis, but also, 
 to some degree, it has arisen from the cumbersome and pedantic nomenclature 
 which has been applied to comparatively insignificant differences in the appear- 
 ances of the lesions. Simple erythema may be conveniently divided into two 
 main classes — namely, idiopathic erythema and symptomatic erythema. 
 
 Idiopathic Erythema. 
 
 This variety of the disorder is excited by the influence of external irritants 
 acting upon the skin, and passes readily into a true inflammatory state. JEry- 
 
1096 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 thema ealoricum is set up by the agency of heat and cold ; erythema traumat- 
 ieum arises from pressure, rubbing, etc. ; and erythema venenatum is produced 
 by the action of animal and vegetable poisons. Two other forms of erythema, 
 both very common in children, are e. intertrigo and e. pernio, or chilblain. 
 
 Erythema Intertrigo. — Intertrigo usually occurs in the groins, in the folds 
 of the neck in fat babies, and wherever, in fact, the skin surfaces come in con- 
 tact ; and it is all the more readily induced by the irritation of the sweat-secre- 
 tion and by urinary and faecal discharges. Intertrigo is always at first a simple 
 hyperaemia of the skin, but when neglected the skin becomes hot and ten- 
 der, the epidermis macerated, a profuse, malodorous, muciparous discharge is 
 present, and in bad cases Assuring, and even ulceration, may occur. 
 
 The eruption is very common, at times appearing suddenly, and, under 
 simple treatment, disappearing again as rapidly ; but if maltreated it may run 
 a long course. In some instances it is symptomatic of grave internal disorders. 
 
 Intertrigo naturally occurs most frequently in summer, but this is by no 
 means the rule with children. Relapses are frequent. 
 
 Diagnosis. — Intertrigo is easy to recognize. Tilbury Fox says it is to 
 be distinguished from eczema by the nature of the characteristic discharge, 
 which does not stiffen linen. The erythematous syphilide of infancy is apt 
 to attack, like intertrigo, the buttocks and genital regions ; but, aside from 
 the color and the general concomitants of syphilis, the diagnosis is facilitated 
 by remembering that intertrigo confines itself to the region of the diaper ; 
 the syphilide runs down toward the heels. 
 
 Treatment. — The preventive treatment demands absolute cleanliness, the 
 use of a bland soap (Eichoff's superfatted thymol soap, for example) and a 
 simple dusting powder, such as oxide of zinc and lycopodium (gij-^vj). For 
 the curative treatment it is necessary to keep the parts separated by the inter- 
 position of thin layers of absorbent cotton, and to apply some remedy that is 
 both astringent and antiseptic. The following is a good example of a powder : 
 
 Ify. Thymol gr. j. 
 
 Pulv. zinci oleatis ^j. — M. 
 
 Sig. Dusting powder. 
 
 A modification of Lassar's paste serves an excellent purpose, besides 
 thoroughly protecting the surfaces from irritating discharges : 
 
 I$*. Acidi salicylici gr. x. 
 
 Bismuthi subnitratis 
 
 Amyli da 3nj. 
 
 Ung. aq. rosae q. s. ad gj. — M. 
 
 Sig. Smear gently over the affected parts. 
 
 Of late the writer has used Pick's paste with much satisfaction : 
 
 1^. Pulv. tragacanthae gr. xv. 
 
 Glycerini ttlxxiv. 
 
 Aquae f^j.— M. 
 
 This makes a transparent adhesive dressing, called by its originator linimen- 
 tum exsiccans. By adding to it 10 per cent, of oxide of zinc and 1 per cent, 
 of carbolic acid there will result a most admirable preparation. 
 
 Erythema Pernio, or Chilblain.— Chilblains are prone to occur in chil- 
 
 
DISEASES OF THE SKIN. 1097 
 
 dren with poor circulation, and especially in weakly, anaemic girls. The lesions 
 consist of erythematous patches of various sizes and shapes, and attack by pref- 
 erence the heels, toes, sides of the feet, fingers, knuckles, ears, and tip of the 
 nose. The spots are light red in the beginning, but later on become bluish - 
 red. The burning and itching that accompany their development are much 
 aggravated by warmth. The surface of the patches in bad cases may vesicate 
 and result in the formation of large blebs, possessing serous or sero-sanguin- 
 olent contents : or the parts may become denuded and slough. 
 
 Treatment. — The internal treatment is symptomatic, but, as most of the 
 cases occur in the weakly, tonics and general hygienic measures are urgently 
 demanded. Woollen stockings and loose shoes, without elastic sides, are to be 
 preferred, and the habit of " toasting " at fires and registers is to be prohibited. 
 Friction with snow or cold water should be tried in threatening cases, and after- 
 ward soothing, somewhat astringent, lotions prescribed, such as the lotion of 
 zinc and calamine. Pick's paste is also useful at this stage. Later, if the 
 erythematous condition has become fully developed, stimulating local treatment 
 becomes necessary. 
 
 The unbroken surface may be painted with iodine or with oil of peppermint, 
 pure or diluted. Jackson recommends — 
 
 Jfy. 01. cajuputi . 
 
 Liq. ammon. fort da f^ij. 
 
 Lin. saponis comp f^iij- — M. 
 
 Sig. Local use. 
 
 In very chronic patches Pringle recommends painting with a solution of 
 nitrate of silver (gr. xvj) in spirits of nitrous ether (f 3j), or a 5 per cent, solution 
 of salicylic acid in traumaticin. Ulceration and sloughing, when they occur, 
 should be treated on general surgical principles. 
 
 Symptomatic Erythema. 
 
 The symptomatic erythemata are very numerous and are due to a great 
 variety of causes. It is well for the practitioner to remember that many general 
 diseases — e. g. variola, diphtheria, measles, scarlatina, and vaccinia — are often 
 preceded, accompanied, or followed by erythematous rashes. The scarlatini- 
 form rash that is not infrequently seen in connection with septicaemia, the 
 puerperal state, etc. is also, according to Crocker, an accompaniment of malarial 
 disorders in children. However, it is necessary to bear in mind that quinine 
 in susceptible subjects induces an erythematous rash. Various other drugs 
 are capable of evoking congestions of the skin. 
 
 Erythema Infantile. — This form of erythema, also called roseola infantilis, 
 is comparatively frequent, and possesses an importance out of proportion to its 
 severity on account of the confusion in diagnosis to which it gives rise. Tem- 
 porary congestions of the skin are quite common in teething children and in 
 those suffering from alimentary derangements. The eruption is usually rose- 
 olous ; that is to say, made up of variously sized and shaped patches and blotches 
 having a general resemblance to the rash of measles. Much of what is called 
 "scarlatina" is undoubtedly this symptomatic erythema. Accompanying the 
 eruption there is usually some slight elevation of temperature, together with 
 some redness, without swelling, of the palate and fauces. 
 
 This infantile erythema is an ephemeral affair, and its only importance is 
 of a negative sort. The diagnosis, however, is at times difficult to the inex- 
 
1098 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 perienced. It is to be differentiated from scarlet fever by the fact that in the 
 latter affection there is a high temperature, great heat of skin, glandular 
 engorgement, the characteristic state of the tongue and throat, and the location 
 of the eruption — symptoms that are absent in infantile erythema — while the 
 catarrhal prodromal stage, the fever, the maculo-papular rash on the mucous, 
 membranes and the skin, are significant of measles, and not of erythema. 
 Rotheln is manifestly the result of contagion, two or more children in the 
 family perhaps being simultaneously attacked : the glands behind the neck are 
 apt to be swollen, the eruption is less evanescent and is more papular than 
 erythematous. 
 
 New-born babies are often attacked with an eruption made up of minute 
 red papules seated on a hyperaeinic base, which may be made to fade away 
 under pressure. The back and chest are the usual sites of the rash. It lasts 
 but a few days, and disappears with slight desquamation. The mucous mem- 
 branes are not involved, and there is no fever. 
 
 Treatment. — The internal treatment of the various erythemata is purely 
 symptomatic. A little calamine lotion or a dusting powder is all that is 
 required locally. 
 
 Erythema Multiforme. 
 
 Erythema multiforme is an exudative affection of the skin in which various 
 erythematous, papular, vesicular, bullous, tubercular, and nodose lesions may 
 appear separately or coincidently. Preceding the outbreak of this eruption, 
 the patient may experience more or less malaise, gastric disturbance, sore throat, 
 rheumatic pains, and fever. Crocker, who has paid much attention to the skin 
 diseases of children, says that the fever and general symptoms are more marked 
 in them than in the adult, the lesions are more severe, and when vesicles form 
 their contents are prone to become purulent and leave cicatrices. However,, 
 the lesions are not so apt to be multiform. There are, nevertheless, exceptions 
 to this rule, for often the general symptoms are insignificant, especially when 
 the eruption is limited in extent. 
 
 The local subjective symptoms consist mainly of sensations of burning and 
 tingling. 
 
 When the disease assumes the erythematous form, the fading of the centre 
 of the patch leaves a ringed appearance that has been called e. annulare; 
 or concentric rings, one forming within the other, will leave in their wake, as 
 the effusion becomes absorbed, a variety of different colors, thus justifying the 
 rather fanciful term of e. iris; or these advancing rings, meeting others, 
 become broken into various lines, producing e. gyratum ; or, made up of 
 widely diffused patches with an abrupt and sharply-defined border, it is called 
 e. marginatum. As usually seen, however, the disease makes its appearance 
 in the form of discrete or aggregated flat papules, varying in size from a pin- 
 head to a split pea ; in color they are bright red or purplish. Often the 
 lesions are considerably larger (e. tuberculatum), in which case they have a 
 deeper or violaceous hue that is quite characteristic. Vesicles or bullae may 
 form in connection with any of the above-mentioned lesions, thus constituting 
 e. vesiculosum and e. bullosum. 
 
 The backs of the hands and feet are common sites of the eruption, par- 
 ticularly for the papular and tubercular types ; but the whole surface is often 
 involved. Slight desquamation and pigmentation may occur as sequelae. The 
 usual duration of the disorder is from two to four weeks ; but the general 
 symptoms usually abate at the appearance of the eruption. Relapses are 
 common, especially in the spring, and in a few rare instances, reported by Fox, 
 
DISEASES OF THE SKIN. 1099 
 
 Jackson, and the writer, the disease has relapsed at irregular periods for many 
 years. 
 
 Many authorities look upon erythema iris and erythema nodosum as inde- 
 pendent affections, but the writer regards them as clearly allied to, if not iden- 
 tical with, erythema multiforme. 
 
 Herpes Iris. — It is usually symmetrical, and occurs preferentially on the 
 backs of the hands and feet, but especially the former. There may be one or 
 more patches ; sometimes the whole body is affected, even the mucous mem- 
 branes. The eruption consists of an erythematous base, upon which is seated a 
 conical vesicle ; both vesicle and areola increase in diameter, and presently the 
 outer border of the latter is elevated into an annular ring by fresh effusions, 
 while the central vesicle undergoes absorption and leaves in its stead a pur- 
 plish stain. Here the process may terminate, or else successive rings may 
 form, and the various shades of color thus produced give the rather fanciful 
 rainbow effect. Various other modifications have been noted. 
 
 Erythema Nodosum. — Before the eruption is developed the patient may 
 complain of the general symptoms observed in connection with other types of 
 e. multiforme. The lesions consist of isolated, painful, inflammatory nodes 
 that vary in size from a hickory-nut to an egg or orange. They are usually 
 red at first, but as they decline take on the various shades of a common bruise. 
 They may be well or ill defined, and are at first hard and tense, but later become 
 softer, thus closely simulating abscesses. The favorite site of the eruption is 
 the front of the legs, but it may appear elsewhere. Sensations of burning 
 and tingling are usually present. The disorder may last two to four weeks. 
 Relapses are not infrequent. 
 
 Etiology. — The various types of erythema multiforme avoid the extremes 
 of life as a rule ; the ages between ten and thirty are most obnoxious to its 
 attacks. It seems to occur as the result of the most diverse causes — e.g. 
 changes of temperature, disorders of digestion, as sequelae of vaccination, in 
 connection with epidemic influenza (la grippe) ; and, as regards e. nodosum, 
 it apparently bears some etiological relationship to rheumatism. The explana- 
 tion would seem to be that these various erythemata are of angeio-neurotic 
 origin, and that under favoring conditions toxic and other agents influencing the 
 central nervous system produce these explosions in the vascular and nervous 
 organs of the skin. 
 
 The rash is undoubtedly due to a vaso-motor disturbance, inducing the 
 usual phenomena of inflammation, with a variable amount of exudation. 
 Hsemorrhage into the lesions also occurs. 
 
 Diagnosis. — Erythema multiforme is to be distinguished from urticaria by 
 the stability of the eruption, the greater variety of the eruptive elements, and 
 the less degree of itching. The papules of papular eczema are smaller, more 
 pointed, last longer, and are intolerably pruritic. The nodes of syphilis 
 should not be confounded with e. nodosum. Attention to the history of the 
 case, the possibility of ulceration, and other concomitants of syphilis should 
 sufficiently emphasize the differences. 
 
 Prognosis. — In the majority of cases the prognosis is favorable. Under 
 no circumstances is the disease dangerous to life, but the relapses are not 
 always easy to control. 
 
 Treatment. — The prodromic symptoms of erythema multiforme should be 
 treated on general principles. There is no specific remedy for the disease as a 
 whole. Hygienic measures and tonics are demanded in the anaemic and stru- 
 mous. In rheumatic cases the salicylates are indicated. The calamine-and- 
 zinc lotion, with or without the addition of a little carbolic acid, is a good local 
 
1100 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 application. In e. nodosum the legs should be kept elevated, and the same 
 lotion applied, or a lead-and-opium wash. For e. tuberculatum of the hands 
 the unguentum vaselini plumbicum (see under Eczema), spread on muslin and 
 neatly bound, gives relief. 
 
 Relapsing Scarlatiniform Erythema (Pereol). 
 
 Under the title of " ery theme scarlatiniforme desquamatif recidivant " Fereol 
 and Besnier describe a form of disease that occurs in children and young adults, 
 and which really should be discussed along with the other varieties of exfoli- 
 ative dermatitis. Usually, after a prodromic stage of one or two days, in which 
 the patient feels unwell and has slight fever, a scarlatiniform erythema appears, 
 first on the trunk, and in a few hours, or perhaps not for a couple of days, it 
 spreads over the whole body. In some cases the rash is localized to particular 
 parts of the surface, or it may be widely diffused, but with areas of normal skin 
 between the patches. The oral mucous membranes are also injected. There 
 is some burning and itching present, but the skin remains supple and shows 
 no infiltration. After a few days — one or two — the process comes to an end, 
 and free desquamation occurs. At the end of a week or two the disease has 
 generally run its course ; on the other hand, there may be repeated recrudes- 
 cences and the disorder may be kept up for weeks. Relapses are frequent, 
 especially after vicissitudes of weather or from other general or local exciting 
 causes. It is non-contagious and does not occur epidemically. 
 
 Diagnosis. — The distinction between this affection and scarlatina is at 
 times difficult ; but in scarlet fever the prodromic symptoms are usually more 
 severe, the eruption comes out first on the neck, chest, and flexures of the 
 joints, the fauces are tumid, the tongue has the strawberry-like appearance, 
 the glands at the angles of the jaw are swollen, and, finally, desquamation does 
 not occur nearly so soon. As additional points it may be remembered that 
 this disorder usually gives the history of relapses, and that it is neither due 
 to nor causes contagion. 
 
 Treatment.— This should be directed toward the mitigation of the general 
 and local symptoms — namely, antipyretics and soothing inunctions. 
 
 Eczema. 
 
 Eczema is an inflammatory, non-contagious disease of the skin, character- 
 ized by multiformity of lesion and the presence, in varying degrees, of itch- 
 ing, infiltration, and discharge. It may be acute, subacute, or chronic, and 
 undergoes various secondary changes, such as scaling, crusting, Assuring, and 
 dense thickening of the skin. It was formerly held that eczema was invari- 
 ably a vesicular disease, and that, therefore, the other types which it presents 
 represented other diseases, such as impetigo, lichen, etc. We now fully recog- 
 nize the fact that it is a truly protean affection in its manifestations, although 
 possessing a pathological unity in its essential features that is unmistakable. 
 This view has been very fruitful from the standpoints of diagnosis and treat- 
 ment. So far from eczema being a vesicular disease, it may run its course 
 without the appearance of a single vesicle. On the contrary, the disorder is 
 characterized by a polymorphous eruption, consisting of erythema, papules, 
 vesicles, and pustules. All of these lesions are not necessarily present at the 
 same time, although to a limited extent they may be, and one form of ele- 
 mentary eruption may become transformed into another ; but, as a rule, one 
 or another of them may so predominate as to establish the anatomical general 
 
DISEASES OF THE SKIN. 1101 
 
 type of the eczema ; as, for example, eczema erythematosum, e. pajjulosum, e. 
 vesiculosu)/h e. pustulomm. 
 
 In practice, however, the disease is more often encountered in its subacute 
 or chronic phases, and a brief consideration of these secondary changes will be 
 necessary. 
 
 Eczema rubrum or madidans may develop out of any of the elementary 
 tvpes of the disease, and consists of a raw, red, and weeping surface, the result 
 of exposure of the rete, due to shedding of the upper layers of the epithelium. 
 The itching is very severe. This form of eczema is common on the faces of 
 children. Scaly or squamous eczema may also follow upon any of the element- 
 ary forms of the disease. It appears mostly in patches of variable size, which 
 are red, scaly, and infiltrated ; and finally, owing largely to situation or dura- 
 tion of the disease, the eczematous surface may become of board-like hardness, 
 or warty, or cracked and fissured. 
 
 The chief subjective symptom present in eczema is itching ; in fact, it 
 constitutes the disease. The pruritus will vary considerably in degree, some- 
 times being slight and easily tolerated, or, again, it may be agonizing in its 
 intensity. 
 
 Eczema bears a close resemblance to catarrhal states of the mucous mem- 
 branes, both in its tendency to repeated relapses and, objectively, in its habit 
 of exudation or discharge. This exudation has the property of stiffening 
 and slightly staining linen or cotton fabrics with which it comes in contact. It 
 is not correct to assert that eczema is invariably a " wet disease," for some cases 
 may remain dry throughout ; nevertheless, even a papular or erythematous 
 eczema may be made to weep through the influence of scratching or other 
 irritation. 
 
 Although eczema in children, especially in those under five years, is a very 
 common disease, the writer fails to see wherein it differs essentially from the 
 same disorder occurring in the adult, although this opinion is one very com- 
 monly entertained. Such differences as exist are rather of causation and loca- 
 tion than in clinical expression. In a general way, it may be said that eczema 
 occupies certain situations more often in the child than in the adult — the scalp 
 and face, for example — and that the eruption is more acute, of a more inflam- 
 matory type. All of the elementary lesions of the disease — e. g. erythema, 
 papules, vesicles, and pustules — are seen in children, and often a commingling 
 of them all, although it must be allowed that pustular eczema is of more fre- 
 quent occurrence in children than in adults. Eczema rubrum and eczema 
 squamosum are frequent, but leathery-like infiltration is relatively uncommon. 
 
 Among other features of importance connected with infantile eczema may 
 be noted secondary glandular swellings, cutaneous abscesses, particularly in the 
 scalps of ill-nourished, strumous children, and post-eczematous furunculosis. 
 The implication of the lymphatics, those in the neck being principally involved, 
 as a result of eczema capitis, was formerly regarded as a sure indication of 
 scrofula ; and in eczema occurring after vaccination, with coincident glandular 
 swelling, it was held as proof positive of the introduction of struma by the 
 inoculated lymph. As a matter of fact, this adenitis is purely sympathetic, 
 and is more apt to occur from the irritation set up by pediculi. It is excep- 
 tional for the glands to suppurate. 
 
 A brief summary of some of the more characteristic features of the eczema 
 of children wil 1 now be appropriate. 
 
 Generalized eczema is uncommon in childhood, although there may be 
 present, scattered over the body and limbs, infiltrated patches of variable size, 
 sometimes scaly or composed of aggregated papules exhibiting moist and exco- 
 
1102 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 riated surfaces. The disease also attacks the hands, feet, and legs and the 
 flexures of the j oints. Eczema intertrigo, or that form of the disease found in the 
 groin and between other opposing surfaces of skin, is frequent, but not attended 
 with much itching. The surfaces are very red and moist, and are apt to emit 
 a most disagreeable odor ; moreover, the eruption may spread from these locali- 
 ties to the contiguous portions of the thighs, back, and abdomen. The writer's 
 experience is in agreement with that of Bulkley in regarding the face as the 
 region most frequently first affected. The primary lesions are usually papules, 
 which run together to form exuding, reddened and crusted patches that are 
 intolerably itchy. In this situation the disease is more prone to relapse than 
 elsewhere, as every varying condition of the system is promptly reflected upon 
 a part especially rich in its vascular and nervous supply. A very common 
 starting-point arlso is the scalp, where it is often evoked by the nurse or 
 mother in the effort to clear away the sebaceous secretion that clings to the 
 new-born infant. From this region it may spread to the forehead, ears, and 
 face, and the well-known picture of the typical crusta lactea, or milk crust, 
 is presented. The itching is excessive, and the little sufferers, if old enough, 
 make frantic efforts to get relief by scratching ; while infants will rub the face 
 and head against the pillow or the mother's breast. In neglected cases 
 eczema rubrum is soon developed. 
 
 Etiology. — Eczema is one of the most common of all skin diseases, and 
 it is most frequent during childhood. 1 Even within this period — nay, up to 
 the tenth year — the disease is most frequently developed during the first five 
 years, and, according to Crocker's statistics, one-third of all cases in children 
 begin within the first year of life. 
 
 Leaving out of consideration for the present the essential nature of the ecze- 
 matous process, it may be said that eczema is a catarrhal inflammation of the skin, 
 which may be evoked by a great number of exciting agencies, both internal 
 and external. With children these influences are often sufficiently obvious. 
 
 It is not uncommon to find that eczematous parents have eczematous chil- 
 dren, but, nevertheless, the disease is not inherited in the sense that syphilis 
 is ; it is rather the transmission of a predisposed and vulnerable skin than the 
 inheritance of a diathesis. The ill-nourished and strumous are especially prone 
 to eczema, particularly of the pustular type, with swollen glands, ciliary 
 blepharitis, and otorrhoea as concomitants ; and such children, according to 
 Unna, may subsequently develop local or general tuberculosis. 2 It will be 
 found equally true that depressing influences of all sorts, unhygienic surround- 
 ings, insufficient or improper food, both for the child and the nursing mother, 
 may be regarded as causative factors of no slight importance. It is no uncom- 
 mon thing for eczema to follow in the wake of the eruptive fevers, especially 
 measles, in this latter instance often assuming the form of eczema tarsi. 
 Vaccination is often held responsible for inducing eczema, but so also may 
 the operation of piercing the ears for earrings. 
 
 As stated above, various dietetic errors induce the disease by provoking 
 gastric and intestinal disorders. The mother's milk may be of an inferior 
 quality from lack of proper nourishment on her part, or it may be at fault 
 from too great indulgence in rich food and stimulating liquids. Over-feeding 
 
 1 In the writer's practice, out of a total of 6724 cases of skin disease of all classes, there 
 were 2148 patients with eczema, or 31.40 per cent. In 3000 cases of eczema analyzed by Bulkley, 
 907 occurred during the first ten years of life, and 676 of these were observed in children five 
 years old and under; that is, one-quarter of the whole number could be regarded as infantile. 
 
 2 This latter statement must be taken with many reservations, at least from the standpoint 
 of American experience; for many tubercular children never develop eczema at all, and many 
 children with so-called tuberculous eczema never get tuberculosis. 
 
PLATE XXIV 
 
 
 m 
 
 
 
 * 
 
 
 
 
 / 
 
 ■i 
 
 
 
 #» 
 
 ±^y~~ 
 
 
 ■- 
 
 P 
 
 ^a 
 
 ECZEMA RUBRUM 
 
DISEASES OF THE SKIN. 1103 
 
 is more apt to evoke eczema than under-feeding in children. Very few chil- 
 dren are properly fed, and it is no uncommon thing to find very young infants 
 allowed everything that appears on the table. The writer has long maintained 
 that oatmeal is a pernicious food for the eczematously disposed, especially the 
 hastily-cooked article reinforced by rich cream and great quantities of sugar. 
 Jamieson of Edinburgh doubts that oatmeal in itself can initiate an eczema, 
 but he thinks it is quite probable that it can light up an imperfectly cured 
 eczema or perpetuate one already existing, as any other cause of eczema may. 
 
 Spoon-fed babies are more apt to develop eczema than those nursed by 
 healthy mothers, but here also it is to be remembered that they are liable to 
 disorders of the alimentary canal. 
 
 The local and reflex irritations of the eruption of teeth plays no inconsid- 
 erable role among the exciting causes of eczema, but to regard teething as the 
 sole cause of the disease is unscientific, and the reassuring advice often given 
 that the disease will recover after teething is frequently not fulfilled. 
 
 Any form of external irritant may provoke an eczema — e. g., cold, heat, 
 bad soap, hard water, rough under-garments, etc. Seborrhoea is a prolific 
 source of the disease, and the effort to remove the seborrheal exudation, espe- 
 cially from the scalp of infants, is perhaps one of the most common causes of 
 the disease in that situation. The agency of micro-organisms is probable, 
 especially in localized forms of the affection where the cutaneous secretions 
 have undergone decomposition. 
 
 From the foregoing considerations it will be seen that there is no one cause 
 for eczema. Whatever the essential nature of the disease may be, it is obvious 
 that the eczematous subject has a specially vulnerable and susceptible skin, and 
 that under given conditions the disorder may be evoked by any cause, internal 
 or external, that will arouse this susceptibility. 
 
 Diagnosis. — Papular urticaria, the so-called lichen urticatus, bears a 
 general resemblance to papular eczema. In lichen urticatus the papules are 
 larger and more discrete, and the presence of the ordinary urticarial wheal 
 may be detected at some period of the case ; moreover, the urticarial papules 
 never run together to form the characteristic scaling, infiltrated, and weeping 
 patch of eczema. 
 
 Scabies and eczema are usually confounded by the inexperienced. Both 
 itch severely, and in both multiform lesions may be present ; but in scabies 
 contagion can nearly always be made out, the other children in the family or 
 the mother being similarly affected, and the eruption occupies certain preferen- 
 tial localities — namely, between the fingers, the flexor surfaces of the wrists 
 and arms, including the axillae, the lower part of the trunk, both before and 
 behind, and in older boys the penis. In children of some age the eruption 
 will not be found on the face or feet, but in infants both of those regions may 
 be affected. It is safe to say that a generalized multiform itchy eruption, occu- 
 pying portions of the body that are normally moist and warm, either from the 
 pressure of garments or from contact of contiguous parts, is almost necessarily 
 scabies. The characteristic burrow, or cuniculus, is more readily demonstrated 
 in the child than in the adult. 
 
 Various forms of the syphilide, especially the papular and pustular, are 
 liable to be confounded with eczema. In general it may be said that the spe- 
 cific eruption is most apt to be seen about the mouth, nose, and genitals, and 
 that the individual lesions are larger, less acute in aspect, and of a darker color, 
 besides often presenting a circular arrangement. The weazened appearance of 
 the child, the presence of snuffles, and the discovery of mucous patches are 
 important aids in diagnosis. Moreover, syphilitic eruptions do not itch. 
 
1104 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Pediculosis capillitii bears some resemblance to pustular eczema of the 
 scalp, but the dermatitis is usually confined to the occiput, whereas eczema 
 is apt to involve the whole head, and a little search will easily discover the 
 pediculi or their nits. 
 
 The possibility of confounding eczema with ringworm and favus should be 
 borne in mind. (See those diseases.) 
 
 Treatment. — Before entering upon the subject of treatment it is well to 
 take notice of the opinion still lingering among the laity, and occasionally 
 entertained by physicians, that the cure of the disease may be attended with 
 the most serious consequences. This apprehension — a revival of the old 
 humoralistic theory of peccant humors — both modern science and accumulated 
 experience unite in pronouncing absolutely baseless. Hebra acutely suggested 
 that when the protest against a cure comes from a medical man, it is quite 
 likely that it is ^ue to failure on his part to effect it. 
 
 In the matter of internal medication it may be distinctly stated that there 
 are no specifics for the affection. In every instance a searching investigation 
 must be made for possible exciting causes or probable complications. Routine 
 is to be avoided and each case managed on its merits. 
 
 It not infrequently happens that the little patient is in apparently perfect 
 general health, the disorder being due to external causes, and no treatment 
 beyond the necessary local applications is demanded. Even in such cases 
 proper attention to diet will prove beneficial, and all the more beneficial if a 
 connection can be established between the eruption and dietetic errors. If the 
 child is being suckled, the mother should abstain from stimulating foods and 
 drinks, but if, on the other hand, she is ill-nourished and anaemic, her condi- 
 tion should receive appropriate attention. As regards the child itself, if old 
 enough to be fed, the strictest attention should be paid to the character of the 
 food and to the time and frequency of meals. The usual stuffing with unwhole- 
 some and indigestible food should be strictly forbidden, and the physician will 
 find it wise to write out carefully prepared diet tables. The writer has long 
 been in the habit of using the admirable tables, prepared for different ages, to 
 be found in Dr. Louis Starr's valuable work on the diseases of the digestive 
 organs in children. We would reiterate the statement, already made above, 
 that oatmeal, especially when served with cream and sugar, is harmful to ecze- 
 matous children. Corn grits with salt and butter are just as nutritious and 
 apparently harmless. 
 
 The condition of the alimentary canal must be strictly inquired into, so 
 that constipation, gastric and intestinal catarrhs, or other complicating disorders 
 may receive proper attention. An occasional minute dose of calomel will prove 
 useful in nearly all cases. Anaemic and strumous children, who usually suffer 
 from pustular eczema, are much benefited by the use of iron, particularly the 
 syrup of the iodide, and some form of cod-liver oil. A favorite and agreeable 
 method of administering the oil is as follows : 
 
 fy. 01. morrhuae .... f|iv. 
 
 Pancreatini saccharati 3j. 
 
 Pulv. acaciae q. s. 
 
 Glyceriti hypophosphit f.liv. 
 
 Syr. calcis lactophosphatis 
 
 Aquae da f gv. 
 
 Olei gaultheriae gtt. xxx. — M. 
 
 Sig. — From a teaspoonful to a dessert-spoonful, according to age, three 
 times a day, after meals. 
 
DISEASES OF THE SKIN. 1105 
 
 The habit of prescribing arsenic in all cases of eczema is almost a matter 
 of routine with most physicians. Notwithstanding excellent authority to the 
 contrary (Wilson, Bulkier), the writer must insist that this is bad practice. 
 The drug should never be given in acute attacks, and its beneficial effects, 
 even in chronic types of the disease, are by no means constant. Its chief 
 value is in the dry and scaly forms of eczema. Before giving arsenic at all, it 
 is absolutely necessary to see that the digestive functions are unimpaired. 
 Children bear relatively larger doses than adults. Erasmus Wilson, who was 
 a great advocate of the employment of arsenic in infantile eczema after a 
 proper eliminative treatment with mercury, recommends two minims of Fowler's 
 solution for a child from a month to a year old, to be repeated three times a 
 day with, or immediately after, meals : 
 
 1^. Yini ferri f^ss. 
 
 Liq. potassii arsenitis TTlxxxij. 
 
 Syr. tolutani f gss. 
 
 Aquge anethi fgj. — M. 
 
 Sig. One teaspoonful three times a day. 1 
 
 As a general thing, the various local measures should be sufficient to allay 
 itching and procure sleep, but at times it is necessary to resort to internal 
 medicines. Any form of opium is inadmissible, as it increases the pruritus. 
 Small doses of phenacetin are of value in allaying restlessness, and it appears 
 to have no ill effect on the eruption. Quinine is particularly recommended by 
 Dr. Pye-Smith as an antipruritic — a half grain for a child of one year an hour 
 before bedtime, a grain at two years, and five grains at the age of fifteen. 
 Where a rebellious eczema is probably due to reflex irritation, the result of a 
 tight prepuce, circumcision or other methods of uncovering the glans should 
 be recommended. 
 
 The local treatment of eczema is of the utmost importance ; perhaps, taking 
 all the facts into consideration, of more importance than any direct internal 
 medication ; for, as the writer has expressed it elsewhere, in quite a large 
 number of cases internal remedies are not demanded at all, either because the 
 disease is due to entirely local agencies, or because the internal exciting cause 
 has ceased to be operative, and there remains only the effects, which may be 
 got rid of by topical means. 
 
 In order to determine the character and stage of the disease, it is a pre- 
 requisite that all scales, crusts, and other secondary products be removed. 
 Poultices should be avoided, as a rule, but free inunctions with a bland oil will 
 generally suffice for this purpose. The rule that an eczema should never be 
 washed is absolute. The habit of daily washing eczematous surfaces is per- 
 nicious in the extreme, and is the principal reason of the apparent rebellious- 
 ness of these cases to treatment. Even after recovery is seemingly established 
 the use of an indifferent soap will speedily provoke an exacerbation. 2 When 
 the eruption is at its height it is better to let the parts go unwashed, or a little 
 warm milk and water will answer the purposes of cleanliness sufficiently. 
 
 The principles underlying the local treatment of eczema are in reality very 
 simple. When the disease is acute, soothing remedies should be applied ; when 
 subacute, they may be made somewhat astringent ; and when the chronic stage 
 
 1 In the writer's judgment such large doses of arsenic as recommended by "Wilson should 
 be administered with great caution, if at all. 
 
 2 The best soaps known to the writer are the superfatted kinds made in Germany. Eichoft's 
 thymol, or Kinderseife, is an excellent toilet article. 
 
 70 
 
1106 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 is established, a suitable degree of stimulation is demanded. Some few of the 
 many topical applications used in eczema will now be described, together with 
 their special indications, and the subject will be concluded with a brief consid- 
 eration of the regional forms of the disorder. 
 
 Lotions. — Sedative and somewhat astringent lotions are useful in acute 
 eczema. Preparations of lime-water and opium and solutions of soda or borax 
 may be employed for this purpose, but the calamine-and-zinc lotion is the most 
 valuable of all such applications. (See Miliaria.) It should be applied by 
 means of cheesecloth cut into strips and bound on with a neat bandage. 
 If the itching be severe, from two to five minims of carbolic acid may be added 
 to each ounce of this mixture. 
 
 Lotions of carbolic acid are often indispensable to allay the tormenting 
 pruritus : 
 
 ~fy,. Acidi carbolici f^ss. 
 
 Glycerini TTLx. 
 
 Alcoholis f3J- 
 
 Aquae q. s. ad f^iv. — M. 
 
 Sig. Local use ; apply several times a day. 
 
 This may be used alone or in conjunction with other measures. 
 
 Chronic infiltrated patches of limited extent may be made to heal under 
 brisk friction with a tar-and-soap solution : 
 
 1^. 01. cadini f^ij. 
 
 Saponis viridis 
 
 Alcoholis ad f.^ij. — M. 
 
 This may be quickly rubbed in, then washed off with water, and the parts 
 covered over with unguentum vaselini plumbicum spread on cloth. The neces- 
 sity for such stimulating treatment does not often arise with children. 
 
 Powders. — In general acute erythematous eczema and in the forms of the 
 disease found between folds of the skin, powders are sometimes useful, but as 
 a rule other measures serve a better purpose : 
 
 ly. Pulv. amyli £v. 
 
 Zinci oxidi 3jss. 
 
 Pulv. camphorse 3ss. — M. . 
 
 Sig. Dust on with a puff. 
 
 fy- Thymol gr. j. 
 
 Pulv. zinci oleatis 3j. — M. 
 
 This is a good formula in mild cases of eczema intertrigo. 
 
 Ointments. — Salves are of especial value where there is crusting and 
 exudation, and since most cases are seen by the physician at this stage, it fol- 
 lows that they are more used than all other preparations together. To secure 
 success it is necessary that the ingredients should be fresh and that the oint- 
 ment should be thoroughly prepared. Soothing salves should always be spread 
 on suitable strips of muslin and bound on the parts, but when stimulation is 
 desired the remedy may be rubbed in with the finger. When it is desired 
 merely to protect the parts with a bland unguent, the unguentum aquae rosae is 
 very beneficial : a little bismuth (3ij-Ij) may be added with advantage. To 
 increase its astringency and to allay pruritus the following combination may be 
 advised : 
 
BISEJSES OF THE SKIN. 1107 
 
 R. Bismuthi subnitratis 3iv. 
 
 Zinci oxidi gss. 
 
 Acidi carbolici TTLx. 
 
 Yaselini 3ij. — M. 
 
 A standard preparation of great value is the unguentum vaselini plum- 
 bicirni : 
 
 E. . Emplastri diachyli 3ss. 
 
 Yaselini 3ss. — M. 
 
 These should be melted together by gentle heat and stirred until cold. In 
 subacute and moderately thickened eczema, and in the pustular form of the 
 disease, there are few better preparations. 
 
 In the great majority of cases of eczema in children, as ordinarily encoun- 
 tered — that is to say, cases in the subacute stage with slight infiltration and 
 intense itching — there is nothing comparable to the zinc-and-tar salve : 
 
 Ify. Zinci oxidi 3j. 
 
 Ung. picis liquidae . . gij. 
 
 Ung. aquae rosae 3ij. 
 
 Lanolini 3iv. — M. 
 
 Sis:. Local use. 
 
 - 
 
 This should be applied on strips of muslin, but, as children will not usually 
 submit to the face-mask or other bandaging, it does almost as well to smear it 
 on gently with the finger repeatedly during the day and night. To get good 
 results with this ointment it is absolutely essential that the prescription should 
 go to a pharmacist accustomed to the preparation of ointments. Under the use 
 of this ointment, so promptly does it relieve itching, the writer has been 
 enabled in a large measure to abstain from the harsh methods of physical 
 restraint sometimes advocated. 1 
 
 It is a safe rule even in seemingly chronic eczema to commence with one 
 of the milder preparations, but if the case prove obstinate, we may then proceed 
 to more stimulating applications, as follows : 
 
 1^. Hydrarg. ammoniati gr. x-xv. 
 
 Liq. carbonis detergentis Tftxx-f^ss. 
 
 Lanolini Ij. — M. 
 
 Sig. Apply two or three times daily. 
 
 1^. 01. rusci 3ss-j. 
 
 Ung. zinci oxidi 3j. — M. 
 
 Sig. To be rubbed into the parts. 
 
 1 Bulkley (Eczema and its Management) makes the following sensible remarks on the appli- 
 cation of ointments: " The first application of any ointment may be resisted by the child, and 
 may seem not to give relief; but if a suitable application has been selected, and if it is renewed 
 as often as it falls off or is brushed off, relief will soon be obtained, and the child who first 
 resisted the application will shortly crave it. This matter of the constant protection day and 
 night of eczematous surfaces from the irritating action of the air and external contact must be 
 insisted upon, and carried out at all hazards with rigid severity. Attendants will often neglect 
 it, and the application will often be intentionally removed in anticipation of the visit of the 
 physician, or when inconvenient on account of ordinary matters of daily life. A single neglect, 
 for even a short period, followed by scratching and irritation of the skin, can result in more 
 damage than can be repaired by long treatment." It may be added that a single washing of an 
 eczematous skin will be equally injurious. 
 
1108 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Pastes. — These preparations are very useful when there is neither too 
 much crusting nor too great infiltration ; moreover, they are very valuable 
 when an adhesive and protective application is required, as they are not readily 
 scratched off or washed away by secretions. They find their principal utility 
 in irritable papular and erythematous patches and in eczema intertrigo. Las- 
 sar's well-known formula is as follows : 
 
 ly. Acidi salicylici . . 3ss. 
 
 Zinci oxidi 
 
 Amyli dd 3vj. 
 
 Vaselini §ij. — M. 
 
 A small amount of tar may be added to secure greater stimulation. 
 This paste is also valuable : 
 
 fy. Resorcini gr. x-3j. 
 
 Lanolini 3ij. 
 
 Vaselini 3ij. 
 
 Zinci oxidi 
 
 Pulv. amyli da 3ij . — M. 
 
 Pick's linimentum exsiccans may also be mentioned under this head : 
 
 1^. Pulv. tragacanth gr. xv. 
 
 Glycerini Tt[xxiv. 
 
 Aquae f sj- — M. 
 
 The writer is in the habit of adding to this 10 to 15 per cent, of oxide of zinc 
 and 1 per cent, of carbolic acid or 3 to 5 per cent, of tar. Thus combined, 
 this preparation is of the greatest merit, particularly in cases similar to those 
 mentioned as suitable for pastes in general. The various glycerin jellies have 
 been almost entirely discarded in its favor. 
 
 Plasters. — The plaster and salve mulls of Unna, made by Beiersdorf of 
 Hamburg, are very beneficial in suitable cases. The salve mulls are made by 
 incorporating the required remedy, such as lead, mercury, zinc etc., with a 
 base made of benzoated suet and lard, and spread on one or both sides of 
 undressed muslin. The plaster mulls are made of gutta-percha faced with some 
 adhesive substance containing the remedy, and backed with muslin. The salve 
 mulls may be used in subacute cases when a fixed dressing is necessary ; the 
 plaster mulls are to be employed only when there is considerable infiltration. 
 In these latter cases the writer's modification of Pick's soap plaster does just 
 as well, and is much less expensive : 
 
 Ify. Empl. plumbi 3xxv. 
 
 Pulv. saponis Biv. 
 
 Aquae q. s. 
 
 Vaselini 3v. 
 
 Camphorae gr. xx. 
 
 Acidi salicylici gr. x-xx. — M. 
 
 Sig. Spread on strips of muslin and change once a day. 
 
 This plaster serves an excellent purpose for thickened patches of eczema on the 
 hands and feet. 
 
DISEASES OF THE SKIN. 1109 
 
 Paints. — Fixed dressings made with collodion or solution of gutta-percha 
 are of limited range of application, but may occasionally be used to advantage : 
 
 R. 01. nisei 3ss-j. 
 
 Collodii, vel liq. gutta-perchae fgj. — M. 
 
 Sig. Apply with earner s-hair pencil. 
 
 This may be painted on chronic patches of eczema about the mouth, both to 
 secure the healing effect of the tar and the protective action of collodion or 
 gutta-percha. 
 
 Prognosis. — The prognosis of infantile eczema is generally favorable, pro- 
 vided the nature of the disease and the fundamental principles of treatment 
 are thoroughly understood. That it is prone to relapse, like all catarrhal 
 inflammations, when exposed to the manifold exciting causes that are capable 
 of evoking it, must be admitted ; but with patience and perseverance, and the 
 hearty co-operation of parents in the general management, the physician is 
 usually rewarded in his efforts. While it is true that the tendency to relapse 
 decreases with age, the assurance often given that the disease will disappear at 
 certain specified periods — for example, at the cessation of dentition — is not 
 borne out by experience. There is a small minority of cases of eczema that 
 almost justifies the term " malignant." In such cases the disease commences in 
 childhood and recurs with greater or less frequency during life. Fortunately, 
 they are rare. 
 
 Treatment of the Regional Forms of Eczema. — Eczema of the Scalp. 
 — Remove crusts if present, and clip the hair. If the eruption is acute, apply 
 almond or olive oil with 1 per cent, of carbolic or salicylic acid. A bismuth 
 salve (3J-5J) is also soothing. After subsidence of the inflammatory symptoms 
 the tar-and-zinc ointment (Ify. Zinci oxidi, 3J ; Ung. picis liq., Ung. aq. rosos, 
 da 3ij ; Lanolini, 3iv. — M.) makes the best application. In children with little 
 or no pain the ung. vaselini plumb icum, spread on muslin, is efficacious. For 
 scaly eczema salicylic acid and sulphur give speedy result (1^. Acidi sali- 
 cglici, gr. x; Sulphuris prcecip., £ss ; Vaselini, ^j. — M.). If the eczema is 
 secondary to pediculosis, the pediculi and their nits must be first destroyed. 
 
 Eczema of the Ears. — The calamine-and-zinc lotion (Jfy. Zinci oxidi, oSS ; 
 Pulv. calamince prcep., Biv ; G-lycerini, f§j ; Liq. calcis, f^vij. — M.) is the most 
 suitable application for acute eczema of the auricle. Strips of cheese-cloth 
 should be wet with this solution and bound over the parts. The unguenturu 
 vaselini plumbicum spread on muslin is well adapted for subacute and chronic 
 cases. The cracked, infiltrated condition found behind the ears is frequently 
 cured after a brisk friction with the tincture of green soap (Ify. Saponis viridis, 
 Alcoholis, da §iv. — M.), followed by the lead-and-vaseline salve. (The reader 
 is referred to another section of this work for the treatment of eczema of the 
 auditory canal.) 
 
 Eczema of the Face. — The calamine-and-zinc lotion affords the best results 
 for very acute erythematous eczema of this region. In children, however, the 
 disease usually begins more insidiously, and when first seen the parts are gen- 
 erally raw and weeping and covered with crusts. These latter may first be 
 removed by oil inunctions or the immediate application of the ung. vaselini 
 plumbicum spread on muslin. This ointment may be continued, or the tar- 
 and-zinc salve above given may be substituted for it, or else used from the 
 beginning. As stated above, this is by far the best application for almost 
 all forms of infantile eczema. Of course the amount of tar may be increased 
 or diminished according to the effect. In slight patches, or toward the end of 
 
1110 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 a more pronounced case, Pick's paste (see above) with oxide of zinc and tar 
 may be smeared over and allowed to dry on. This makes a valuable protective 
 dressing, which is not readily scratched off. Lassar's paste is also of use 
 under these circumstances. When it is necessary to employ any of the oint- 
 ments above mentioned, it is best, if the child will allow it, that the muslin 
 strips upon which the salve is spread be kept in place by a light skeleton 
 mask. This is not necessary for the pastes. Chronic infiltrated areas may be 
 treated two or three times a day by working in a little mercurial-and-tar salve 
 (Ify. Hydrarg. ammoniati, gr. x ; Liq. earbonis deter g., Tttxv-f3ss ; Lanolini, 
 |j. — M.). Eczema about the mouth is slow to heal, owing to the movements of 
 the parts and the trickling of saliva and food over the inflamed surfaces. 
 Here some form of fixed dressing is indicated (Bp. Olei rusci, gss ; Collodii, 
 f§j), or one of the adhesive pastes just mentioned. 
 
 Eczema of the Lids. — Eczema of the surface of the lids is usually of the 
 erythematous type, and generally demands soothing measures, such as the 
 ointment of cold cream with a little oxide of zinc added to it. Eczema tarsi 
 occurs mostly in strumous children, and is a common sequela to the eruptive 
 fevers. Internally cod-liver oil and iron are invaluable, and locally the yellow- 
 oxide-of-mercury ointment is especially beneficial (Jfy. Hydrarg. oxidi flav., 
 gr. ij-viij ; Vaselini, 3j. — M.). 
 
 Eczema of the Umbilicus. — The disease in this region is often secondary 
 to seborrhoea, and is very intractable. Ung. vaselini plumbicum makes a good 
 application, but it is usually best to add five or ten grains of salicylic acid to 
 each ounce. Unna's diachylon salve mull is also to be advised. Duhring 
 suggests an ointment of oleate of zinc and calomel. Boracic acid is also 
 useful. 
 
 Eczema Intertrigo. — As a prophylactic measure infants should be kept 
 well dusted with some bland borated powder in those parts liable to the dis- 
 order ; that is, in the genital organs, under the neck, and in the axillae. When 
 the disease has become established, the affected surfaces should be washed as 
 little as possible, and protected with Lassar's paste (Tfy. Acidi salicylici, gr. 
 x; Zinci oxidi, Pulv. amyli, ad 3ij ; Vaselini, q. s. ad |j. — M.). Pick's lini- 
 mentum exsiccans, with 10 per cent, oxide of zinc and 1 per cent, carbolic 
 acid, is perhaps even better. 
 
 Eczema occurring in other regions of the body requires no special descrip- 
 tion, and should be treated upon the general principles set forth in the fore- 
 going sections of this article. 
 
 Lichen Planus. 
 
 As ordinarily encountered, lichen planus consists of an eruption of slightly 
 umbilicated, broad, flat, glazed, purplish-red papules with an angular outline. 
 The papules may remain discrete, or they may be arranged in groups, lines, or 
 bands. By coalescence of the lesions, variously sized, elevated, and sharply 
 defined patches decked with thin scales may be formed. The lesions leave in 
 their wake atrophic spots and distinct pigmentation. Pruritus is sometimes 
 slight or it may be very intense. 
 
 The eruption is generally bilateral, and the usual sites of predilection are 
 the flexor surfaces of the wrists, flanks, lower part of the abdomen, around the 
 knees, and on the calves. The face is usually exempt. The mucous mem- 
 branes may also be implicated. 
 
 The disease is rare in children, but Crocker describes an infantile form as 
 follows : " The eruption comes out acutely in groups, each papule of which is 
 
DISEASES OF THE SKIN. 1111 
 
 sometimes acuminate at first, but the top seems to die down and a scale comes 
 off, leaving a smooth, shining, angular papule, of a brighter red than usual, 
 though it may get a purplish tint subsequently. It may be on the limbs or 
 trunk, or both, is attended with considerable itching, and gets well in a few 
 weeks with the help of a soothing application." Rickets was present in some 
 cases, conjunctivitis and miliaria in others, while still others were in apparent 
 health. 
 
 Etiology. — The causes of lichen planus are obscure. In the acute infantile 
 form Crocker thinks that a sudden chill while in a profuse perspiration is the 
 
 exciting agencv. 
 
 Diagnosis. — If the characteristic and typical features of the lichen-planus 
 papule be kept in mind, it is not easy to make a mistake in diagnosis. Even 
 when the lesions have run together into patches, a few outlying angular umbil- 
 icated papules may be discovered. When, as sometimes happens, the usual 
 papular eruption is accompanied by an acute erythematous rash, the diagnosis 
 must be held in abeyance for the time being. 
 
 Prognosis. — Neglected cases are prone to run an indefinite course, but with 
 proper treatment a favorable issue may be expected. 
 
 Treatment. — In acute cases attention to diet and gentle laxatives and 
 diuretics may be beneficially prescribed ; and locally, calamine-and-zinc lotion, 
 with a little carbolic acid for the itching, will often speedily remove the erup- 
 tion. In chronic cases Fowler's solution, with or without iron, is of great value. 
 For external application tar in some form is of most benefit. The following 
 lotion does good: 
 
 Tfy. Saponis olivse prsep ,liv. 
 
 Olei rusci 
 
 Glycerini da fjj. 
 
 Olei rosmarini . . f^iss. 
 
 Alcoholis q.s. ad f^viij. — M. 
 
 Sig. Rub in with a piece of flannel. 
 
 A weak tar ointment with mercury is also serviceable : 
 
 ~fy. Hydrargyri ammoniati gr. x. 
 
 Liq. carb. detergentis fes. 
 
 Lanolini Ij. — M. 
 
 Sig. Apply twice daily. 
 
 Wilson recommended a bichloride-of-mercury lotion, and Unna extols an 
 ointment of carbolic acid and mercury. 
 
 Psoriasis. 
 
 Psoriasis is a chronic inflammatory disease of the skin, exhibiting lesions 
 of various sizes having red bases covered with white dry scales. The disorder 
 attacks the extensor surfaces by preference, especially in the neighborhood of 
 the elbows and knees, but it is also found elsewhere on the body, and almost 
 invariably on the hairy scalp. It is almost always symmetrical. The lesions 
 of psoriasis make their first appearance as minute pinhead-sized spots of con- 
 gestion that are slightly elevated and surrounded by normal integument. The 
 eruption, although discrete, is usually made up of multiple spots, which enlarge 
 peripherally to the size of large or small coins. The papules may then remain 
 
Ill 2 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 isolated, or they may run together, and in this way form patches of different 
 sizes and shapes, but possessing a general circular arrangement. Various 
 terms are used to designate the manifold shapes and sizes the psoriatic lesion 
 may assume — viz. : p. punctata, p. guttata, p. nummularis, p. circinata or 
 orbicularis, p. gyrata, and p. diffusa. Psoriasis nummularis, or the coin-like 
 form, is perhaps the most common variety ; but, whatever the shape or the 
 dimension of the lesions, the essential clinical features of the disease remain 
 unaltered. The lesions are infiltrated, and sharply defined against the unaffec- 
 ted skin, and they are covered with shining, mother-of-pearl, imbricated, easily- 
 detached scales, which upon being scraped off show a punctate bleeding surface. 
 
 The eruption has no discharge feature, and itching is either entirely absent 
 or very slight. The patches usually disappear by central involution, and in 
 this way rings and segments of circles may form. The eruption upon its dis- 
 appearance leaves no traces of its previous existence, except that there may be 
 slight pigmentation on the legs. The disorder is rare on the palms and soles, 
 but the nails are usually rough and brittle. The extension of the eruption 
 from the scalp to the forehead in the shape of a band along the border of the 
 hair is quite common. The hair suffers no permanent injury, and even tem- 
 porary alopecia is unusual. Children rarely suffer from the more pronounced 
 forms of the disease : in them the eruption is mostly discrete, and made up of 
 small lesions rather generally distributed over the body. The elbows, knees, 
 and scalp are the parts commonly first attacked. 
 
 Psoriasis is essentially a chronic affection, although at times having an 
 acute aspect. Repeated relapse is the rule ; in some cases, indeed, the patient 
 is practically never entirely free of the eruption, but usually longer or shorter 
 periods intervene between the outbreaks. It is, as a rule, worse in winter than 
 in summer. It not infrequently temporarily disappears during the course of 
 acute diseases. 
 
 Etiology. — Psoriasis is common to both sexes and to all conditions of life. 
 In this country it represents about 3 per cent, of all cases of skin disease. The 
 disorder makes its first appearance during childhood more frequently than is 
 generally supposed. It is not contagious. In many cases the fact of hereditary 
 transmission is readily established. The disease has been observed in connec- 
 tion with gout and rheumatism, and it may follow in the wake of scarlatina, 
 varicella, and vaccinia. In fact, our knowledge of its essential nature is obscure, 
 and we may assume, as in the case of eczema, that the psoriatic possesses a 
 specially vulnerable skin, and that his disorder may be evoked by a great 
 variety of widely-differing agencies. It may be added that Lang regards psori- 
 asis as due to a special parasite, while Polotebnoff looks upon it as a vaso-motor 
 neurosis. The histological investigations are contradictory. 
 
 Diagnosis. — Seborrhoea, eczema, and syphilis are the diseases that bear 
 the closest resemblance to psoriasis. In seborrhoea of the scalp the scales are 
 greasy and yellowish, and not dry and white, as in psoriasis, and the eruption 
 does not take the form of bands and patches, as in the latter disease ; more- 
 over, seborrhoea affecting the scalp may be limited to that region, whereas 
 psoriasis of the scalp will occur in connection with the same eruption on the 
 elbows and knees and other parts of the body. Seborrhoea of the body is not 
 necessarily symmetrical, and is found particularly about the sternal and inter- 
 scapular region, while psoriasis is nearly always symmetrically disposed, and 
 affects the elbows and knees in addition to other parts of the body. The 
 character of the scales is the same as in seborrhoea of the scalp, and they differ 
 altogether from those found in psoriasis. 
 
 Scaly or squamous eczema in patches sometimes strongly simulates psoriasis. 
 
PLATE XXV. 
 
 PSORIASIS. 
 (From the Collection of Geo. H. Fox, M. D.) 
 
DISEASES OF THE SKIN. 1113 
 
 but the patches of eczema are not symmetrically arranged, occur on the flexor 
 rather than the extensor surfaces, and the scales are light, tenacious, and do not 
 show a punctate bleeding surface when removed ; besides, eczema itches 
 markedly, and there is usually a history of discharge. 
 
 The scaling syphilides are not unlike psoriasis in a superficial way. The 
 history of the case must always be taken into consideration, and the presence 
 of concomitant symptoms noted. The scales of the squamous syphilide are 
 dirtier-looking and more adherent than in psoriasis, and the patch is usually 
 more infiltrated. Again, the fact that psoriasis is almost always found on the 
 elbows and knees on both sides of the body, and that the syphilide observes no 
 such localization, is to be kept in mind. 
 
 Prognosis. — The prognosis as to permanent cure is unfavorable, but it is 
 usually easy to remove the eruption temporarily. 
 
 Treatment. — Beyond remedying obvious defects of health and instituting 
 a rational system of diet, the internal treatment of psoriasis in children is mainly 
 restricted to the use of arsenic, which in this disease is of undeniable value. 
 As young children tolerate relatively larger amounts than adults, it may be 
 given in considerable doses without inconvenience. If the patient is angemic, 
 it may advantageously be combined with iron. (See formula under head of 
 Eczema.) If, however, the eruption is acute, the use of arsenic should be 
 deferred until the disease has assumed a less inflammatory aspect. 
 
 Before undertaking the local treatment it is necessary to remove the scales 
 thoroughly from the patches. In recent outbreaks this is best accomplished 
 by means of warm soda baths, followed by inunctions with vaseline. These 
 measures will sometimes alone be sufficient for the removal of the eruption. If 
 the disease has existed for some time, the scales may be taken off by scrubbing 
 with soap and water or by means of friction with salicylic acid and alcohol 
 (3j to fgiv). 
 
 Chrysarobin is by far the most efficacious remedy in psoriasis, but it must 
 be used very cautiously with children, as it sets up so much irritation. When 
 the eruption is sparse the following pigment may be tentatively employed : 
 
 1^. Chrysarobini gr. xx. 
 
 Acidi salicylici . gr. xx. 
 
 Liq. gutta-perchae f 3J- — M. 
 
 Sig. Apply with camel's-hair pencil. 
 
 This may be painted on every fourth day, a bath being taken at the end of this 
 period and before each reapplication. If this causes too much dermatitis, its use 
 should be intermitted for a season. The chrysarobin is, however, too severe 
 for some skins, and other remedies should be tried. Bulkley recommends the 
 following application : 
 
 Jfy. Acidi carbolici . . . gr. v. 
 
 (vel Resorcini, gr. x). 
 
 Bismuthi subnit 3ss. 
 
 Ung. hydrarg. ammon 3J-ij- 
 
 Ung. aq. rosse q. s. adgj. — M. 
 
 Sig. To be rubbed into affected parts. 
 
 For delicate skins it may need to be made weaker. 
 
 Greenough suggests the employment of a tar lotion consisting of equal 
 parts of alcohol, glycerin, and oil of cade. This prescription may also be con- 
 siderably diluted. 
 
1114 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Among other remedies may be mentioned thymol, naphthol, salicylic acid, 
 sulphur, and the mercurials. 
 
 Psoriasis of the scalp is best treated with an ointment of tar and mercury : 
 
 Jfy. Hydrarg. ammoniati gr. x. 
 
 Liq. carbonis detergentis Ulxx. 
 
 Lanolini 3j. — M. 
 
 Sig. Local use. 
 
 It is first necessary, however, to remove the scales with a green-soap shampoo, 
 consisting of 
 
 ]^. Saponis olivae praep. (Bagoe) .... 
 
 Spt. odorati da giv. — M. 
 
 Sig. Shampoo. 
 
 For psoriasis of the face nothing succeeds so well as a salve of white pre- 
 cipitate : 
 
 3^. Hydrarg. ammoniati gr. x-xx. 
 
 Ung. aq. rosse 3j- — M. 
 
 Sig. Local use. 
 
 Pemphigus. 
 
 Pemphigus is a very rare disorder. It is characterized by the appearance 
 of successive crops of variously-sized blebs. It may be acute or chronic, but as 
 ordinarily encountered it runs a chronic course. It is customary to speak of 
 two principal forms of the disease — viz. p. vulgaris and p. foliaceus — but the 
 nomenclature is encumbered with an infinite number of sub-varieties, partly 
 dependent upon the clinical appearances of the lesions, and largely also on the 
 imagination of the observers. 
 
 Pemphigus Vulgaris. — Constitutional symptoms are rare, but when the erup- 
 tion is widespread each outbreak may be preceded by a chill. The blebs usually 
 appear first as minute vesicles, but soon reach the maximum dimensions. They 
 are oval or hemispherical, tense, and vary in size from a pea to an orange, but 
 more generally are the diameter of a hazelnut or walnut. They may arise on 
 normal skin, or they are preceded at the point of eruption by a degree of 
 erythema. The contents of the lesions are at first clear, but gradually become 
 turbid, and sometimes even purulent. The life of a bleb is from two to ten 
 days ; it rarely ruptures spontaneously, but desiccates with a thin dry crust. 
 After the fall of the crust the site of the bulla shows slight excoriation, and 
 lastly more or less pigmentation. 
 
 Pemphigus may occur on any part of the body, but is more frequent on the 
 face, limbs, and trunk. The mucous membranes, including the alimentary and 
 respiratory tracts, may also be attacked. In the mild forms of the disease the 
 eruption may be kept up by successive crops, more or less continuous or markedly 
 intermittent, for weeks or months ; but in malignant pemphigus death may 
 ensue in a few weeks. 
 
 As to the existence of an acute pemphigus there has been considerable 
 difference of opinion. Undoubtedly there has been much confusion of diag- 
 nosis in this regard, and instances of bullous erythema, urticaria, varicella, 
 etc. have been so classified ; but the writer has convinced himself, from obser- 
 
DISEASES OF THE SKIN. 1115 
 
 rations made in infants' asylums and elsewhere, that an eruption bearing the 
 clinical features of pemphigus and running an acute course really occurs 
 among children. So good an observer as Crocker agrees in this opinion, and 
 says That there are grades of severity in the acute pemphigus of infants, from 
 the mild, usual type to cases in which those attacked die in a few days. On 
 the other hand, many of the so-called cases of pemphigus contagiosa undoubt- 
 edly represent varicella bullosa and impetigo contagiosa (Crocker). 
 
 Pemphigus foliaceus is rare even in adults, but Jamieson reports a case in a 
 child which followed the ordinary form. In this type of the disease the bullae 
 are flaccid, with cloudy contents, and display a sticky secretion when their 
 covers are removed. The whole body eventually becomes involved, and after 
 a time, when the bullous stage has passed away, the surface has the appearance 
 of an exfoliative dermatitis. 
 
 Etiology. — The disease is equally common in both sexes, and is met with 
 far more frequently in children than in grown persons. Pemphigus has been 
 observed in connection with a variety of different conditions, such as diseases 
 of the nervous system, disorders of nutrition, after local injury, etc. It also 
 occurs in the apparently healthy. An hereditary tendency to the malady has 
 been noted, and septic influences recognized. Morbid changes in the cord 
 and the peripheral nerves have been discovered in some cases. 
 
 Diagnosis. — The mere occurrence of blebs does not constitute pemphigus, 
 for lesions of this character are encountered in erythema, erysipelas, scabies, 
 syphilis, urticaria, and as the result of traumatism ; but in all these instances 
 the history of the case and the concomitant symptoms will usually establish the 
 points of difference. 
 
 Prognosis. — The prognosis must be guarded, as it is difficult to forecast the 
 ultimate outcome of any case ; still, in children at least and in the more acute 
 forms, a favorable termination may be expected. 
 
 Treatment. — In acute pemphigus an endeavor should be made to discover 
 the exciting cause or causes of the disease, and to meet such complications as 
 may arise in its course. In the chronic form of the disorder the strength 
 should be maintained by suitable nourishment. So far as direct medication is 
 concerned, arsenic is the chief reliance. It should be given in full doses, 
 freely diluted and frequently administered. According to Bulkley, the 
 quantity of the drug should be fearlessly increased until the disease yields or 
 until it causes diarrhoea or other evidences of disagreement. Opium, an 
 excellent remedy in itself for pemphigus, according to Hutchinson, may be 
 combined with the arsenic, or, if the latter is not tolerated, it may be given 
 alone. Fowler's solution and the deodorized tincture of opium are the best 
 preparations of the respective remedies. 
 
 Locally, the tense blebs may be punctured at their bases, so as to allow 
 their roofs to form a protective covering over the excoriated surfaces beneath. 
 Cloths dipped in lime-water and linseed oil, to which may be added 1 per cent, 
 of carbolic acid, make a good application. 
 
 The calamine-and-zinc lotion is sometimes grateful, or a powder of oxide 
 of zinc and lycopodium may be dusted on and covered with cotton wool. Raw 
 surfaces may be dressed with the following salve : 
 
 1^. Zinci oxidi 9j. 
 
 Ung. aq. rosse 3ij- 
 
 Lanolini 3vj. — M, 
 
 Two or three drops of carbolic acid may be added to each ounce of this oint- 
 ment. 
 
1116 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Herpes Simplex. 
 
 This affection, variously known by the names of herpes facialis, herpes 
 febrilis, fever blisters, and cold-sore, is an acute inflammatory disorder char- 
 acterized by the eruption of one or more groups of vesicles seated upon red- 
 dened bases. ' The vesicles come out abruptly, usually being preceded by sen- 
 sations of burning and tingling. Their contents are at first clear, but presently 
 — that is, in a day or two — become puriform, and the lesions dry up into light- 
 brown crusts which show no loss of substance upon being detached. The whole 
 process occupies eight or ten days. 
 
 The favorite sites of the eruption are the lips, the angles of the mouth, and 
 anywhere on the face below the forehead. The mucous membranes may also 
 be attacked. Herpes simplex is usually symptomatic of febrile disorders, and 
 is often preceded by chilly sensations ; in other cases it is due to gastric dis- 
 turbances or is produced by local irritation. Repeated recurrence is not an 
 uncommon feature. 
 
 Diagnosis. — This offers no difficulties. 
 
 Treatment. — Regulation of the diet and appropriate remedies for gastro- 
 intestinal disturbances are demanded in recurrent cases, but if there are no 
 obvious causal indications, small doses of Fowler's solution will probably do 
 good. Herpes symptomatic of general febrile states requires no treatment 
 other than that for the exciting cause. Locally, the vesicles should be pro- 
 tected from rupture, and this is best accomplished by painting them over with 
 flexible collodion or mopping on the calamine-and-zinc lotion. 
 
 Herpes Zoster, 
 
 Herpes zoster, zona, or shingles, is an inflammatory disease of the skin 
 which is characterized by grouped vesicles seated on reddened bases and fol- 
 lowing the distribution of cutaneous nerves. Although the eruption most 
 frequently occurs around the trunk in the course of the intercostal nerves, 
 it is well to remember that it may develop anywhere else, so that, for example, 
 according to the anatomical seat of the disorder, it will be designated as z. 
 capillitii, z. frontalis, z. ophthalmicus, z. nuchas, z. facialis, etc. 
 
 Before the eruption of the vesicles the patient may complain of considerable 
 pain in the part to be attacked, or there may be slight febrile reaction. The 
 lesions vary in size from a pinhead to a split pea, and by the coalescence of 
 one or more vesicles a quite considerable bulla may be formed. Their contents 
 are at first serous, in rare cases hemorrhagic, but presently become puriform. 
 It is characteristic of herpetic vesicles that they do not rupture spontaneously, 
 but in the course of some ten days to three weeks they desiccate into brown 
 crusts, which, falling off, exhibit a reddened surface and not infrequently slight 
 loss of substance. In children the neuralgic pain may entirely cease when 
 the eruption appears, or in severe attacks it may persist throughout. 
 
 In nearly every instance the eruption is unilateral, and but rarely recurs. 
 Zoster is usually a descending interstitial neuritis of the spinal ganglion, but 
 Kaposi points out that it may be of cerebral, spinal, ganglionic, or peripheral 
 origin. 
 
 Etiology. — Zoster is very common in young people, and is perhaps most 
 prevalent in the spring and autumn of the year. It is contended by some 
 authorities that this affection should be classed with the acute infectious dis- 
 eases. Hutchinson thinks that zoster is prone to develop during an arsenical 
 treatment. 
 
PLATE XXVI. 
 
 HRRPF.S ZO^TTTP 
 
DISEASES OF THE SKIN. 1117 
 
 Diagnosis. — The recognition of an ordinary case of shingles presents no 
 difficulties : the grouped vesicles following the distribution of cutaneous nerves, 
 the neuralgic pain. etc. are sufficiently patent symptoms. There are two points, 
 however, worth remembering — viz. first, that zoster occurs elsewhere than 
 around the trunk ; and, secondly, that sometimes there are abortive forms — 
 that is. merely reddened patches or clustered papules that do not become 
 vesicular; but in both instances the grouping and distribution of the eruption 
 are the same, as is also the pain. 
 
 Prognosis. — In children the prognosis of zoster is always favorable. 
 
 Treatment. — Zoster is an acute self-limited disease, which, however, runs 
 a very variable course, and conclusions as to the value of internal medication in 
 its treatment are, therefore, usually fallacious. It is idle to attempt to abort 
 an attack by remedies in our possession, and such treatment is restricted to the 
 relief of pain. As a rule, children suffer but little inconvenience in this latter 
 regard, and a few appropriate doses of phenacetin at night are ail that is 
 required. 
 
 Some writers believe that it is possible to limit the amount and duration of 
 the eruption by local measures. Duhring advises a weak galvanic current, and 
 Leloir praises pure alcohol or alcoholic solutions of certain drugs for this pur- 
 pose : 
 
 ]$>. Alcoholis (90 per cent.) f^j. 
 
 Resorcini gj. — M. 
 
 ^. Alcoholis (90 per cent.) . . ... . . . f§j. 
 
 Menthol gr. xv. 
 
 Ext. cannabis Indicae gr. xxv. — M. 
 
 Pads made of wadding are to be wet with these solutions and frequently 
 applied. 
 
 The essential point of treatment is to prevent the vesicles from rupture. 
 Flexible collodion, with or without a little morphia, makes an excellent pro- 
 tective dressing and gives marked relief. Pick's paste, the linimentum 
 exsiccans, is also excellent when made as follows : 
 
 Ify. Zinci oxidi gr. xlviii. 
 
 Acidi carbolici Tttx. 
 
 Tragacanthae gr. xxiv. 
 
 Glycerini ttlx. 
 
 Aquae f^i. — M. 
 
 Sig. Smear gently over the parts, and allow to dry on. 
 
 Various bland dusting powders, such as oxide of zinc, corn starch, and 
 rice powder, are also useful. It is well to protect the parts with absorbent cot- 
 ton and a bandage to prevent friction. Ointments should never be prescribed, 
 as they are prone to macerate the vesicles and thus produce ulceration. Should 
 ulceration occur, it may be treated on general surgical principles. Persistent- 
 neuralgia following zoster is very unusual with children, but, should it super- 
 vene iron and arsenic may be given internally and galvanism applied locally. 
 
 Impetigo Contagiosa. 
 
 Impetigo contagiosa is an acute contagious disease of the skin characterized 
 by the appearance of vesico-pustules or bullae. In some cases the eruption is 
 
1118 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. 
 
 preceded by slight fever, but more often this symptom is absent. Crocker is 
 authority for the statement that in the febrile cases the eruption appears in 
 successive groups for about a week, but that when unattended by elevation of 
 
 Fig. 1. 
 
 Impetigo Contagiosa (after Lesser). 
 
 temperature the cutaneous manifestations are more limited, and the course of 
 the affection is less ' definite. 
 
 The lesions begin as small, isolated, acuminate vesicles that slowly increase 
 to the size of a split pea or silver quarter-dollar, that are surrounded for a short 
 time by a slight erythematous halo. The contents, at first serous, soon become 
 sero-purulent, and the fully-formed flat or slightly umbilicated vesico-pustule 
 dries to a thin, straw-colored granular crust. As by this time the erythematous 
 ring around the lesions has faded away, the crusts have the appearance of being 
 " stuck on" (T. Fox). When the crusts drop off the underlying surface is red 
 and has the appearance of a burn, but there is no loss of substance. 
 
 Jackson calls attention to another variety of the disease, in which the 
 lesions consist of large blebs of an irregular oval shape and several inches long, 
 but usually other typical forms are found elsewhere. 
 
 Impetigo contagiosa is generally seen on the face and hands. The lesions 
 may be discrete or else coalesce into patches. Itching is not marked. The 
 disorder runs no special course ; it may last two or three weeks, or by repeated 
 auto-inoculations a considerably longer time. 
 
 Etiology. — Children are the usual subjects. It is contagious, and often 
 many children in the same house or neighborhood, especially among the indigent, 
 are simultaneously attacked. The writer has known of dozens of cases in a 
 single poor settlement. It is apt to appear in summer. A number of different 
 fungous elements have been described as occurring in the crusts, but definite 
 results are lacking. By some authorities the affection has been ascribed to 
 pus-inoculation from any source, but the clinical facts do not bear out this con- 
 
DISEASES OF THE SKIN. 1119 
 
 tention. Its connection with vaccinia has been remarked, but this is perhaps 
 accidental. 
 
 Diagnosis. — The presence of large, generally discrete, slightly umbilicated, 
 non-pruritic vesico-pustules, occurring on the lower part of the face or on the 
 hands, is generally sufficiently distinctive for purposes of diagnosis. Bearing 
 these symptoms in mind, it is usually easy to exclude pustular eczema, chicken- 
 pox, and pemphigus. Even when the lesions have run together into patches, 
 or the large bullous form predominates, a few at least of the more usual vesico- 
 pustules may be found. 
 
 Prognosis. — Favorable under proper treatment. 
 
 Treatment. — The removal of the eruption is comparatively easy. A weak 
 preparation of mercury generally suffices : 
 
 1^. Hydrarg. ammoniati gr. x-xv. 
 
 Ung. zinci oxidi §j. — M. 
 
 Sig. Apply to lesions after removal of the crusts. 
 
 To prevent auto-inoculation it is a good plan to smear boric-acid paste over 
 the intervening skin : 
 
 ~Sy. Acidi boraci 3ss. 
 
 Pulv. amyli 3ij. 
 
 Zinci oxidi £ij. 
 
 Vaselini q. s. ad gj. — M. 
 
 Dermatitis Exfoliativa Neonatorum. 
 
 Bitter has called attention to a severe form of exfoliative dermatitis that 
 occurs between the second and fifth weeks of life. It is apparently non-con- 
 tagious and unaccompanied by fever. The affection begins around the mouth 
 as an erythema, and extends to the rest of the body. The surface has the ap- 
 pearance of an extensive burn, and the epidermis exfoliates after some amount 
 of fluid has accumulated beneath it. In some cases the eruption resembles an 
 eczema, in others a pemphigus ; or, again, when it is limited, it is dry through- 
 out, and the skin becomes infiltrated and fissured. The whole process lasts 
 about a week. Often it is followed by eczema, furunculosis, and gangrenous 
 processes. Death results in one-half the cases. Bitter regards the disorder as 
 of septic character, while Behrend thinks it is merely a foliaceous pemphigus. 
 The treatment is symptomatic. 
 
 Other forms of exfoliative dermatitis may occur in children either as primary 
 or secondary processes, but they are unusual. Belapsing scarlatiniform erythema, 
 which is in reality an acute exfoliative dermatitis, has been already described. 
 
 Dermatitis Gangrenosa Infantum. 
 
 Gangrene of the skin is not uncommon in strumous and syphilitic chil- 
 dren, especially following in the wake of chicken-pox and vaccination, and 
 also developing from simple pustular affections. The disorder varies in 
 intensity : in some instances the gangrenous patches are widespread and 
 numerous, with high temperature and a rapid lethal ending, or, on the other 
 hand, there may be present a series of small pustules, each of which sloughs 
 and leaves a small scar, and the disease may be prolonged indefinitely by 
 successive crops (Pringle). As stated elsewhere, T. C. Fox regards the vari- 
 
1120 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cella-prurigo of Hutchinson as in reality a form of urticaria. Secondary gan- 
 grene of the skin is comparatively rare in this country, even in the infant asy- 
 lums, and the writer has never met with a case in private practice. 
 
 Treatment. — The general treatment consists in the administration of ton- 
 ics, such as iron, quinine, and the hypophosphites, with cod-liver oil. Good 
 food and proper hygienic surroundings are. essential adjuncts. Locally, it is 
 necessary to employ the usual antiseptic dressings. 
 
 Urticaria. 
 
 Urticaria, nettlerash, or hives, is characterized by evanescent efflorescences 
 called wheals or pomphi, which come out suddenly, retain their forms for a 
 few minutes or several hours, and as suddenly disappear, leaving no trace 
 behind. The lesions usually vary in size from a pea to the diameter of the 
 finger-nail, or they may be much larger. Wheals are generally oval or 
 circular in shape, but also occur in bands or streaks, and observe no special 
 grouping. They are somewhat elevated above the general surface, are flat, and 
 present a sense of resistance to the touch. They are usually white in the cen- 
 tre and bright-red or pink at the periphery. The mucous membranes may 
 also be attacked. The eruption is accompanied by intense burning, itching, and 
 tingling. There may be considerable febrile disturbance accompanying the 
 outbreak in the skin in acute cases, or there may be a day or two of malaise, 
 with coated tongue and other evidences of indigestion, before the rash appears. 
 Sometimes no deviation from the normal condition can be detected. 
 
 The type of the disease most commonly seen in young children is the papu- 
 lar — urticaria papulosa or lichen urticatus. In these instances, as a result of 
 the inflammatory effusion, a small solid papule remains after the disappearance 
 of the more evanescent wheal. In many cases the urticarial element is not 
 manifest to a casual inspection, and the only visible lesions are white or pale- 
 red miliary, scratched papules, more or less discretely scattered over the sur- 
 face. The eruption is accompanied by intense itching, usually worse at night. 
 Interspersed among the papules, various crusted and excoriated lesions, the 
 result of scratching, may be detected. 
 
 T. C. Fox. says that while the usual lesion is papular, it may be vesicular, 
 pustular, or bullous as a result of the evolution of the lesion itself, and not as 
 a secondary result of irritation. He claims, moreover, that Bateman's lichen 
 urticatus, Hutchinson's varicella-prurigo, the infantile prurigo of the English, 
 and many of the papular, vesicular, and pustular rashes following vaccination, 
 should be included as phases of infantile eczema. 
 
 In addition to the usual form of the disease just described, several other 
 varieties are observed. The titles are sufficiently descriptive — viz. urticaria 
 papulosa, u. tuberosa, u. vesiculosa or bullosa, u. hcemorrhagica, and, in cases 
 artificially produced by scratching or other irritation, u. factitia. 
 
 Etiology. — The exciting causes are very numerous, and may be of central, 
 peripheral, or reflex character, acting upon the vaso-motor system. The wheal 
 is probably brought about by a spasmodic contraction of the capillaries, which 
 in return is followed by relaxation and consequent serous effusion. Among 
 the local causes may be mentioned bites of insects, coarse under-clothing, and, 
 in fact, irritants of any sort. 
 
 Grastro-intestinal derangement occupies the first place among the indirect 
 causes of urticaria. Many foods have a bad reputation in this regard, such as 
 oatmeal, buckwheat cakes, pork, pastry, and especially strawberries. Intes- 
 tinal worms often excite the disease in children. Malaria is known to set up 
 
DISEASES OF THE SKIN. 1121 
 
 an intermittent type of the disorder. Many medicines also induce it, especially 
 the preparations of cinchona. While it is true that in dispensary practice the 
 papular urticaria of infancy is often caused by bites of insects and other irri- 
 tating local influences, the writer believes that the majority of cases are due to 
 gastro-intestinal disturbances the result of injudicious diet. 
 
 Diagnosis. — The ordinary type of urticaria is readily recognized. Occa- 
 sionally, when the eruption occupies the greater part of the body in continuous 
 sheets and with accompanying fever, scarlatina may be suggested ; but the his- 
 tory of the case, the absence of the scarlatinal throat implication, and the dis- 
 covery of isolated urticarial wheals somewhere on the body will usually clear up 
 the diagnosis. 
 
 Papular urticaria, especially if commingled with ecthymatous lesions, bears 
 a close likeness to scabies ; but the localization of the eruption in the latter 
 disease, the absence of burrows, and the freedom of other members of the same 
 family from a similar eruption furnish sufficient grounds for the distinction. 
 
 Prognosis. — The prognosis of the acute cases is favorable if properly 
 managed. Papular urticaria is exceedingly obstinate often lasting for months, 
 but even these cases eventually get well. 
 
 Treatment. — In all cases the cause must be assiduously sought out, and, 
 if possible, removed. Acute attacks are generally due to gastric disturbance 
 from injudicious diet, and a brisk emetic, followed by a laxative, will be apt to 
 bring about a speedy recovery. The more persistent attacks, kept up by 
 repeated exacerbations, are rare in children. Above all, the diet must be care- 
 fully regulated. Quinine is of much value when malaria is suspected. Phena- 
 cetin will often cut short an attack. The usual empirical remedies, such as 
 atropine, ergot, pilocarpine, and salicylate of sodium, are scarcely demanded. 
 
 In the chronic papular form it is first necessary to remove all sources of 
 external irritation, and, secondly, to clearly indicate the proper method of diet 
 to be pursued. Constipation should be relieved, and appropriate remedies 
 prescribed for any gastric irregularity that may be present. 
 
 There is a great variety of measures recommended for the local treatment. 
 Among the household remedies may be mentioned lotions of soda, vinegar 
 (pure or diluted), and the application of cologne-water or other spirits. The 
 calamine-and-zinc lotion, as previously given, with carbolic acid (gr. ij to f ^i) is 
 especially valuable. Menthol in solution (^ss-f^iv) is also a good antipruritic. 
 
 In lichen urticatus the same preparations may be employed. Fox recom- 
 mends the following : 
 
 ]^. Liq. plumbi subacetatis f^ss. 
 
 Liq. carbonis detergentis f^ijss. — M. 
 
 Sig. Add a teaspoonful to a pint of water. 
 
 The same authority advises a dilute white-precipitate ointment or paste for the 
 pustular form. 
 
 Urticaria Pigmentosa. 
 
 This is a rare form of disease, only a few cases having been observed in this 
 country. It begins within the first six months of life in the form of wheals 
 that come out suddenly, singly or in numbers. The lesions are brownish-red, 
 split-pea sized tubercles, and in the beginning are surrounded by a delicate pink 
 areola ; subsequently, however, they increase in size and assume a buff color. 
 
 The course of the disease is chronic, and while the first lesions are under- 
 going involution new ones are constantly forming, so that all the varied stages 
 71 
 
1122 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 can be seen at the same time. Urticaria pigmentosa affects principally the 
 trunk and neck, then the head, face, and limbs. It may or may not itch. 
 In the pruritic variety factitious urticaria is common. The disease is usually 
 arrested at puberty. 
 
 The cause of the affection is unknown, and the treatment purely symp- 
 tomatic. 
 
 Pityriasis Rosea. 
 
 Pityriasis rosea is a trivial disorder, its only special importance arising 
 from the liability to confound it with grave affections. It is claimed by 
 some writers that the cutaneous eruption is preceded by some elevation of 
 temperature, but this symptom is by no means constant. Brocq states that 
 he has observed that the more general eruption is preceded by a single patch 
 that makes its appearance about the waist, neck, or arm. The lesions in the 
 beginning are minute pinkish papules, which soon enlarge into circular or 
 oval macules having slightly depressed centres and a defined raised border. 
 They are covered with somewhat greasy yellowish or yellowish-white scales. 
 When the patches, by peripheral extension, have reached a diameter of 
 one-half to three-quarters of an inch, the centre assumes a yellow-parch- 
 ment hue, while the extending scaly margins are distinctly reddish. The 
 patches may remain discrete, or they may run together and produce irregular 
 gyrate areas : these bizarre outlines are also formed by the central recovery and 
 peripheral extension of the single lesions. The skin is but little thickened, 
 and pruritus is, as a rule, insignificant. The eruption is usually found on the 
 trunk, but it may migrate over the body generally with the exception of 
 exposed parts. Papules, ringed patches, and patches that are undergoing 
 involution may be present at one and the same time. The disorder is self- 
 limited, and tends to spontaneous recovery in from two weeks to two months. 
 
 Etiology. — English and continental writers state that this affection prin- 
 cipally attacks young children, but this is not true in the writer's experience, 
 although he has been brought much in contact with the skin diseases of infants 
 and young persons. It occurs in quasi-epidemics, especially in the spring and 
 fall, but considerable differences of opinion exist as to its contagiousness, and 
 neither has its parasitic nature been satisfactorily demonstrated. 
 
 Diagnosis. — Pityriasis rosea is distinguished from the scaling circinate 
 syphilide by its more inflammatory color and the absence of pigmentation ; 
 besides, along with the syphilide would be found other evidences of syphilis. 
 Its resemblance to seborrhcea of the body is superficially close, but in sebor- 
 rhea the eruption is usually found only over the sternum and between the 
 shoulders, while in pityriasis rosea it is not so limited ; moreover, the scales of 
 seborrhcea are thicker and greasier, and there is often a history of considerable 
 chronicity. Pityriasis rosea differs from ringworm in its wider distribution, 
 the absence of papules, vesicles, or pustules from the borders of the patches, 
 and the absence of the tricophyton fungus in the scales. 
 
 Prognosis. — The disease undergoes spontaneous arrest within from a fort- 
 night to two or three months. 
 
 Treatment. — Internal treatment is useless ; indeed, treatment of any sort 
 is unpromising. The calamine-and-zinc lotion is agreeable when itching is a 
 symptom, and ointments of sulphur and boracic acid may be prescribed. A 
 pigment of salicylic acid has seemed to be serviceable : 
 
 Tfy. Acid, salicylici gr. x-xv. 
 
 Liq. gutta-perchae flj. — M. 
 
DISEASES OF THE SKIN. 1123 
 
 Prurigo. 
 
 Prurigo is a chronic inflammatory disease of the skin characterized by 
 an eruption of pale papules accompanied by severe itching. This disease 
 begins in infancy, the lesions first consisting of urticarial wheals, to which 
 the papules succeed. The papules are quite small, and, as it w r ere, bur- 
 ied in the skin, so that they are more easily felt than seen ; their color is in 
 the beginning that of the surrounding skin, but in time, as the result of 
 scratching, they become of a darker hue. The most noticeable feature of 
 prurigo is the intense itching, which at times becomes unbearable. The dis- 
 ease is most marked upon the extensor aspects of the limbs, while the flexor 
 surfaces, the genitals, the scalp, and the face are rarely attacked. 
 
 Various secondary changes in the skin are to be noted, such as infiltration, 
 pigmentation, desquamation, etc. A severe form of the malady (prurigo ferox) 
 is marked by intercurrent attacks of wheals, severe dermatitis, pustulation, 
 scabbing and deep pigmentation, and enlargement of the lymphatic ganglia, 
 especially those of the groin. 
 
 In a few cases prurigo directly causes death by the constant worry and loss 
 of sleep, setting up a condition of marasmus ; but usually it is not fatal. 
 
 Etiology. — By some writers prurigo is regarded as a neurosis of the skin. 
 Others do not admit it is an entity, but think it only a group of symptoms 
 caused by the action of various irritants upon a sensitive skin. Prurigo is 
 mainly found among the poor, who cannot have its earlier manifestations treated. 
 The disease is not so rare in this country as it was at one time supposed, 
 a number of cases having been recently reported by Zeissler. 
 
 Diagnosis. — Unless the whole course of the disease be taken into consider- 
 ation, together with the lesions actually present at any one time, there is danger 
 of confounding prurigo with eczema, scabies, and pediculosis. Careful atten- 
 tion to the history and to the situation of the lesions will usually enable a 
 diagnosis to be made. 
 
 Prognosis. — The earlier in a case treatment is begun, the better the chance 
 of cure. In cases of very long standing, though a cure may not be effected, 
 the condition may be much benefited. 
 
 Treatment. — The diet should be carefully regulated, all those articles which 
 are calculated to provoke a nettle-rash being eliminated. 
 
 The general health will often demand tonics and cod-liver oil. Some cases 
 seem to have improved under arsenic. Bromide of potassium, carbolic acid, 
 cannabis Indica, and the salicylates have been used for their effect upon the 
 itching. Pilocarpine and atropine are both well recommended, but since they 
 act best when given hypodermatically, they are rarely ever used in children. 
 
 Locally, bathing in quite warm baths, followed by the inunction of an 
 ointment, w T ill probably yield the best results. The ointment may contain tar, 
 sulphur, naphthol, or salicylic acid in quantities varying with the condition 
 of the patient. 
 
 Furunculus. 
 
 A furuncle is a circumscribed phlegmonous inflammation occurring about 
 a hair-follicle or a gland of the skin. The appearance of a boil may be 
 preceded by a slight tingling or itching of the skin. In a short time 
 a small red papule will be noticed, which is very sensitive to pressure and 
 is accompanied by a burning sensation. The skin immediately around the 
 papule becomes hard and swollen, and thus a hemispherical nodule is formed, 
 varying in size from a pea to a walnut. The color of the boil itself is a 
 
1124 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 dull red or purplish, while the skin in the immediate neighborhood is of a 
 brighter red. The furuncle at this stage is firm and hard to the touch, very 
 tender, and accompanied by a dull throbbing pain. Within a week or ten 
 days pus accumulates in the boil, and if it is not opened the skin ruptures, 
 giving exit to a more or less free discharge. Lying in the centre of the fur- 
 uncle is now exposed the core, a whitish necrotic mass, which if left alone 
 comes away of itself in a few days. As soon as the pus is evacuated the pain 
 in a boil ceases, and when the core has separated the hardness in the surround- 
 ing skin gradually disappears, while the small cavity remaining fills by granu- 
 lation. A scar results, which is at first of a violaceous hue, but in time becomes 
 white. Occasionally a boil stops short of suppuration and resolves : this is 
 known, in popular parlance, as a blind boil. 
 
 Furuncles may occur singly, or numbers may be on the body at the same 
 time. In some cases the affection is indefinitely prolonged by the appearance of 
 one crop after another, constituting the condition known as furunculosis. Boils 
 may occur on any part of the body except on the palms and soles. In children 
 they are common on the back, the head, the eyelids, and in the axilla. When 
 a boil occurs in a ceruminous gland in the auditory canal, there is great pain 
 on account of the denseness of the tissues in that region. 
 
 When boils are single or in small numbers, there is, as a rule, no constitu- 
 tional disturbance, but in furunculosis appetite and flesh may be lost, while 
 sleep is disturbed by the pain. 
 
 A furuncle always commences about a hair-follicle, a sebaceous gland, or a 
 sweat-gland. The severe inflammation causes the death of the follicle or 
 gland, which then constitutes the core. 
 
 Etiology. — Boils may be the result of local injury, such as bruising or 
 pressure, as on the buttocks from prolonged sitting. They often occur in 
 depraved conditions of health, as after scarlatina or measles. In summer they 
 often accompany prickly heat. Boils are contagious under certain conditions, 
 such as sleeping in the same bed with a person affected. They may arise dur- 
 ing the course of any pruritic disease, probably from inoculation of the skin 
 by scratching. The pus from a boil will produce other boils if inoculated upon 
 another part of the body or upon another person. The virus may be carried 
 from one person to another by flies. These facts, together with the observation 
 that pus-cocci are always found in boils, seem to warrant the conclusion that the 
 disease is due to the presence of a micro-organism. 
 
 Diagnosis. — The only disease of infancy with which furuncle is apt to be con- 
 founded is that rare syphiloderm described by Barlow, in which several circum- 
 scribed abscesses in the skin occur ; but here the inflammatory symptoms will 
 be less severe, other symptoms of syphilis will be present, while the abscesses 
 possess no core. In children carbuncle is a rare affection, and can be differ- 
 entiated from furuncle by the fact that it has several centres of suppuration, 
 which in turn become so many openings. 
 
 Prognosis. — The prognosis of furunculus is, as a rule, favorable. Whenever 
 suppuration occurs permanent scarring is the result. In furunculosis the 
 prognosis must be guarded, as in some cases successive crops of boils occur in 
 spite of the best-directed therapeutic efforts. 
 
 Treatment. — In the treatment of furuncle the first step is to look for and 
 to correct any condition of general health which might act as a predisposing 
 cause. All local conditions which may be presumed to favor the development 
 of boils should be removed. 
 
 Various remedies, such as yeast, sulphide of calcium, hypophosphite of 
 sodium, have been advised for internal administration in the treatment of 
 
DISEASES OF THE SKIN. 1125 
 
 furuncle, but their effect upon the local condition is, to say the least, proble- 
 matical. A great many different drugs have been recommended as possessing the 
 power to abort boils : the apex may be cauterized with a solid stick of nitrate 
 of silver : Guigeot advises painting with tincture of iodine till quite a thick 
 layer covers the boil ; boric acid in saturated solution may be frequently 
 sprayed upon the affected surface, and by this means some authorities claim 
 excellent results ; the following formula is given by Jamieson : 
 
 §.. Tr. iodi fsj. 
 
 Acidi tannici 3ss. 
 
 Pulv. acacias 3ss. — M. 
 
 This mixture is to be painted upon the boil and the surrounding skin in 
 successive layers, each one being allowed to dry before the next is put on, till 
 a thick coating is obtained. Unna's carbolic-acid-and-mercury plaster will 
 sometimes cause a boil to disappear : a piece of the mull a little larger than the 
 boil, with its centre cut out to avoid pressure on the sensitive apex, should be 
 applied, and renewed every twenty-four hours. Hypodermatic injections into 
 and around the boil, as well as electrolytic puncture, may succeed in arresting 
 the process, but these methods are too painful to be of use in children. 
 
 One of the best methods of treating a boil consists in applying a pledget of 
 absorbent cotton saturated with 2J per cent, carbolic-acid solution, over 
 which is placed a piece of rubber tissue large enough to cover the cotton and 
 a small area of the surrounding skin ; even if this does not prevent suppura- 
 tion, it will be found to give relief. 
 
 Poultices in their ordinary forms are to be entirely discarded, as they favor 
 the development of other boils around the ones to which they are applied. 
 
 The skin for some distance around a furuncle should be frequently anointed 
 with an antiseptic ointment, to prevent the inoculation of the neighboring hair- 
 follicles. The following is an appropriate formula : 
 
 1^. Acidi boraci gr. xx. 
 
 Zinci oxidi 3ij. 
 
 Lanolini |j. — M. 
 
 As soon as pus is collected in a boil a free opening should be made, the 
 cavity washed out with some antiseptic solution, then dusted with iodoform, and 
 an antiseptic dressing applied. 
 
 In the treatment of furuncles in the auditory canal, Cholewa recommends 
 inserting into the ear a plug of absorbent cotton which has been moistened 
 with a 20 per cent, solution of menthol in olive oil. Spencer inserts a cotton 
 plug, having first applied to the boil an ointment of extract of arnica, extract 
 of belladonna, and morphine. 
 
 HEMORRHAGES. 
 
 Purpura. 
 
 The term "purpura" is applied to certain conditions in which haemor- 
 rhages occur in the skin or mucous membranes. The lesions of purpura may be 
 of a bright red or of a livid bluish hue. They do not disappear upon pressure. 
 The individual haemorrhages vary much in size, and from this fact various 
 names have been applied to them, as petechias, where the extravasations occur 
 
1126 AMEBIC AN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 in the form of minute points ; vi bices, where they occur as streaks ; ecchymoses, 
 where they occur as larger spots or blotches. At times haemorrhages are com- 
 bined with other lesions of the skin ; thus we may find blood eifused into a 
 papule or a bulla. Occasionally blood finds its way into the sweat-glands, 
 whence it is extruded along with the perspiration, giving to it a hemorrhagic 
 appearance — haematidrosis. 
 
 Haemorrhages occur in the skin under such manifold conditions that any 
 classification upon an etiological basis is impossible. Clinically, three forms 
 are found with sufficient frequency to warrant a description as special diseases. 
 The mildest form in which the affection occurs is known as purpura simplex. 
 The person affected is usually in good health when the disease manifests itself: 
 the lesions appear suddenly upon any part of the body — in children especially 
 about the neck, upper portion of the trunk, and arms. The eruption is com- 
 monly made up of petechiae, though streaks and larger spots may also occur. 
 The haemorrhages usually remain discrete, and when sufficiently copious may 
 cause a slight elevation of the skin. The duration of the disease is prolonged 
 by the repeated appearance of fresh crops of the lesions. Each crop, as resorp- 
 tion occurs, passes through the different changes in color that we remark in a 
 bruise. There are no subjective symptoms. The condition is most likely to be 
 confounded with flea-bites. 
 
 In purpura rheumatica the extravasation of blood into the skin constitutes 
 the most remarkable feature of the disease, and for this reason it is classed 
 among haemorrhages. The appearance of the skin affection is preceded by 
 malaise ; pain in the joints is complained of, and frequently swelling may be 
 detected. After a day or two a petechial eruption shows itself upon the sur- 
 face. In its general characters this eruption does not differ from the lesions 
 found in purpura simplex, except that there is a tendency to localization about 
 the affected joints. The disorder may be indefinitely prolonged by relapses, and 
 sometimes passes into a condition simulating purpura haemorrhagica. The 
 heart may become implicated during the course of the malady, with a resulting 
 lesion of the valves. Henoch and Couty have described a form of purpura 
 which occurs most frequently in children, and is characterized by pains in the 
 joints, vomiting and intestinal pain, and a localized oedema of the skin. 
 (See Purpura Haemorrhagica.) While purpura rheumatica is at its height 
 there is often a moderate rise in temperature. 
 
 The most severe form in which purpura occurs is as purpura haemorrhagica 
 (morbus Werlhofii). In this affection we find, in addition to the phenomena 
 of purpura simplex, bleeding from various mucous membranes and haemor- 
 rhages into various internal organs. The disease may develop suddenly or be 
 preceded by symptoms of an indefinite kind, such as headache, loss of appetite, 
 lassitude, etc. The haemorrhages into the skin are frequently larger than 
 those found in purpura simplex, and effusion of blood occurs also in the mucous 
 membranes, as indicated by its escape from the mouth, nose, anus, vagina, and 
 urethra. Bleeding occurs also in the parenchyma of the organs, and when the 
 brain is thus affected speedy death may result. The serous cavities often con- 
 tain blood. 
 
 The disease is usually accompanied by a moderate fever. When the amount 
 of blood lost is not large, recovery may follow, but relapses are not uncommon. 
 
 For purpura haemorrhagica as it occurs in the new-born the designation 
 purpura neonatorum has been given. The disease hardly warrants a special 
 description, since it presents symptoms similar to those found in purpura 
 haemorrhagica, its only point of distinction being that it occurs within the first 
 few days of life. 
 
i DISEASES OF THE SKIN. 1127 
 
 Etiology. — In those cases in which haemorrhage into the skin is merely a 
 secondary or symptomatic phenomenon a cause for the affection can often be 
 ascribed. Illustrations of such cases would be the purpura that often occurs 
 with the specific fevers, as measles, scarlatina, and malaria ; or where certain 
 drugs, such as quinine or iodide of potassium, have been ingested ; or in 
 cases where we may be able to determine some decided obstruction to the blood- 
 current, as some valvular heart trouble ; or where a congenital or acquired 
 weakness of the vessel-walls may be supposed to exist, as in haemophilia, 
 rickets, or syphilis. In those cases in which the effusion of the blood seems 
 to constitute the chief feature of the disease the etiology is far from being 
 definitely determined. In that form which manifests itself in the new-born 
 babe it has been supposed that the violent changes which then occur in the 
 circulation may account for the phenomenon. Of late years the presence of 
 various forms of micro-organisms has been invoked to explain the occurrence 
 of purpura. Petrone injected blood from patients with purpura into rabbits, 
 and produced a general haeruorrhagic state. Letzerich found a bacillus which, 
 injected in pure culture into rabbits, occasioned haemorrhages. Several other 
 investigators have made somewhat similar observations. Hanot and Luzet 
 found in the body of a foetus, the mother of which was dead of purpura, strep- 
 tococci of identical characteristics with those found in the mother. These 
 observations, though as yet too recent to be wholly relied upon, serve to show 
 that there may be certain cases of purpura which are acute, infectious diseases; 
 and this assumption is corroborated by the clinical history in some instances. 
 
 Diagnosis. — The diagnosis of purpura rarely presents any difficulty, as 
 the lesions differ from those caused by inflammatory conditions in not disap- 
 pearing under pressure. A fleabite differs from a petechia in having a central 
 point, indicating its traumatic origin. Scurvy may be distinguished from pur- 
 pura haemorrhagica by the fact that it is caused by a diet deficient in vege- 
 tables, that it attacks more than one of those so situated, and that in it we find 
 a spongy condition of the gums, loosening of the teeth, and brawny swelling 
 of the limbs. 
 
 Prognosis. — Care must be exercised in giving an opinion as to the course 
 and ultimate result even in simple cases of purpura, as the complications which 
 may arise are manifold. As a rule, the simple forms recover, though the attack 
 may be prolonged by relapses. The prognosis in purpura haemorrhagica is 
 always grave. 
 
 Treatment. — Mild cases of purpura will require no special treatment. In 
 all cases rest in bed is of prime importance, as in this way further haemor- 
 rhage is best guarded against. When the haemorrhages from the mucous cav- 
 ities threaten danger, an effort should be made to arrest them by means of 
 tampons, hot and cold water, or a spray of perchloride of iron or other as- 
 tringent. In the way of drugs to be administered internally, turpentine, 
 acetate of lead, dilute sulphuric acid, ergot, and iron have the best reputation. 
 A combination that has proved of service to the writer is the following : 
 
 ]^. Ext. ergotae fid 
 
 Tr. ferri chloridi, . . . . : ad fjss. — M. 
 
 Sig. Three to ten drops in water, t. d. 
 
 In purpura rheumatica the salicylates may benefit the affection of the 
 joints. 
 
1128 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 HYPERTROPHIES. 
 
 Lentigo. 
 
 The affection known as lentigo, or freckles, consists in the appearance, 
 mostly upon exposed surfaces, of variously-shaped, usually small, yellow, 
 brownish, or black spots. Freckles are most common on the hands and 
 face, but may occur on covered parts. As a rule, the affection appears in 
 the second decade of life, though Wilson mentions congenital cases. The spots 
 are prone to become darker and more numerous in the summer, while in the 
 winter they may almost disappear. In its pathology a freckle is a circum- 
 scribed hyperpigmentation situated in the rete. 
 
 Etiolog-y. — Lentigo is rarely seen before the sixth or seventh year. It 
 affects especially those of a light complexion. Exposure to the effects of sun- 
 light is, by universal consent, the most common cause, though, that it is not 
 the only one is shown by the occurrence of freckles on parts not exposed. 
 
 Treatment. — Freckles may be temporarily removed by many stimulating 
 ointments and lotions. One of the best of the former is — 
 
 1^. Hydrarg. ammoniati 3J- 
 
 Bismuthi subnit 3J- 
 
 Ung. aq. rosse Ij. — M. 
 
 Sig. Apply at night. 
 
 In cases where the pigment is very black, pricking each freckle, very 
 superficially, with a needle attached to the negative pole of the galvanic bat- 
 tery often hastens its disappearance. 
 
 Freckles, though they have disappeared, are prone to return under exposure 
 to exciting causes. 
 
 Ichthyosis. 
 
 Ichthyosis is a congenital disease characterized by dryness and scaliness 
 of the skin, and at times by the development of thickened warty patches. 
 Two principal varieties are described, though their difference is of degree 
 and not of kind. Ichthyosis simplex affects the general surface, but is often 
 most marked on the extensor sides of the limbs. Often there is only to 
 be noticed a dryness and scaliness of the skin, with small papules due to an 
 accumulation of horny cells in the hair-follicles. In more severe cases a thick- 
 ening of the skin exists and painful fissures may occur. Large scales form 
 on the surface, which get to be of a dark color from accumulations of dirt ; 
 and from their being somewhat of a diamond shape may give the skin a re- 
 semblance to the hide of an alligator. The face, scalp, palms, and flexor sur- 
 faces are apt to be but little involved, the disease in these parts manifesting 
 itself as a branny desquamation. The hair is often harsh and without lustre, 
 and the nails rough and brittle. Both sweat and sebaceous matter are deficient 
 in quantity. The condition grows better in summer and worse in winter. 
 
 In ichthyosis hystrix there is present in localized areas an exaggeration of 
 the condition just described : the skin is rough and bark-like, or may be covered 
 by actual spines, due to a papillary hypertrophy in addition to the thickening 
 of the epidermis. The usual sites for ichthyosis hystrix are the back, the 
 neck, and the extremities. The lesions may be distributed along the course of 
 a nerve. Occasionally ichthyosis is present at birth, but, as a rule, it first 
 manifests itself after some months or even a couple of years. 1 
 
 1 Sometimes ichthyosis exists at birth, or in the premature ; the " harlequin foetus " of 
 
DISEASES OF THE SKIN. 1129 
 
 Though the disease remains through life, the general health is entirely un- 
 affected. The most striking microscopical changes are thickening of the 
 epidermis, with more or less hypertrophy of the papillary layer of the cutis. 
 
 Etiology. — The only recognized factor in the etiology of ichthyosis is 
 heredity. It is apt to recur in successive generations of the same family, 
 though this is not always the case. 
 
 Diagnosis. — The diagnosis will be easy if the history be considered along 
 with the characteristic appearance of the disease. 
 
 Prognosis. — The disease persists through life, but does not show any 
 detrimental effect on the health. 
 
 Treatment. — Arsenic and pilocarpine have been recommended, though in 
 the experience of the writer they exert no permanent influence on the malady. 
 The local treatment is of importance, since by it much relief may be given. 
 In mild cases frequent warm baths, followed by inunctions with glycerin or 
 lanoline, suffice. In cases of greater severity it is advisable to use alkaline 
 baths. Duhring recommends that some simple ointment be rubbed on ; after 
 this has remained a few hours a hot bath with green soap is given, and then 
 rinsing in simple water, after which ointment is again applied. The following 
 ointment is recommended : 
 
 Ify. Adipis benzoati !j. 
 
 Glycerini Tttxl. 
 
 Yaselini gss. — M. 
 
 Sig. Apply after bathing. 
 
 Various authors recommend the following ointment for constant use : 
 
 1^. Potassii iodidi Bj. 
 
 Glycerini . 3j. 
 
 Adipis benzoati 
 
 01. bubuli da §ss. — M. 
 
 Sig. Rub in once a day. 
 
 Naphthol in 5 per cent, ointment, with the use of naphthol soap, is advised 
 by Kaposi. Sulphur or ichthyol (one drachm to an ounce of vaseline) may be 
 used as a daily inunction. In ichthyosis hystrix large horny growths must be 
 removed by the knife or other surgical means. Smaller patches may be treated 
 by the application of salicylic-acid plaster mulls, as devised by Unna, or a 
 solution of the same drug in collodion or traumaticin : 
 
 1^. Acidi salicylici 3J-3iss. 
 
 Traumaticini %j. — M. 
 
 Sig. Apply every two or three days after removing the application pre- 
 viously made. 
 
 Molluscum Epitheliale. 
 
 Molluscum epitheliale is a comparatively rare affection. The lesions are 
 from a pinpoint to a pea in size, according to the duration of the disease. 
 They form little tumors, usually sessile, varying in color from white to a decided 
 pink, often semitransparent, resembling wax, and presenting at one point on 
 
 English writers. The body is covered with plates of fatty epidermis separated by furrows. 
 If these children are born alive, they succumb in a few days. 
 
 
1130 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the surface a pit or umbilication indicating the situation of a follicle. Through 
 this orifice on firm pressure a milky fluid may be sometimes squeezed. The 
 lesions are generally few in number, and most frequently occur on the face, on 
 the eyelids, cheeks, and chin. They may be found in other regions, as the 
 neck, breast, or genitals. After the tumors have attained their full size they 
 may remain stationary for an indefinite time, or become inflamed and undergo 
 spontaneous cure by suppuration. Subjective symptoms are absent in mollus- 
 cum epitheliale. As to the anatomical changes present there are various 
 opinions. Virchow considers that the process begins as a hyperplasia of the 
 hair-follicles, while Leloir and Vidal support the older view, that the tumor is 
 the result of changes occurring in sebaceous glands. 
 
 Etiology. — The affection is commoner among children than adults. It 
 is without doubt contagious. As to the cause of the malady there is much 
 difference of opinion, Neisser and others believing it to be the result of some 
 form of coccidia ; Wickham contending that molluscum epitheliale is a cuta- 
 neous psorospermosis ; while Piffard is among those who hold that the patho- 
 logical process at the basis of the disease is a corneous degeneration of the 
 epithelium. 
 
 Diagnosis. — No other affection of childhood is apt to be confounded with 
 molluscum epitheliale. 
 
 Treatment. — The little tumors may be successfully treated by laying them 
 open with a knife and pressing out the contents ; the base should then be 
 touched with nitrate of silver. Electrolysis also may be used in the treatment 
 of molluscum epitheliale, each lesion being transfixed several times by a slender 
 steel needle attached to the negative pole of a galvanic battery. In a few days, 
 if the operation has been successful, the tumors shrivel up, and eventually dis- 
 appear : if this result is not attained by the first sitting, the operation must be 
 repeated. Jamieson's method of touching each tumor with pure carbolic acid, 
 and then painting over it with flexible collodion, is said to be effective. 
 
 Verruca. 
 
 Warts represent papillary hypertrophies, and present great variations in 
 appearance : they may be congenital or acquired. They may occur upon 
 any portion of the body in numbers or singly, though exposed surfaces, 
 such as the hands and face, seem their favorite sites. Various names have 
 been applied to the different clinical manifestations of verruca. Verruca 
 vulgaris occurs most often on the hands of children as one or more elevations 
 from a pinhead to a large pea in size, of the natural color of the skin or of a 
 dark hue, with a smooth or rough, shagreen-like surface ; verruca digita is 
 usually found on the scalp, and, as the name implies, presents one or more 
 finger-like projections from the skin, caused by an unusual outgrowth of indi- 
 vidual papillae ; verruca acuminata is found in such parts as are kept damp 
 and warm and are subject to the irritating influences of discharges, as about 
 the genitals or anus : this wart occurs as a vascular growth, sessile or peduncu- 
 lated, of a reddish or purplish color, and is frequently accompanied by an 
 offensive purulent discharge. Various other more or less fanciful names have 
 been applied to different forms of warts, but their importance is not sufficient 
 to warrant description here. 
 
 No matter how different the outward form of verrucse may be, microscop- 
 ically they consist of exaggerated papillary growths covered by epidermis more 
 or less thickened. 
 
 Etiology. — The etiology of warts is enveloped in obscurity : some forms 
 
PLATE XXVII. 
 
 MOLLUSCUM EPITHELIALE 
 
DISEASES OF THE SKIN. 1131 
 
 seem to be contagious ; and an explanation for this clinical fact is offered by 
 various observers, who have found micro-organisms — sometimes micrococci, 
 sometimes bacilli, sometimes psorosperms — in the affected tissues. 
 
 Diagnosis. — The only other disease of childhood with which verruca may 
 be confounded is that rare form of lymphangioma circumscriptum in which the 
 dilated lymph-spaces are covered and concealed by warty growths. Here 
 careful examination will demonstrate that the seeming warts contain lymph- 
 like fluid. 
 
 Treatment. — Recently Epsom salts in sufficient doses to cause two or three 
 evacuations a day has been said to bring about rapidly a cure of warts : this is 
 endorsed by good authority, but the writer has had no experience of it. 
 
 Where children can be induced to endure the pain, the wart may be caused 
 to disappear by transfixing it one or more times with the needle attached to 
 the negative pole of a galvanic battery. 
 
 One of the best topical remedies is a saturated solution of salicylic acid in 
 alcohol painted on once or twice a day ; or this formula may be used : 
 
 1^. Acidi salicylici 3ss. 
 
 Collodii fsj. — M. 
 
 Sig. Paint on the wart every other day. 
 
 Sometimes powders kept dusted over the affected area will bring about a 
 cure ; this powder is as good as any : 
 
 ^. Pulv. zinci oleatis §ss. 
 
 Bismuthi subnit ^ss. — M. 
 
 Sig. Dust on the part. 
 
 Nearly all of the various caustics have been used to remove warts, but the 
 methods mentioned are equally effective and much safer. 
 
 Njevus Pigmentosus. 
 
 By the term " ncevus pigmentosus" or mole, is meant a circumscribed 
 deposit of pigment in the skin, which may be congenital or may develop 
 at a later period. The size of moles varies from a pinhead to a bean, and 
 in some instances a large part of the body is involved. The most frequent 
 sites of naevus pigmentosus are the neck, face, and back. The color of moles 
 varies from a light brownish-yellow to black. Superpigmentation may be the 
 only pathological condition present, or this may be accompanied by other ana- 
 tomical changes : these differences in structure have given rise to special names, 
 such as ncevus spilus, w T here a simple smooth deposit of pigment exists : ncevus 
 verrucosus, where the surface is warty and uneven ; ncevus pilosus, where the 
 mole is covered with hairs. 
 
 Moles are of importance from a cosmetic point of view, and because, in 
 later years, they may undergo a malignant change. Anatomically, a mole is a 
 collection of pigment in the rete, often accompanied by an increase in the con- 
 nective tissue of the skin. 
 
 Etiology. — No cause for the appearance of nrevus pigmentosus has yet been 
 certainly ascertained. The fact that moles sometimes occur scattered along the 
 course of a nerve seems to point to a neurotic origin in some cases. 
 
 Prognosis. — Pigmentary naevi persist through life, only rarely disappear- 
 ing spontaneously. Where practicable, it is best to remove them, because 
 
1132 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of the possibility of a cancerous or sarcomatous growth originating from the 
 moles as life advances. 
 
 Treatment. — Electrolysis offers the best method of removing moles of 
 ordinary size. A needle attached to the negative pole of a galvanic battery is 
 introduced into the mole at several points till, in the judgment of the operator, 
 a sufficient amount of destruction is accomplished. To avoid scarring it is best 
 not to attempt to complete the removal at one sitting. For the minutiae of the 
 operation the reader must be referred to works in which the subject is treated 
 more fully, as space is not here afforded. Electrolysis presents advantages in 
 the removal of large nsevi, as there is no haemorrhage, and scarring is less than 
 by most other methods. The operation is, however, tedious, as a number of 
 sittings are required for the larger growths. When time is an element in treat- 
 ment, excision with the knife gives the most satisfactory results. It is not 
 good practice to attack moles with caustics, as the results are less favorable 
 than by the methods mentioned, while a malignant change may possibly be 
 provoked. 
 
 Sclerema Neonatorum. 
 
 Sclerema neonatorum manifests itself as an induration and stiffening of 
 the skin in new-born children. The disease may be congenital, but when 
 this is the case the children are usually still-born. More frequently the 
 trouble develops within the first few days of life. The skin of the legs is 
 usually first attacked, and successive portions of the integument are affected till 
 the whole surface has become involved. Occasionally the disease begins in the 
 cheeks and spreads downward. At first the skin is of a whitish, waxy appear- 
 ance, and feels thick when pinched between the fingers ; but as the malady 
 advances a livid hue is developed, and the skin becomes adherent, so that it can 
 no longer be picked up. When the process is fully developed the child lies 
 rigid, with no perceptible motion save that due to its feeble respirations. The 
 joints are not readily flexed, and the child may be picked up by the legs and 
 held out horizontally ; the jaws are so stiff that nursing is impossible. The 
 pulse decreases to 60 per minute ; the respirations are slow and shallow ; and 
 the temperature is below the normal by two or three degrees : under such con- 
 ditions life cannot long persist, and is generally extinguished in five or six days. 
 
 Sclerema neonatorum was until the time of Parrot confused with oedema, 
 which may occur in the new-born from various causes. Parrot makes the 
 essence of the disease a drying up or desiccation of the skin ; he denies that 
 there is a true sclerosis. Langer attributes the stiffness of the integument to 
 solidification of the subcutaneous fat; in infants the fat becomes solid at 
 89.6° F., while in adults this occurs at a temperature lower than 32°F. If by 
 any depressing cause the infant's temperature is sufficiently reduced, the fat 
 solidifies, and sclerema neonatorum is the result. 
 
 Etiology. — The disease is most common in those born prematurely. Any 
 conditions which depress the general health, such as congenital heart affections, 
 bronchitis, diarrhoea, exposure to cold, etc., seem to act as predisposing causes. 
 
 Diagnosis. — Sclerema neonatorum is distinguished from oedema by the 
 fact that the skin is stiff and unyielding, and that there is no pitting on pres- 
 sure. (For the differential diagnosis between sclerema neonatorum and sclero- 
 derma the reader is referred to the article on the latter subject.) 
 
 Prognosis. — The disease is nearly always fatal. Encouragement is, how- 
 ever, offered by the few cases that have recovered. 
 
 Treatment. — An effort should be made to bring the temperature of the 
 child to the normal by enveloping it in cotton wool, or, better, by placing it in 
 
DISEASES OF THE SKIN. 1133 
 
 an incubator. As nursing is impossible, nourishment must be maintained by 
 other methods. Milk with brandy may be administered per rectum or by 
 means of a catheter passed into the stomach through the nose. Money reports 
 success in two cases by inunctions of mercury. 
 
 Scleroderma. 
 
 Clinically, scleroderma presents itself as a thickening and induration of 
 the skin. A limited area or the whole surface may be involved. 
 
 The disease may occur on any part of the body, but shows a preference for 
 the upper portions — the head, the thorax, or the upper extremities. The malady 
 may come on acutely, and in a few days involve the entire surface ; but more 
 commonly the progress is so slow that the person affected does not notice the 
 presence of the disease till the skin is already hard and stiff. Sometimes the 
 real infiltration is preceded by oedema. When fully developed the affected 
 area is to the touch dense, hard, and will not pit on pressure. The skin can- 
 not be picked up from the underlying structures, nor slid about, as in the nor- 
 mal state. The diseased area is usually on the same level with the healthy 
 integument, and passes so gradually into it that no line of demarcation can be 
 seen. Generally, the surface is somewhat paler than normal, though it maybe 
 a uniform or mottled brown from increased pigmentation : it is most often 
 smooth and shining, with the markings of the natural skin obliterated, but in 
 some instances it is scaly. Around the border of the area there is sometimes 
 a zone of hyperemia. The movement of all the parts affected is limited by the 
 rigid skin, so that the face is expressionless, the neck cannot be easily turned, 
 respiration is hindered, and the joints are not readily flexed. Sensation may 
 be increased or diminished, but pressure on the diseased skin is acutely pain- 
 ful. The mucous membranes may become involved, as may also the muscles. 
 Having persisted in this stage for an indefinite time, the affected skin may 
 become normal, or it may pass into the second or atrophic stage. It then becomes 
 thin, parchment-like, of a dull-white color, with telangiectic vessels showing 
 here and there, and is stretched tensely over the underlying structures. The 
 pressure thus caused brings about atrophy of the tissues beneath, so that the 
 face may resemble a skull with only the skin stretched over it, and the limbs 
 seem made up of only skin and bones. Various distortions of the hands and 
 extremities occur, and ulceration over bony prominences is common. 
 
 During the course of scleroderma, endocarditis and pericarditis may develop. 
 There is frequently no disturbance in health till the disease has persisted for a 
 long time, when a state of marasmus may appear and death result. In chil- 
 dren the disease is prone to run an acute course, and does not so often ter- 
 minate in atrophy. The denseness of the skin in scleroderma is due to an 
 increase in the connective-tissue elements. The changes are found chiefly in 
 the corium and subcutaneous tissue. There is at times an increase of pigment 
 in the rete. Around the vessels are found masses of cells the exact origin of 
 which is unknown. In a case examined by Mery there was a development of 
 connective tissue in the muscles of the limbs and in the heart. 
 
 Etiology. — The cause of scleroderma is not known. Obstruction of the 
 lymph-channels has been suggested, but this remains an hypothesis. Various 
 observers have detected lesions of the central or peripheral nervous system in 
 connection with scleroderma. The disease seems to have followed exposure to 
 cold, and it has been remarked after erysipelas. 
 
 Diagnosis. — The only disease of childhood with which the first stage of 
 scleroderma can be confounded is sclerema neonatorum : here the time of 
 
HZ± AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 development will suffice to distinguish, as the youngest child in whom sclero- 
 derma has been reported was thirteen months old. 
 
 In the atrophic stage scleroderma most resembles Kaposi's disease, but the 
 history of scleroderma, which begins as a thickening of the skin, will, in most 
 cases, differentiate it from this affection, which begins with pigmentation and 
 atrophy. (For other points of difference see Kaposi's Disease.) 
 
 Prognosis. — It is impossible to give an opinion as to the result when the 
 case is seen in the first stage. When atrophy has occurred it is permanent. 
 
 Treatment. — The body should be clothed with flannel, and exposure to 
 cold, which always seems to aggravate, guarded against. The general nutri- 
 tion should be cared for by a generous diet and the exhibitiou of cod-liver oil 
 and tonics. Hot baths often give comfort to the patient. The suppleness of 
 the skin may be increased by vigorous inunctions of oil. Massage has seemed 
 of service in some cases. The constant current has been recommended by 
 some authors, and in a circumscribed patch of scleroderma in an adult Brocq 
 used electrolysis with apparent improvement. 
 
 MORPHCEA. 
 
 The affection of the skin known by the name "morphcea" is thought by 
 some dermatologists to be only a circumscribed scleroderma. However this 
 may be, the disease presents enough clinical peculiarities to entitle it to a 
 separate description. 
 
 The lesions of morphcea consist of variously sized spots, streaks, or bands 
 with sharply-defined borders surrounded by a zone of dilated capillaries, which 
 zone is often of a violet hue. The affected area is frequently of a waxy-white 
 color, so that it has been likened to a piece of old ivory let into the skin, but at 
 times the color may be pinkish, yellow, brown, purple, or even black. The 
 patches are, as a rule, not raised above the level of the surrounding skin. Gen- 
 erally, the surface is smooth and the skin is not adherent to the underlying 
 tissues, so that it may readily be picked up, when it is found to be slightly 
 thickened ; sometimes in one part of a patch there exists thickening, while 
 in another the skin is thinner than normal. The disease occurs frequently upon 
 the breast, and may affect any part of the body. Sometimes several patches 
 are grouped along the course of a nerve. At times the disease presents itself 
 as a number of small atrophic pits in the skin. 
 
 The subjective symptoms are insignificant, being limited to slight itching. 
 Occasionally, the centre of a patch will be insensitive. 
 
 The disease persists for months or years, and then may disappear, leaving 
 the skin normal ; or the final result may be an atrophy of the skin, and even 
 deeper structures. Crocker found in the earlier stages of morphcea a consider- 
 able infiltration, in the corium, of cells which later become connective tissue, 
 and by their contraction cause atrophy of the blood-vessels and glands. 
 
 Etiology. — The disease may occur at any age beyond two years. It is 
 thought by many to be a neurotic affection, and certain facts lend countenance 
 to this belief, as its occurrence with other disturbances of the nervous system, 
 such as hemiatrophia facialis, canities, alopecia areata, etc., and its being often 
 distributed along a nerve-trunk. 
 
 Diagnosis. — Leucoderma differs from morphoea in not presenting any 
 alteration in the texture of the skin, there being simply an absence of pig- 
 ment. The atrophic spots of leprosy show marked anaesthesia, and the con- 
 comitant symptoms will aid in the diagnosis. Keloid is more vascular and 
 
DISEASES OF THE SKIN. 1135 
 
 denser than morphoea, is redder, and its lesions present the well-known claw- 
 like processes. 
 
 Prognosis. — Although morphoea has a tendency toward recovery in the 
 course of time, with no permanent damage to the skin, yet in view of the cases 
 followed by atrophy the prognosis must be somewhat guarded. 
 
 Treatment. — No internal medication has any effect on the lesions of mor- 
 phoea. and thus far local remedies may be said to be equally futile. 
 
 ATROPHIES. 
 
 Albinism. 
 
 Albinism is a congenital absence of pigment : it may be total or partial. 
 "When general, not only the skin, but also the hair, the iris, and the choroid 
 lack their normal coloring matters. Persons thus aifected are termed albinos, 
 and present the well-known characteristics of a pink skin, white hair, and pink 
 irides. Frequently nystagmus may be observed in albinos, from the irritating 
 effect of the light upon the unsheltered retinae. These persons are often poorly 
 developed, both physically and mentally. Albinos are quite frequently the 
 offspring of negro parents. 
 
 Partial albinism is most common among negroes, and occurs as limited 
 areas in which the pigment of the skin is absent. Should these areas be found 
 in hairy regions, the hair also lacks its coloring matter. In rare cases partial 
 albinism spontaneously recovers by a new deposit of pigment in the affected 
 part. 
 
 Leucoderma. 
 
 Leucoderma is an acquired diminution of the pigment of the skin. It 
 usually occurs as one or more round or irregular-shaped areas, in which the skin 
 is of a much. whiter color than the surrounding integument. Such patches of 
 skin vary in size from a quarter of an inch in diameter up to several inches, 
 and their borders are strongly defined from the healthy skin by a line of abnor- 
 mally deep pigmentation which surrounds the leucodermic plaque. Hairs grow- 
 ing on the affected areas may be white or may retain their natural color. 
 Save for the absent pigment the diseased skin is quite normal. 
 
 Leucoderma is generally symmetrical, and occurs most frequently on the neck, 
 face, backs of the hands, and about the hips. The disease tends to slowly 
 progress, till in the course of time the whole body may become involved. 
 When leucoderma has thus extended over a whole member, it is often thought 
 to have recovered, as the contrast with the healthy skin can no longer be 
 remarked. As a matter of fact, the pigment is rarely if ever restored. The 
 disease appears to grow worse in summer, because at this season the pigment of 
 the normal skin becomes darker. 
 
 Etiology. — Leucoderma usually develops between the ages of ten and 
 thirty, though the writer has seen it in a child four years old. Beyond the 
 fact that the malady seems to be due to some disturbance in innervation, noth- 
 ing is known as to its etiology. It is sometimes secondary to other diseases, 
 such as morphoea, alopecia areata, and eczema. 
 
 Diagnosis. — From the congenital absence of pigment known as partial 
 albinism leucoderma is distinguished by its history, its symmetry, and its pro- 
 
 i 
 
1136 AMERICAN TEXT-BOOK OF DISE SES OF CHILDREN. 
 
 gressive tendency. From morphoea it will be differentiated by the fact that in 
 the former disease there is a change in the structure of the skin. From the 
 white spots which occur in nerve-leprosy, leucoderma can be told by the fact 
 that the macules of leprosy are anaesthetic and often scaly. 
 
 Prognosis. — There is little hope of recovery, though in time, by the spread 
 of the disease, the effect is rendered less startling. 
 
 Treatment. — No drug, either internally or locally. Las any effect upon the 
 disease. The most that can be done is to remove the hyperpigmented border 
 and thus relieve the contrast. (For the various means of accomplishing this 
 see Treatment of Lentigo.) Tatooing or staining the patches with walnut- 
 juice may be tried where the cosmetic effect must be cared for. 
 
 Fig. 2. 
 
 Alopecia Areata. 
 
 Sometimes, after certain premonitory symptoms, such as headache or burn- 
 ing or itching, the hair is lost from the scalp in one or more circumscribed 
 spots ; more frequently, however, these sensations are absent, and the patient's 
 attention is first attracted by the peculiar and striking areas of baldness. The 
 patches are usually quite white and perfectly smooth, and give the appearance 
 of slight depression. There may be one or many bald spots, and they may 
 vary in size from a dime-piece to that of the palm, the larger areas usually 
 resulting from coalescence of the smaller ones. Sometimes the loss of hair is 
 general, but this must be rare in children. The disorder runs a chronic course. 
 It may persist from a few months to several years. When recovery sets in, the 
 returning hairs are white and downy, but gradually attain their normal size 
 and color. 
 
 Etiology. — The disease is comparatively frequent in children. It is some- 
 times noted to occur after various illnesses, but more often there is no such 
 
 history. A blow on the head, or, in 
 the adult, persistent neuralgia, is occa- 
 sionally apparently responsible for 
 limited areas of the disease. By some 
 authorities it has been regarded as con- 
 tagious (Hillier and others), but cer- 
 tainly in the majority of instances this 
 is not so, and it is likely that the re- 
 corded cases of such character are 
 susceptible of some other explanation. 
 Neither has the parasitic theory been 
 maintained. The writer is in agreement 
 with most dermatologists in looking 
 upon alopecia areata as a trophoneurosis. 
 Diagnosis. — The disease is so strik- 
 ing that its recognition is a matter of 
 little difficulty. Ringworm of the scalp 
 bears the closest resemblance, but in 
 this latter affection the patches are not 
 smooth and glistening, but are covered 
 with grayish scales, and scattered over 
 the surface are to be seen the stumps of broken-off hairs ; besides, if any doubt 
 arise, the microscope will soon settle the question. Favus, syphilis, and cer- 
 tain forms of folliculitis would also be differentiated. 
 
 Prognosis. — The alopecia areata of young people generally tends to spon- 
 
 Alopecia Areata. 
 
DISEASES OF THE SKIN. 1137 
 
 taneous recovery, although undoubtedly much hastened by appropriate treat- 
 ment. 
 
 Treatment. — There is no special internal treatment beyond attention to 
 any obvious defects of the general health. In rebellious cases small doses of 
 arsenic might be tried. Locally, the demand is for thorough and persistent 
 stimulation. The following, briskly rubbed in twice a day, is useful : 
 
 1^. Acidi salicylic 9j. 
 
 Sulphuris prsecipitati gj. 
 
 Vaselini |j. 
 
 Olei rosas q. s . — M. 
 
 Equal parts of tincture of cantharides and glycerin serve an equally good 
 purpose. Pilocarpine in ointment or the fluid extract of jaborandi in lotion 
 may be advised. Galvanic stimulation with a metallic brush (negative pole) is 
 also to be recommended. In obstinate cases blistering limited regions at a 
 time with cantharidal collodion gives excellent results. 
 
 NEW GROWTHS. 
 
 Kaposi's Disease. 
 
 This disease, which is also known as xeroderma pigmentosum and angioma 
 pigmentosum et atrophicum, develops in the first year of life, frequently 
 as an erythema, upon the disappearance of which small, variously colored pig- 
 ment-spots, resembling freckles, are noted. Sometimes the pigmentation is the 
 first morbid change observed. In a short time small atrophic spots begin to 
 appear, and as the atrophy advances vascular telangiectases of various sizes 
 develop, which may, in severe instances, form small elevated blood-tumors. 
 Often warty growths are seen arising from the pigmented spots. As the 
 malady progresses the atrophic skin, by contraction, may cause marked defor- 
 mities. Ulcers are prone to form, and these or the warty growths referred to 
 may be the starting-point for malignant tumors which often terminate the 
 patient's life. The most frequent sites of the malady are those parts which are 
 habitually exposed — the face, neck, hands, and feet. 
 
 Kaposi's disease is essentially an atrophy of the skin beginning in the 
 papillary body and epidermis. The tumors which are associated with this 
 process are usually described as epitheliomata, though some observers found 
 papillomata and sarcomata. 
 
 Diagnosis. — The atrophic stage of some cases of scleroderma most 
 resembles the disease under consideration, but the history of the two affections 
 is entirely different. 
 
 Prognosis. — The prognosis is in all cases bad, for after the malignant 
 growths have once developed the patient has only a few years, at the most, to 
 live. 
 
 Treatment. — No internal medication has any effect upon this disease. The 
 ulcers should be treated on general surgical principles, and the tumors removed 
 at as early a date as possible. 
 
 N^ivus Vascularis. 
 
 The affection known as nsevus vascularis consists in a congenital new- 
 growth of blood-vessels, which may be manifest at birth or may show itself 
 
 72 
 
1138 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 at a later period. The clinical picture will vary much according to the size 
 of the vessels involved and the presence or absence of implication of other 
 structures, such as the connective tissue, hair-follicles, or fatty tissue. 
 
 As usually seen, naevus vascularis consists of spots of various sizes, in color 
 from a pale red to a bluish hue, not raised above the skin, disappearing largely 
 on pressure, and due to a new formation of capillary vessels. Sometimes there 
 will be only a small pinhead-sized point, radiating from which are numerous 
 red lines (naevus araneus) : at other times areas as large as the palm may be 
 involved (port-wine mark). This capillary form of naevus may spontaneously 
 disappear, may remain stationary, or may increase rapidly in size till large 
 areas become involved. According to Depaul, one-third of the children born 
 at the Clinique de la Faculte de Medecine in Paris have this form of birth- 
 mark, but in most cases the mark disappears within a month. 
 
 Often over the surface of a capillary naevus warty growths occur, and at 
 times small erectile vascular tumors may be seen. The most common sites for 
 this form of naevus are the face, scalp, neck, arms, and genitals. 
 
 When the vascular channels constituting the naevus are of a larger size, we 
 find elevated areas, usually of a bluish color, often lobulated, soft and frequently 
 fluctuating, compressible, but rapidly filling again when pressure is removed. 
 In such tumors pulsation may at times be observed. Naevi of this form seem 
 sometimes to develop from the capillary variety. They vary in size from a pea 
 to an orange, and occasionally attain enormous proportions. In some instances 
 these growths lie entirely in the subcutaneous tissue, the skin being simply 
 stretched over them, but not altered otherwise. Naevi of this kind most often 
 occur on the neck about the lower jaw, on the buttocks, and on the lower limbs. 
 
 As a rule, vascular naevi are not accompanied by any subjective symptoms, 
 but in some of the pulsating tumors there are neuralgic pains. 
 
 Naevus, especially naevus vascularis, consists of new-formed vessels which 
 are variously distorted, being convoluted or varicose. Sometimes, from pressure, 
 parts of the intervening vascular walls are broken through, and irregular inter- 
 communicating chambers are formed (cavernous tumors of some authors). In 
 connection with the growth of the vessels there may be an increased development 
 of other elements of the skin — connective and fatty tissue, glands, hairs, etc. 
 
 Etiology. — Maternal impressions are thought by some to determine the 
 location of naevi, and such views have been supported by many instances. 
 When we consider how common naevus vascularis is, it does not seem strange 
 that there should often be an accidental coincidence of birth-mark in the child 
 and " maternal impression " in the parent. 
 
 Diagnosis. — Naevus vascularis cannot readily be confounded with any other 
 affection of the skin, and the diagnosis is easy. 
 
 Prognosis. — The prognosis must be guarded. Though small naevi may 
 remain stationary, or may even disappear as the child grows older, on the other 
 hand they often increase rapidly in size, and this may occur after the growth 
 has remained stationary for years : this is especially true of the prominent and 
 pulsating naevi. 
 
 Treatment. — For the cure of the elevated or pulsating naevi, when the 
 area involved is of limited extent and a reasonable hope of cure in a few 
 sittings may be entertained, the most satisfactory means is the coagulating 
 effect of electricity. The child must be anaesthetized, as the operation occa- 
 sions a good deal of pain. A slender steel needle attached to the negative pole 
 of a galvanic battery is thrust into the tumor ; the positive sponge electrode 
 is then placed upon some convenient portion of the child's body. The length 
 of time the current should be passed must be determined by the thickness 
 
 
DISEASES OF THE SKIN. 1139 
 
 of the skin and the size of the vessels of the tumor. As coagulation occurs, 
 a paling of the tumor usually follows. The needle must be passed through 
 different parts of the naevus ; the number of times will depend upon the size 
 of the growth. A current from twenty to thirty cells of a galvanic battery 
 will suffice. To secure the complete cure a number of sittings will generally 
 be required, and this fact constitutes the principal objection to the method. 
 Some operators plunge needles attached to both the positive and negative poles 
 into the tumor, but the writer prefers the method above described. 
 
 When naevi of this class are very large, their treatment must be under- 
 taken by surgical means, a discussion of which is not within the scope of this 
 article. 
 
 In the treatment of the superficial naevi, where the affected vessels are capil- 
 laries, electrolysis is not so satisfactory, for if the area involved be of any extent, 
 an indefinite number of repetitions of the operation will be required, and, 
 moreover, as the vessels to be destroyed are so small and so numerous, each 
 sitting must be of considerable length ; as the operation requires anaesthesia 
 in young children, the number of the sittings and the length of time employed 
 in each become serious objections to its performance. 
 
 Unless the birth-mark is very small, other methods will be found more 
 applicable. Ethylate of soda may be painted over the naevus, and when the 
 eschar thus formed has separated the remedy may be reapplied till a cure is 
 effected. 
 
 A 4 per cent, solution of corrosive sublimate in collodion is recommended, 
 and it is stated that the resulting cicatrix is thin and smooth. 
 
 Pure carbolic acid may be brushed over the naevus ; by several applications 
 a cure will usually be effected. A host of other escharotics has been recom- 
 mended, but those mentioned are among the most reliable. 
 
 Multiple puncture and incision, though strongly advocated by some, have 
 failed in the hands of many careful operators. 
 
 Lupus Vulgaris. 
 
 Lupus vulgaris is a chronic granuloma of the skin, depending upon the 
 presence of the tubercle bacillus. It usually manifests itself in early child- 
 hood as small brownish-red spots, which may be a trifle depressed below the 
 skin, on a level with the surface, or even slightly raised. Several such spots 
 are generally noticed in the same neighborhood: as they grow older they 
 increase in size, while at the same time an infiltration of the skin occurs : 
 they are then of a brownish color, semi-transparent, softer than the surround- 
 ing tissues, so as to be more readily broken down under pressure, and consti- 
 tute what is known as lupus tubercles. These tubercles gradually coalesce 
 by peripheral extension to form patches of a brownish-red color, raised at 
 the borders, often depressed in the centre, accompanied by deep and firm 
 infiltration of the skin. The typical lupus tubercles, which have been likened 
 to masses of apple-jelly, though they may not be discoverable in such a patch, 
 may generally be detected about its edges. After remaining in this condi- 
 tion for an indefinite time, one of two processes occurs in the lupus patch : 
 interstitial absorption may take place, producing eventually a shining depressed 
 cicatrix ; or the lupus tissue may break down, leaving ulcers of various shapes 
 and depths, often covered with crusts and having raised infiltrated borders. 
 When healing takes place after ulceration the scars are thick and rough. 
 
 Various accidental features may present themselves during the course of 
 lupus, which have given rise to a number of special names : thus, if warty 
 
1140 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 growths are present on the patch, the disease is known as lupus verrucosus, if 
 granulations are exuberant, it is lupus hypertrophicus ; if the borders advance 
 in a sinuous manner, the title lupus serpiginosus is given. 
 
 Lupus usually occurs on the face about the nose and cheeks, but it may 
 attack any part of the body except the forehead, chin, palms, soles, and penis, 
 which portions of the body seem to be exempt. The mucous membranes may 
 be involved, but this is most often by extension from the adjacent skin. 
 Whole organs or entire regions may ultimately be destroyed by the disease, 
 but the onward progress of lupus is so slow that such ravages are usually not 
 witnessed till the patient is of some age. 
 
 The course of the malady is not uniform ; at one period it advances with 
 great rapidity, and then for long intervals it may remain quiescent. 
 
 Various complications may arise during the course of lupus : when the 
 disease occurs upon the limbs and extremities, the bones may be destroyed by 
 caries; erysipelas sometimes develops in the lupus patch, but often exercises a 
 favorable influence upon the malady ; the inflammatory processes accompany- 
 ing lupus may involve the lymph-vessels, which, becoming obstructed, give rise 
 to a condition resembling elephantiasis. 
 
 Microscopically, lupus tissue is made up of a reticulum of fibrous tissue, 
 the meshes of which are filled with round cells and a varying number of giant- 
 cells. Some observers have been able to demonstrate the presence of tubercle 
 bacilli, but they usually occur in such small numbers that their discovery is 
 difficult. 
 
 Etiology. — Lupus generally begins in childhood, and is more common in 
 females than in males. It is stated by excellent observers that a tubercular 
 family history may be obtained in a majority of the cases, though compara- 
 tively few of those suffering from lupus have consumption. The observations 
 of Koch, Pick, Doutrelepont, and others make it very certain that lupus 
 vulgaris is a tuberculosis of the skin. 
 
 Diagnosis. — The history of the case and the presence of the lupus tuber- 
 cles generally make the diagnosis easy. In children the only disease with 
 which it might be confounded would be a gummatous syphilide, and this is 
 very rare in childhood ; when a gumma appears, it goes through its evolutions 
 much more rapidly than lupus, frequently breaking down into a punched-out 
 ulcer with sharp-cut, thin borders, which readily heals under appropriate 
 treatment. 
 
 Prognosis. — The progress of lupus is so slow that, save in those rare 
 instances where the disease involves a vital organ, death results more often 
 from some intercurrent trouble than from the disease itself. If neglected, hor- 
 rible deformities occur, and even in those cases where a cure results from 
 treatment, permanent and disfiguring scarring is left. 
 
 The disease justly has the reputation of being very rebellious to treatment. 
 Perhaps one of the chief reasons for this is that treatment to be successful 
 must be so long protracted that the patient becomes discouraged ere it is com- 
 pleted. 
 
 Treatment. — Lupus demands both constitutional and local treatment. 
 The child should be given the most nutritious diet ; plenty of fresh air and 
 sunshine should be recommended; the sleeping apartment should be well 
 ventilated, and habits of cleanliness insisted upon. The two remedies for 
 internal administration are cod-liver oil and the preparations of iodine. As 
 large doses of the oil should be given as can be borne by the stomach. The 
 iodide of potassium or the syrup of the iodide of iron will be found the most 
 eligible forms for the administration of iodine. 
 
DISEASES OF THE SKIN. 1141 
 
 Hypodermatic injections of tuberculin, as proposed by Koch, have 
 not yielded the brilliant results at first expected of the remedy, and the most 
 enthusiastic can now only claim for this method of treatment a very limited 
 field. 
 
 The local remedies that have been used in lupus are so many that merely 
 to enumerate them would require more space than can here be given. When 
 a case of lupus is first seen it is often of benefit to apply for a time soothing 
 remedies, as in this way external irritation is removed and it is possible to see 
 what part of the trouble is due to the lupus and what part to accidental inflam- 
 matory complications : for this purpose nothing is better than unguentum 
 vaselini plumbicum spread on linen and changed twice a day. With the idea 
 of destroying the tubercle bacilli, any ulcers present may be dusted with iodo- 
 form before the ointment is applied. 
 
 One of the oldest methods, and still regarded by some as the best, for 
 destroying the lupus growth is by the application of the stick of nitrate of 
 silver : this is of special use in small patches. To be effectual the sharpened 
 point should be bored deeply into the affected tissues. 
 
 Pyrogallic acid is one of the remedies most frequently used, and is an 
 efficient caustic : it may be applied in the form of a plaster, for which Duh- 
 ring's formula is — 
 
 1^. Acidi pyrogallic 3ij. 
 
 Emp. plumbi • 3j. 
 
 Cerati resinae comp 3v. — M. 
 
 Sig. Apply on cloth. 
 
 This plaster should be renewed every twenty-four hours for three days, 
 and then the surface dressed with a simple oil dressing till the eschar is sep- 
 arated. A mild mercurial ointment then forms a most excellent dressing. 
 The procedure may have to be repeated several times before cicatrization is 
 secured. 
 
 Hebra's modification of Cosme's paste often produces excellent results. 
 The formula is — 
 
 1^. Acidi arseniosi gr. xx. 
 
 Hydr. sulphuret. rubri 3J. 
 
 Ung. aq. rosse - 3J- — M. 
 
 Sig. Apply on muslin. 
 
 This should be renewed once a day for two or three days : it should never 
 be used on a large surface at a time, for fear of arsenical poisoning. 
 
 Unna's salicylic-creasote plaster-mull is highly recommended by some 
 writers : this mull is prepared in strengths varying from 5 to 20 per cent, of 
 salicylic acid, with twice as much creasote ; the strength used will depend 
 upon the age of the patient and the amount of infiltration in the lupus patch. 
 A piece of the mull sufficiently large to cover the area which it is desired to 
 attack should be applied each day until enough destruction has been produced : 
 a mild mercurial ointment should be applied on cloth until the healing 
 occurs. 
 
 Various surgical procedures have been used in the treatment of lupus. Mul- 
 tiple linear scarification has been much employed in the early stage of the 
 disease, the tissue being minced as finely as possible by numerous cuts made 
 at right angles to each other ; but this method of treatment has been largely 
 
1142 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 superseded by other more successful procedures. It is probable that when a 
 surgical operation is found necessary, scraping with Volkmann's spoon will be 
 most satisfactory : the lupus tissue is softer than the healthy structures, and is 
 more readily broken down by the curetting. After it is judged that all the 
 diseased tissue is removed, the area operated upon should be cauterized with 
 an 8 per cent, solution of chloride of zinc or with the galvano-cautery ; the 
 wound should then be dressed in an antiseptic manner. No matter how 
 thoroughly curetting may be done at each sitting, it will usually have to be 
 repeated several times before a cure is effected. 
 
 The galvano-cautery or Paquelin cautery may be used to destroy the 
 lupus growth : after the tissue has been thoroughly burned away, the wound 
 should be dressed with a moist antiseptic dressing till the slough has sep- 
 arated, and then dusted with iodoform and a dry dressing applied. 
 
 When very small nodules only are present, electrolysis may be used for 
 their destruction : the needle is to be thrust into the lupus nodule and the 
 skin immediately surrounding it until it is judged that sufficient destruction 
 has been produced. After two or three weeks, if the lupus process still seems 
 active, the operation must be repeated. The tediousness of its use forms the 
 principal objection to electrolysis. 
 
 Whatever method may be employed, the treatment must be actively fol- 
 lowed, and the operations repeated again and again as long as any of the 
 lupus tissue remains. 
 
 Scrofuloderma. 
 
 As to which diseases shall be grouped under the term "scrofuloderma" 
 there is great difference of opinion among authors. Three different forms of 
 skin trouble occur with considerable frequency in those who are affected with 
 the tuberculous diathesis ; these diseases will here be considered as the scrofulo- 
 dermata proper. 
 
 The most frequent form of scrofuloderma is the ulcerous lesion which is 
 often found over tubercular lymphatic ganglia, especially in the neck.- When 
 such an enlarged ganglion begins to soften and break down, the skin over it 
 becomes thinned and of a violaceous hue. Finally, the pus and necrotic rem- 
 nants of the ganglia break through the skin, and an ulcer results. Such ulcers 
 are round or oval, their edges purplish and frequently undermined, their floors 
 covered with pale, unhealthy granulations. A thin more or less purulent fluid 
 is constantly secreted, which dries into thin, light-colored crusts. The progress 
 of these ulcers toward recovery is very slow, and when healing does occur 
 thick, ridged scars result. 
 
 Duhring describes a scrofuloderm which consists of one or more large flat 
 pustules seated upon an inflamed base. A crust, which is thin and brown, 
 forms slowly ; underneath is an ulcer which has the " peculiar scrofulous cha- 
 racter:" the scars are flat and superficial. The same author describes an 
 eruption of small pustules which occurs on the face and extremities in scrofu- 
 lous subjects, and leaves variola-like scars. 
 
 Another eruption which occurs usually in the scrofulous is the lichen 
 scrofulosorum. The disease consists of numerous pinhead-sized papules of a 
 red or yellowish color, situated usually on the trunk, sometimes on the limbs, 
 and not accompanied by itching or other subjective symptoms. The papules 
 often have a grouped arrangement. Each papule is crowned by a few thin 
 scales. This affection is very rare in this country. 
 
 Etiology. — The scrofulodermata occur most often in children. That form 
 
DISEASES OF THE SKIN. 1143 
 
 which is found with tuberculous lymph-ganglia is due to the presence of the 
 tubercle bacillus. 
 
 Lichen scrofulosorum is an inflammation which commences about a hair- 
 follicle or sebaceous gland, but whether this inflammation is of microbic origin 
 is not vet determined. 
 
 Diagnosis. — Scrofulous ulcers are to be distinguished from those of syphilis 
 by the history, the concomitant symptoms, and the differences in appearance 
 of the ulcers themselves. Lichen scrofulosorum differs from the other papular 
 rashes in that it occurs in subjects presenting evidences of scrofula, and further 
 that it is not accompanied by itching. 
 
 Treatment. — The therapeutic efforts must be directed especially toward 
 bringing the general health up to the highest point. The best of food and 
 out-door life and sufficient exercise will be indicated. Cod-liver oil-, iron, and 
 some form of iodine are the drugs most to be recommended. The local treat- 
 ment of the diseased glands and the consequent ulcers of the skin belong more 
 to the realm of surgery than to dermatology, and the reader is referred to 
 works on this branch of medicine for full details of the various operative pro- 
 cedures. When the ganglia have not yet broken down an ointment of iodo- 
 form, rubbed in several times a day, is said sometimes to cause their resolution. 
 This ointment may be made thus : 
 
 1^. Iodoformi 3j. 
 
 Vaselini §j. — M. 
 
 In lichen scrofulosorum the remedy most in favor is cod-liver oil, given in 
 full doses and also rubbed into the affected skin. 
 
 Syphiloderma. 
 
 Under the term syphiloderma are included all those manifestations of 
 syphilis which occur upon the cutaneous surface. In children syphilis is 
 almost exclusively a congenital disease. In those exceedingly rare cases where 
 it is acquired it runs the same course and presents the same lesions as the 
 acquired disease in adult life. In congenital syphilis, however, the skin mani- 
 festations present certain peculiarities which place the syphilodermata of child- 
 hood, as it were, in a special class. 
 
 A foetus affected with syphilis may die in utero, and thus occasion an 
 abortion ; the pregnancy may progress to term and the child be born with the 
 signs of the disease upon its body ; or it may be born apparently healthy, and 
 the skin lesions of syphilis develop only after several weeks. At times infants 
 will be seen presenting evidences of hereditary syphilis in whom no actual 
 eruption may be found upon the skin, but in whom the nutrition of the skin 
 is evidently affected, as it is thin and dry, wrinkled, and parchment-like. 
 
 The syphilodermata are accompanied by the general manifestations of the 
 disease, such as inflammations of the nose and larynx, giving rise to "snuffles" 
 and hoarseness ; periostitis and epiphysitis of the bones ; loss of the hair and 
 eyelashes ; iritis, etc. 
 
 Congenital syphilis of the skin presents itself as erythematous, papular, 
 vesicular, pustular, bullous, and tubercular eruptions ; but it must be remem- 
 bered that these various elementary lesions may coexist in the same subject 
 or be evolved from one another, just as happens in the acquired forms of the 
 disease. Upon the bodies of infants the erythematous sypliiloderm may pre- 
 sent an appearance and grouping similar to the erythematous syphilide as it 
 
1144 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 occurs in acquired syphilis : this, however, is not the most common appearance 
 of this form of eruption. The erythematous rash usually begins about the but- 
 tocks and perineum, or at times about the neck, as reddish macules, which soon 
 coalesce to form sheets of yellowish-red, shining, often slightly moist skin, 
 which resembles an intertrigo. The eruption differs from intertrigo in that 
 it is not confined to those parts kept warm and damp, as by the diaper, but 
 extends both above and below, being found especially along the back of the 
 thighs and legs, and even on the soles. In regions where warmth and moist- 
 ure are not present the rash is usually accompanied by a slight branny 
 desquamation. While the eruption is upon the body the palms and soles may 
 be found red and scaling. 
 
 The papular syphiloderm is the next most common rash of congenital 
 syphilis. The papules are generally discreet, sometimes grouped, flat, more 
 rarely acuminate, and may exist alone or be combined with erythematous erup- 
 tions ; the papules occasionally scale slightly, are of the brownish-red tint of 
 syphilis, and when of an irregular angular outline may somewhat resemble the 
 lesions of lichen planus ; when they occur around the mouth or anus or in 
 other regions where they are exposed to irritation, they may become trans- 
 formed into mucous patches exactly like those which are found with acquired 
 syphilis. Around parts which are much in motion the presence of the papules 
 causes cracks and fissures, which result in scars, such as are commonly seen in 
 the angles of the mouth and nose in syphilitic children. 
 
 The vesicular lesion, as the primary form of congenital syphilis, is rarely 
 seen ; vesicles are more commonly found developing after some other lesion, 
 as upon papules. 
 
 The pustular syphiloderm occurring early indicates a severe affection; it 
 may be present on any part of the body, but is usually most abundant on the 
 face, buttocks, and thighs ; about the mouth crusts are apt to form, covering 
 superficial ulcers ; pustules sometimes form around the borders of the nails. 
 Secondary suppuration may supervene upon any syphilitic rash, and is to be 
 distinguished from the real pustular syphilide. Barlow has described a syph- 
 ilitic eruption which occurs as small cutaneous abscesses, resembling boils, but 
 having no cores. 
 
 The bullous syphiloderm occurs quite frequently in the first two weeks of 
 life, and indicates a severe phase of the disease. The bullae nearly always 
 affect the palms and soles ; they may occur on other portions of the limbs and 
 about the lower part of the face, but often spare the trunk entirely. The 
 bullous lesions develop upon dusky-red areas as small vesicles or pustules, 
 which rapidly grow to the size of a pigeon's egg or larger ; they may be tense 
 or flaccid, round or irregular in outline, and are usually filled with a cloudy, 
 purulent fluid which sometimes is bloody. When the bullae rupture a dark 
 brownish-red, somewhat thickened base remains covered with the remnants 
 of the roof of the bulla ; at times greenish crusts form, covering an unhealthy 
 ulcerating surface. Death frequently follows this form of syphilis, though by 
 prompt and efficient treatment life may be saved. 
 
 The tubercular syphilide is not frequent in hereditary syphilis, and then it 
 occurs late, so that it will rarely be found in children. When seen, this erup- 
 tion is similar to that found in the adult, and most frequently occurs on the 
 face and anterior surface of the legs. 
 
 The gumma is a lesion not uncommon in hereditary syphilis, though it is 
 usually a late lesion. Gummata when present exhibit the ordinary signs of 
 these lesions as seen in acquired syphilis, which are so well known as not to 
 
DISEASES OF THE SKIN. 1145 
 
 require special description here. They may occur upon any part of the body, 
 singly or in groups. 
 
 Etiolog-y. — Syphilis occurring in children is usually the result of a pre- 
 viously existing syphilis in one or both parents. The disease may be transmitted 
 by either mother or father. If the mother be syphilitic, abortion is more likely 
 to occur than where the disease is transmitted by the father, since not only is 
 the ovum directly syphilized by her, but the nutrition of the embryo is inter- 
 fered with by the impaired state of the parent's blood. In regard to the 
 question whether a woman who is free from syphilis at the time of her impreg- 
 nation by a healthy man, but who contracts the disease at a later period of her 
 pregnancy, can then infect her foetus, there is great difference of opinion. 
 The experiments of Pellizzari go to show that the vehicles of syphilitic virus 
 are cells, or, at all events, formed albuminous bodies. Under ordinary cir- 
 cumstances only the serum of the blood of the mother passes into the circula- 
 tion of the foetus, and we should not expect it to become thus infected ; but 
 the writer can see no reason why, if some syphilitic inflammation occur in the 
 placenta, the cellular elements bearing the poison might not pass directly into 
 the foetus. 
 
 It seems to be a fact founded on careful observation that mothers of syph- 
 ilitic children who are themselves apparently healthy do not acquire the dis- 
 ease from nursing and handling the children, while healthy nurses often do : 
 the facts disclosed by modern research concerning the immunity against infec- 
 tions conferred by the so-called antitoxins of the blood-serum of an animal 
 suffering from the disease, when introduced into the blood of another animal, 
 are of interest in this connection. 
 
 Diagnosis. — In making the diagnosis of hereditary syphilis a thorough 
 knowledge of the personal history of both parents is of importance ; but in 
 the absence of such knowledge the diagnosis can usually be made by attention 
 to the characteristics of the lesions as they present themselves upon the child's 
 body. 
 
 The erythematous syphilide is most apt to be mistaken for an intertrigo 
 on account of its situation, but it differs in the fact that it extends beyond 
 the regions which alone would be involved in intertrigo. 
 
 The bullous syphilide may be mistaken for acute pemphigus neonatorum, 
 but it can be distinguished by the facts that the bullae are in the palms of the 
 hands and upon the lower part of the face, while the trunk is left almost free, 
 and that they are often seated on an infiltrated brownish-red base and contain 
 cloudy serum or pus. 
 
 Prognosis. — In a general way it may be said that the greater the length 
 of time between the acquiring of syphilis by the parent and the procreation 
 of the child, the better will be its chances for life. The date of appearance 
 of the rash on the infant and its severity will largely determine the prognosis ; 
 thus a child born with a bullous eruption will very likely die in a few days, 
 while one developing a roseola in the second month will probably survive. 
 
 Treatment. — The treatment of hereditary syphilis is conducted in accord- 
 ance with those principles which govern the therapy of acquired syphilis in 
 the adult, with such modifications as are demanded by the age of the patient. 
 For a very long time efforts have been made to introduce medicaments into 
 the nursing infant along with the mother's milk : for this purpose mercury 
 has been administered to the mother even when she gave no evidence of the 
 disease. Only the most minute quantity of mercury has ever been discovered 
 in the milk under such circumstances, so that, save as an accessory form of 
 treatment, it is not to be recommended. 
 
1146 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 The best method of administering mercury to infants is unquestionably by 
 a modified form of inunction. The preparation best adapted for this purpose 
 is an ointment of equal parts of unguentum hydrargyri and vaseline. A piece 
 of this as large as a hazelnut is rubbed into the abdomen of the child night 
 and morning, and the entire abdomen is closely covered with a white flannel 
 binder. Once a day the abdomen should be washed with warm water and 
 white castile soap before new ointment is applied. The same binder should be 
 used continuously, as it becomes gradually charged with the ointment, so that it 
 produces a constant inunction with every motion of the infant. In case the skin 
 becomes irritated, the application may be temporarily suspended, or inunctions 
 given in the usual way may be substituted till the binder can again be applied. 
 
 If there be lesions upon the belly which will prevent the use of the method 
 just described, mercury should be administered by the mouth. Calomel and 
 mercury with chalk are the preparations most used ; from one-eighth to one- 
 half grain of either preparation, made into a powder with sugar of milk, should 
 be placed upon the infant's tongue just before it is to be nursed, three times 
 a day. Tannate of mercury, in doses of one-twentieth to one-eighth of a grain, 
 is prompt in its action, and is said not to be likely to cause intestinal disturb- 
 ance. The bichloride of mercury has many enthusiastic advocates. One of the 
 best methods of giving it is in the form of Van Swieten's liquid, the formula 
 of which is — 
 
 3^. Hydg. bichloridi 1 part. 
 
 Spts. rectificat 100 parts. 
 
 Aquae 900 parts.— M. 
 
 Five to ten drops of this should be given three times a day. 
 
 The administration of mercury by hypodermatic injection has been in use 
 for many years : it gives prompt results, and the intestinal tract is not irri- 
 tated as when the remedies are given per os. As the method partakes some- 
 what of the nature of a surgical operation, the parents nearly always raise 
 objections to its employment; its use will therefore usually be confined to 
 those cases in which the symptoms are very urgent. In the hypodermatic 
 administration of mercury the bichloride is the most satisfactory salt, and 
 should be given in doses of one one-hundredth to one twentieth of a grain. 
 
 The use of bichloride-of-mercury baths is of value, principally as an aid 
 to other methods of giving the drug. Seven to thirty grains, with an equal 
 quantity of ammonium chloride, are dissolved in some hot water, which is 
 added to a bath consisting of eight gallons of warm water ; the child should 
 remain in the bath from five to ten minutes, and should then be warmly 
 wrapped up ; the bath may be repeated every second or third day. If no 
 signs of weakness or loss of appetite result and the patient improves, the use 
 of the baths may be continued. 
 
 The use of iodide of potassium is restricted to the later manifestations of 
 hereditary syphilis, such as gummata, bony lesions, cerebral affections, eye and 
 ear troubles, etc. When thought necessary, it may be given by itself in doses 
 of one to five grains three times a day, freely diluted, or it may be prescribed 
 with more benefit in combination with mercury : 
 
 1^. Hydg. bichloridi gr. j. 
 
 Potass, iodidi fss. 
 
 Syr. aurantii cort 
 
 Aquae da flij. — M. 
 
 Sig. Five to ten drops, with plenty of water, three times a day. 
 
DISEASES OF THE SKIN. 1147 
 
 Aside from the specific treatment of syphilis itself as detailed above, the 
 general health of the child should be cared for. It should have mother's milk 
 if possible : when this cannot be given, a young syphilitic wet-nurse should 
 be obtained, for a healthy woman by suckling a syphilitic child exposes her- 
 self to great risks. In the absence of either one of these means of supplying 
 nourishment, cow's milk, properly diluted to render it as nearly as possible 
 like human milk, should be given. It will often be of the utmost importance 
 to endeavor to assist the general nutrition by the administration of cod-liver oil, 
 malt, and hypophosphites. If the child be anaemic, some preparation of iron 
 will be beneficial ; it may be given in the form of the saccharated carbonate, 
 or, if mercury be administered by the mouth, the lactate of iron may be com- 
 bined with it : 
 
 1^. Hydrarg. chlor. mit gr. iss. 
 
 Ferri lactatis gr. v. 
 
 Sacchari albi q. s. — M. 
 
 Ft. pulv. No. x. 
 Sig. One to four a day. 
 
 In whatever form mercury is given, its effect must be closely watched ; 
 upon the appearance of anaemia or intestinal trouble or general weakness it 
 should be temporarily suspended. Even if the child be doing well it is always 
 best to stop the drug, during the whole course of treatment, at the end of 
 every month ; after a week or so it may be again resumed. The treatment 
 should be continued for some time after all signs of syphilis have disappeared, 
 and the patient should then be constantly under the notice of the physician, 
 so that at the first sign of any relapse treatment may be resumed. 
 
 In the presence of ulcerative lesions local applications should be made ; 
 after the ulcer is thoroughly cleansed with some antiseptic solution, it should 
 be dusted with the following powder : 
 
 1^. Zinci oxidi 3iij. 
 
 Iodoformi 3ss. 
 
 Hydg. chlor. mit 3ss. — M. 
 
 The ulcer, if discharging, should then be dressed with bichloride gauze, 
 but if fairly dry unguentum vaselini plumbicum may be spread on cloth and 
 placed over it. Condylomata and mucous patches should be frequently washed 
 with a 2 per cent, carbolic-acid solution, thoroughly dried, and then dusted 
 with the same powder. In some cases the use of iodoform excites a dermatitis 
 of the surrounding skin ; it should then be left out of the formula. 
 
 Affections of the mucous membranes, such as " snuffles," should be treated 
 by douches of a 2 per cent, boric-acid solution, and any localized lesions 
 touched with nitrate of silver in strengths appropriate to the condition. 
 
1148 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 PARASITIC AFFECTIONS. 
 
 Tinea Favosa. 
 
 Favus is a vegetable parasitic disease affecting the skin and its append- 
 ages. It is most common on the hairy scalp, though it occurs on the gen- 
 eral surface, and at times attacks the nails. On the scalp the favus fungus 
 grows in the hair-follicle, in which it gives rise to an inflammation which 
 often spreads to the adjacent tissues. If seen in the beginning, erythem- 
 atous, scaly, itching patches will be noticed ; after a time the scutula de- 
 velop, and these are the characteristic clinical signs of the disease. At its 
 full development the scutulum is a sulphur-colored, cup-like mass, slightly 
 
 Fig. 3. 
 
 Achorion Schoenleinii in hair-shaft and follicle (after Kaposi). 
 
 elevated above the surface of the scalp, surrounding a hair and dipping into 
 the follicle ; these cups are about an eighth of an inch in diameter. In the 
 the course of time the scutula touch each other and become fused into a 
 grayish crust, which, firmly adhering to the base of the hairs, may cover a 
 large portion of the scalp. The hairs in the affected area become dry and 
 
PLATE XXVIII. 
 
 
 
 %©|> 
 
 wmm 
 
 «® 
 
 
 fill 
 

 DISEASES OF THE SKIN. 
 
 1149 
 
 lustreless, and, as their nutrition is destroyed by the fungus, gradually fall, 
 thus leaving irregular more or less bald areas. A peculiar odor is to be 
 detected in those suffering from favus, which has been likened to the odor of 
 a mouse's nest. When favus attacks the general surface, it usually commences 
 as vesicles surrounded with inflammatory areolae ; after a time the characteristic 
 scutula develop upon the skin. When the nails are involved a yellow spot, 
 in reality a scutulum, may occasionally be seen at one point : more often, how- 
 ever, the nails become rough, dry, brittle, pitted, and gradually crumble away. 
 When the disease has existed upon the scalp for any length of time, permanent 
 atrophy and loss of hair result. The affection generally begins in childhood, 
 and, untreated, may persist for years or throughout life. The subjective symp- 
 toms are limited to a slight itching. 
 
 Under the microscope the scutula are seen to be formed almost entirely 
 of fungus. 
 
 Etiology. — All those conditions which depress the general nutrition, such 
 as bad food, foul air, and filthy surroundings, predispose to favus. The dis- 
 ease exists in many of the lower animals — cats, mice, etc. — and it is likely 
 that it is often conveyed from these to man. The cause of tinea favosa is the 
 achorion Schoenleinii (Fig. 3), which invades the horny layers of the epidermis, 
 the root-sheaths of the hair especially, and often the hair itself. Recently, 
 Quincke, Unna, and others have separated the achorion Schoenleinii into sev- 
 eral varieties : certain trifling clinical differences in favus may be accounted 
 for by the presence of one or the other of these forms. 
 
 Fig. 4. 
 
 Achorion Schoenleinii (after Kaposi). 
 
 Microscopically, the fungus of favus is distinguished by the short and 
 jointed appearance of the mycelia, by the rarity of the smooth-bordered 
 mycelia, and by the great number of conidia (Fig. 4). Unna states also that 
 the mycelia of favus grow at right angles to the strata of the horny layer of 
 the epidermis, while in other fungi the direction is more nearly parallel. 
 
 Diagnosis. — Only in the beginning, or after the scutula have united into 
 a large mass will the diagnosis be difficult : here it is necessary to distinguish 
 favus from eczema, ringworm, psoriasis, seborrhoea, and lupus erythematosus. 
 The simplest way of arriving at a definite diagnosis is by an appeal to the 
 microscope. 
 
 Prognosis. — The prognosis must be given with care. When upon the 
 
1150 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 scalp, if the disease has been of long standing, there will be permanent loss 
 of hair. When apparently cured it is prone to relapse. 
 
 Treatment. — Whatever method of treatment may be pursued, it must be 
 supplemented by patience and perseverance. In recent cases the disease may 
 yield promptly, but in those of longer duration treatment must be continued 
 for months. If any depraved state of the general health be noted, it must 
 receive attention. The treatment of the disease itself is purely local. First, 
 the crust must be removed ; this is best done by cutting the hair short and 
 then saturating the scalp for a night or two with sweet oil, when the crusts 
 may be readily scraped away with a spatula. Perhaps the most important part 
 of treatment is epilation, as by this procedure not only are masses of the fungus 
 actually removed with the diseased hair, but the follicle is thus opened up and 
 more readily permits the entrance of medicaments. Epilation, if practised 
 over a small area at a time, is not a severe operation, especially as the hairs 
 are loosened by the disease. As soon as the hairs have been removed the 
 following solution should be applied : 
 
 !ty. Hydg. bichloridi gr. ij-iv. 
 
 Alcoholis . . . flj. — M. 
 
 This solution should be mopped on the affected area once a day, and especially 
 applied to those parts that have just been epilated. 
 
 An ointment of chrysarobin and ammoniated mercury has been useful in 
 the hands of the writer : 
 
 ^. Chrysarobini £ss. 
 
 Hydrarg. ammoniati gr. xx. 
 
 Vaselini §j. — M. 
 
 Sig. Rub in well at night. 
 
 Chrysarobin is prone to excite in many persons an erysipelatous inflammation 
 of the scalp, and its use therefore demands caution : it is best to begin with 
 a weak ointment and gradually to increase the strength. 
 
 A great number of parasiticides have been recommended by authors, among 
 them sulphur, tar, carbolic acid, salicylic acid, sulphurous acid, oleate of cop- 
 per, various preparations of mercury, etc. It will often be found necessary to 
 vary the use of these drugs, as they seem to lose their effect after a time. 
 
 While the diseased area is being treated with these remedies the whole 
 scalp should be washed daily with a saturated watery solution of boric acid, 
 the intent of this procedure being to prevent the inoculation of the fungus 
 upon new areas. Every two or three days it will be necessary to remove the 
 old ointment by shampooing with a liquid soap made thus : 
 
 fy. Saponis olivae prsep., 3iij. 
 
 Alcoholis fsiij- — M. 
 
 Sig. A tablespoonful for each shampoo. 
 
 After the treatment has been continued till all signs of the disease have 
 disappeared, the patient should be kept under observation for several months, 
 and at the first sign of relapse treatment should again be actively instituted. 
 
DISEASES OF THE SKIN. 
 
 1151 
 
 Tinea Trichophytina. 
 
 The trichophyton fungus grows in the skin, hair, or nails ; in each situ- 
 ation it gives rise to such peculiar clinical phenomena as to merit a special 
 name. As seen on the skin the disease is known as tinea circinata, or ring- 
 worm of the body. The most common sites of the eruption are the ex- 
 posed surfaces — the face, the neck, the hands. The first evidence of the 
 disease is usually a small, faint red, slightly raised, scaling spot ; this soon 
 begins to spread peripherally, while at the same time healing occurs in the 
 centre ; thus there is produced a ring of small scaling papules enclosing a 
 healthy area of skin. The border goes on enlarging till it reaches the size 
 of a dollar, when the disease may spontaneously disappear, or remain station- 
 ary for an indefinite time. Often there are several such rings close together ; 
 as they enlarge their borders touch, and, disappearing where contact occurs, 
 leave gyrate figures. Occasionally several rings may be found, one within the 
 other. If the inflammation excited be severe, we may see the border composed 
 
 Fr.G. 5. 
 
 Trichophyton tonsurans in hair-shaft and follicle (after Kaposi). 
 
 of vesicles or pustules instead of papules. Occasionally the centre fails to 
 clear up as the border grows, and thus plaques of reddened, somewhat thick- 
 ened, scaling skin occur. Rarely the disease involves the nails, when they 
 become rough, lustreless, and brittle. 
 
 Tinea tonsurans, or ringworm of the scalp, is almost never found in the 
 adult, being essentially a disease of childhood. It occurs as one or more circu- 
 lar scaly patches, in which the stumps of broken hairs may be seen, not lying 
 in one way, as is natural to the hair of the scalp, but pointing in all directions. 
 The color of the affected scalp varies, in dark complexions being a dirty gray, 
 while in blonds it is a faint red. When the hair becomes diseased, it loses its 
 lustre and is very brittle, so that it readily breaks off. The loss of hair in 
 
1152 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 the patches is occasionally complete, and the scalp is left smooth and shining, 
 so that the disease is indistinguishable from an alopecia areata. In a rare 
 form of the disease, known as tinea tonsurans disseminata, there occur scat- 
 tered over the scalp small clumps of diseased hairs. Sometimes small pustules 
 may be seen around some of the hairs in an affected area ; this resembles what 
 occurs in a more severe form in kerion, which is an acute folliculitis, giving 
 rise to a circumscribed, doughy swelling, studded over which may be seen the 
 widely-gaping diseased follicles. When pressure is made upon such a swelling, 
 a thick muco-purulent material exudes from the follicles, which have usually 
 lost their hairs. 
 
 Ringworm of the scalp is not accompanied by subjective symptoms. 
 Untreated it may continue indefinitely. 
 
 Etiology. — The cause of ringworm is the trichophyton fungus. 1 It is an 
 odd fact that it attacks the scalp almost always only in children, while the 
 general surface may be affected at any age. The fungus exists in the lower 
 animals, and may be transferred from them to man ; it grows only in the epi- 
 dermic structures, and is not found in living tissues. 
 
 Diagnosis. — Tinea circinata must be distinguished clinically from syphilis, 
 eczema, psoriasis, and seborrhcea. In syphilis the concomitant symptoms will 
 generally suffice for differentiation ; the border of the circinate syphilide is 
 more sharply defined and of a darker red color than the border of ringworm ; 
 the erythematous syphilide is widely diffused and scaling is absent. In eczema 
 the itching forms a marked feature, and the disease, as a rule, does not present 
 the sharply-defined border of tinea circinata, while exudation and crusting are 
 more marked ; furthermore, when tinea occurs in solid plaques, so as to 
 resemble eczema, it is often present simultaneously on the scalp. The lesions 
 of the circinate form of psoriasis present a heavier scaling, and the disease 
 may often be found occupying its characteristic sites on the knees and elbows. 
 In seborrhcea the scales are thick and greasy, and on their removal patulous 
 sebaceous ducts may be seen. 
 
 Tinea tonsurans may be confounded with alopecia areata and eczema, pso- 
 riasis, and seborrhcea affecting the scalp. In eczema the patches are not sharply 
 limited, crusting and itching are present, and the hairs are only matted to- 
 gether, not broken, as in tinea. In psoriasis the scales are thick and abun- 
 dant : the hairs are not affected ; and the disease may be found elsewhere, 
 occupying its favorite sites. Seborrhcea usually affects the whole scalp ; the 
 scales are greasy ; and, though the hair is thin, no broken or twisted stumps 
 are seen. Ordinarily tinea presents a very different appearance from alopecia 
 areata with its smooth shining patches of perfectly bare scalp ; in those cases 
 of tinea mentioned above, which very closely resemble alopecia areata, often 
 some affected hairs may be discovered at the border of the patches, and a 
 microscopical examination may reveal the true nature of the disease. 
 
 In every case of tinea the surest way of avoiding mistakes is by a micro- 
 scopical examination. Scales should be removed or hairs drawn and placed 
 in a few drops of liquor potassse upon a slide and covered with a cover-glass ; 
 after a few hours the scales or hairs will be rendered transparent enough to 
 permit the fungus to be seen. The trichophyton fungus occurs as smooth- 
 bordered branching mycelia, and as conidia, single or in chains (Fig. 5) ; in the 
 hair both forms may be found in the inner root-sheath and in the substance 
 of the hair itself. 
 
 Prognosis. — Ringworm of the body is readily curable. On the scalp it may 
 last indefinitely unless the treatment be kept up with untiring patience and vigor. 
 
 1 Recently Sabouraud and others have described four varieties of the trichophyton fungus. 
 
DISEASES OF THE SKIN. 1153 
 
 Treatment. — The treatment of tinea circinata is purely local ; it is usuj 
 readily cured. Often a few applications of tincture of iodine will suffice, or 
 one of the following ointments may be used : 
 
 E.. Acidi salicylici gr. xxx. 
 
 Sulphuris pnecip 3j. 
 
 Vaselini §j. — M. 
 
 Sig. Rub into affected area once or twice daily. 
 
 1^. Hydrarg. ammoniati gr. xx. 
 
 Lanolini lj. 
 
 Olei olivne f^ij . — M. 
 
 Sig. Apply twice a day. 
 
 Ify. Cupri oleatis 3ss-j. 
 
 Yaselini 3j. — M. 
 
 Sig. Apply twice a day. 
 
 In the treatment of tinea tonsurans the entire armamentarium of the 
 physician will sometimes be required to bring about a cure. As a preliminary 
 step the hair should be cut short and all scales removed. Epilation, though 
 not absolutely necessary, is no doubt of assistance, and should be practised in 
 all inveterate cases ; many advise removing the hairs from the area immedi- 
 ately surrounding the patch of tinea, thus hindering its spread. During the 
 whole course of treatment the head should be washed daily with soap and 
 water, and then sponged with a saturated solution of boric acid. In young 
 children, the disease in the beginning will often yield to a simple ointment like 
 the following : 
 
 1^. Sulph. praecip 3j. 
 
 Ung. aq. rosae 3ij. 
 
 Lanolini 3vj. — M. 
 
 Sig. Apply twice a day. 
 
 Coster's paint may be applied to the patch with a stiff brush every four or 
 five days, the formula of this is : 
 
 1^. Iodine 3ij. 
 
 Colorless oil of wood-tar 3v. — M. 
 
 In an epidemic recently treated, the application of a 1 per cent, aqueous 
 solution of rosanilin hydrochlorate, rubbed in well once a day, served to check 
 promptly the disease in its early development. 
 
 Of the mercurial preparations, the oleate and white precipitate are the 
 most efficacious. They may be prescribed in the form of ointments varying 
 from 2 to 5 per cent. 
 
 In the experience of the writer the most valuable drug in the treatment 
 of chronic cases is chrysarobin. It may be used in the form of an ointment 
 slightly modified from that recommended by Hutchinson : 
 
 1^. Chrysarobini 3ss-j. 
 
 Hydrarg. ammoniati gr. xx. 
 
 Liq. carbonis detergentis Tfl.xx. 
 
 Lanolini 5,j- 
 
 Olei olivae fej. — M. 
 
 Sig. Rub in at night. 
 
 73 
 
1154 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Chrysarobin must always be used with caution on account of its tendency to 
 excite severe inflammation. 
 
 Crocker thinks highly of the use of croton oil in cases of limited extent 
 in children over six years old ; it may be used in a liniment with olive oil, 
 1 : 10, rubbed into the patch until inflammation is excited ; or it may be 
 pricked into the diseased follicle with a needle ; the suppuration which the 
 croton oil excites destroys the fungus. 
 
 Of late much has been said in favor of the employment of electric cata- 
 phoresis in the treatment of tinea tonsurans. The positive sponge electrode 
 is saturated with a 1 per cent, solution of corrosive sublimate and applied to 
 the patch, while the negative electrode is placed upon some other part of the 
 body. 
 
 When the fungus has invaded only a few follicles or remains in a limited 
 number in spite of treatment, the electric needle may be introduced and the 
 follicle destroyed. 
 
 In kerion the hairs should be pulled and some soothing antiseptic ointment 
 applied. 
 
 In any case of tinea tonsurans treatment is to be actively continued as 
 long as any hair-stumps can be detected. 
 
 
 Fig. 6. 
 
 Scabies. 
 
 This disease is not so common in this country as on the Continent. The 
 lesions seen in scabies are due to the ravages of the itch mite (acarus 
 scabiei). It is only the female which attacks the skin, the male merely 
 
 remaining upon the surface. The 
 female burrows under the epithelium 
 for the purpose of laying her eggs. 
 She lives about two months, and 
 lays in this time about fifty eggs, 
 which hatch in two weeks. The 
 itch-mite selects those parts of the 
 skin in which to make her burrow 
 where the epithelium is not very 
 dense, as between the fingers, flex- 
 ures of the joints, axillae, about the 
 genitals, etc. 
 
 The lesions found in scabies are 
 those directly due to the presence 
 of the mite and secondary ones due 
 to scratching. The burrow is the 
 most characteristic lesion. This 
 consists of a small, fine, black, 
 zigzag line, from one-eighth to 
 one-half an inch long, lying just 
 beneath the upper layers of the 
 epidermis. It is often difficult to 
 find the burrows, as scratching 
 and bathing destroy them. Sometimes the acarus 
 one end of the burrow as a small white speck. 
 
 The presence of the itch-mite excites various grades of inflammation: 
 papules, vesicles, and pustules will be found intermingled on those parts of 
 the body where the skin is thin and where warmth and moisture exist. In 
 
 Female Acarus (after Anderson). 
 
 may be seen lying 
 
DISEASES OF THE SKIN. 1155 
 
 infants in arms the face is often involved, as it is kept warm by pressure 
 against the mother when the child nurses ; the feet and buttocks may present 
 the lesions of scabies, as they are protected by the warm clothing. Itching 
 is severe, and we usually find various lesions as the result of scratching — 
 scratch-marks, crusts, furuncles, and pigmentations. None of the lesions of 
 scabies show any tendency toward grouping, but are scattered irregularly over 
 the surface. 
 
 In severe cases nearly the whole body may be involved, while in very mild 
 ones only a few scattered papules or vesicles may exist. If not treated, the 
 disease may persist for years. 
 
 Etiology. — Though markedly contagious, the disease does not seem to be 
 communicated by ordinary contact, but only by prolonged exposure, such as 
 wearing infected garments or sleeping in infected beds. No age, sex, or social 
 condition is exempt, but filth and infrequent bathing give the acarus a better 
 chance by leaving its burrow undisturbed. 
 
 Diagnosis. — Scabies might be mistaken for an eczema, but eczema does 
 
 Fig. 7. 
 
 Larva (after Anderson). Male Acarus (after Anderson). 
 
 not present such multiformity of lesions, is not apt to be so widely dissem- 
 inated, and the individual elements are aggregated or grouped. The finding 
 of the burrow, and more especially of the acarus itself, is proof positive of 
 scabies (Figs. 6, 7, 8). 
 
 Prognosis. — The prognosis of scabies is always favorable. 
 
 Treatment. — The disease is readily cured if the treatment be properly 
 carried out. Before any local application is given the patient should receive 
 a hot bath, with thorough rubbing, using green soap. Probably the most 
 generally successful remedy in the treatment of scabies is sulphur. The fol- 
 lowing ointment should be well rubbed in over all the affected parts of the 
 body morning and evening for three days : 
 
 ]^. Sulphuris prsecip oiij-vj. 
 
 Vaselini o v J* 
 
 01. rosse q- p.— M. 
 
 The same under-clothing and sheets should be used until the treatment is 
 completed ; then the patient takes a hot bath with soap, puts on fresh under- 
 clothes, and sleeps between clean sheets, all that he has previously used being 
 boiled ; his outer garments should be ironed with a very hot iron. 
 
1156 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Many other remedies have been recommended, and a few of the most use- 
 ful formulae are added : 
 
 Ify. Styracis liquidi fj§j. 
 
 Adipis ij.— M. 
 
 Sig. Rub in twice a day. 
 
 ~fy. Sulphuris praecip 3j. 
 
 Balsami Peruv. . . 3ss. 
 
 Vaselini Ij.— M. 
 
 Sig. Rub in twice a day. 
 
 Kaposi advises the use of naphthol. 
 
 It is of the utmost importance, no matter what method of treatment may 
 be used, to prevent reinfection by attention to the rules in regard to clothing 
 and bedding above laid down. If, when specific treatment is completed, the 
 skin remains inflamed and irritable, some soothing ointment should be used ; 
 the following answers very well : 
 
 1^. Zinci oxidi 3J. 
 
 Ung. aq. rosae 3ij. 
 
 Lanolini £vj. 
 
 Sig. Apply as often as necessary. 
 
 Pediculosis. 
 
 In the children of the poor the head-louse is very common, and occasion- 
 ally the pubic-louse may be found on the hairs of the eyebrow or on the 
 
 lashes. On the head the louse (Fig. 9) 
 
 is most apt to confine itself to the occip- 
 ital region ; here the irritation it causes, 
 
 together with scratching, soon sets up a 
 
 dermatitis, which may range from a few 
 
 scattered pustules to a condition in which 
 
 the whole region is covered by crusts 
 
 and exudes a thick, sticky liquid, which 
 
 mats the hair and by its decomposition 
 
 gives rise to a disagreeable odor : this 
 
 purulent matter may be conveyed to 
 
 other parts of the body upon the fingers, 
 
 and thus set up a pustular eruption. 
 
 The lymph-ganglia of the neck, which 
 
 communicate with the lymphatic chan- 
 nels of the scalp, are apt to become enlarged, tender, 
 and in poorly-nourished children may suppurate. If the 
 hair be long, so that it hangs upon the neck, a similar 
 dermatitis may be caused in that region. 
 
 Whenever we find a pustular eczema confined to the 
 occipital region of a child, we should at once look for 
 pediculi. If these are present only in small numbers, 
 it is often easier to discover the eggs or nits than the 
 louse. Usually one or two nits will be attached to a 
 single hair, though sometimes many are found upon one 
 shaft ; they appear as small white specks firmly attached to the side of a 
 hair. They may be mistaken for crusts, but a hair passes through the centre 
 of a crust, and a crust may be easily brushed away, while a nit is firmly 
 
 Fig. 9. 
 
 Fig. 10. 
 
 Male Pediculus 
 
 Capitis 
 (after Kuchen- 
 
 meister). 
 
 Nits of Pediculus Capitis 
 (after Kaposi). 
 
DISEASES OF THE SKIN. 1157 
 
 glued to the shaft. In the rare cases where the pubic louse has infested the 
 eyebrows or lashes of a child, the most noticeable signs of its presence are the 
 punctate haemorrhages in the surrounding skin, caused by the bite of the 
 insect. In these regions the pediculi and their knits may be found upon 
 the hairs close to the skin. 
 
 Etiology. — Pediculosis is contracted by contact with a lousy person or some 
 object containing pediculi, such as hats, caps, and other articles of clothing. 
 
 Treatment. — In children the hair should be cut short and the crusts soft- 
 ened with olive oil and removed. The head should then be thoroughly anointed 
 with petroleum, the parents being warned not to allow the child to approach a 
 lamp or fire while the coal-oil is on the hair. The petroleum, having re- 
 mained on all night, should be washed off the following morning with soap 
 and water. Two such applications, made on successive nights, will kill the 
 pediculi, but the nits are more difficult to destroy. To remove them, in 
 cases where the hair cannot be cut off, it should be taken up in small bunches 
 and carefully sponged with vinegar ; this softens the glue which attaches the 
 nits to the hair-shafts, so that they may be readily removed with a fine-toothed 
 comb. 
 
 The treatment as above detailed, if carefully carried out, will be found 
 entirely satisfactory. If for any reason petroleum cannot be used, the follow- 
 ing ointment may be applied for several days : 
 
 ~fy. Hydrarg. ammoniati gr. xx. 
 
 Vaselini fj. — M. 
 
 Whatever method of treatment may be used, a dermatitis will still remain, 
 which should be treated by soothing ointments. 
 
PART XIII. 
 
 DISEASES OF THE EAR. 
 
 BY B. ALEXANDER RANDALL, A. M., M. D., 
 
 Philadelphia. 
 
 
 The organ of hearing is, in its normal function, one of the most important 
 of the body, especially in the child, since it is the seat of the sense which is 
 second to the sight only, if at all, as the link between the individual and his 
 fellows, and through the help of which a very large part of his education is 
 acquired and his value as a worker made available. Loss of hearing reacts 
 sadly upon most adults in cutting them off from easy intercourse, and is very 
 apt to engender a suspicious and discontented frame of mind ; while in the 
 child it is still more serious, since it bars, to a greater or less degree, so many 
 channels of learning, sympathy, and practical usefulness before they have 
 even begun to convey their wealth to the forming mind. 
 
 The diseases of the ear are of great importance, also, because of their 
 frequency and seriousness — facts which are all too little understood or accepted 
 — for they endanger life, as well as function, much oftener than do the more 
 noticed lesions of the eye, which are probably little more numerous. They 
 are far more insidious and readily overlooked in children than in adults, since 
 complaint is rarely made of any subjective symptom except pain; and only 
 slowly will parents generally appreciate that the alleged " slowness " or 
 " stupidity " of children, and their habit of " asking over again," are due to 
 a real physical infirmity. Add to this the weighty fact that in childhood are 
 quietly laid the foundations for most disqualifying and steadily progressive 
 forms of deafness, which are little amenable to later treatment, and the 
 importance becomes manifest of their recognition at the earlier period, when 
 they can be successfully combated. 
 
 Embryologically, the organ of hearing arises in three distinct portions, the 
 first being the otic vesicle, which forms as a pouch from the epiblastic surface, 
 develops to form the labyrinth, and becomes distinctly nerve-tissue in part 
 and intimately connected, by the auditory nerve, with the brain ; the second 
 is the mucous cavity, extending out and back from the pharynx in the line of 
 the closed second branchial cleft to form the Eustachian tube and tympanic 
 cavity, including the so-called mastoid antrum and the communicating cells ; 
 while the third portion is a cutaneous projection and pouch growing outward 
 and in, respectively, to form the auricle and the external auditory meatus. 
 Mesoblastic tissues remain as barriers between these parts, yet serve to link 
 them together — the tympanum having the drumhead with the malleus separating 
 it from the external ear, and the bony labyrinth-capsule with the membranes 
 of the fenestra constituting the division between it and the internal ear. 
 
 Physiologically and pathologically, this distinction is maintained; the 
 
 1158 
 
DISEASES OF THE EAR. 1159 
 
 internal ear remaining as the sound-receiving apparatus, in contrast to the 
 conducting apparatus external to it : and disease shows that the labyrinth 
 inclines to share in brain disorders ; the tympanum remains part of the upper 
 air-passages, involved in most of the lesions of that tract ; while the external 
 ear suffers little except from the disorders of the cutaneous surface. Clinical 
 work, likewise, maintains the divisions thus defined, and our methods of study 
 fall largely into the three forms of topical, pneumatic, and acoustic measures 
 according as the external, middle, or internal ear is aimed at. Treatment of 
 the aural disorders is principally on the same lines ; and, in spite of the incom- 
 pleteness of the demarcation in some instances, this forms the most natural 
 and advantageous division of our subject. 
 
 In the study and treatment of the ear in children some care is generally 
 requisite as to the holding of the patient. If small, he is usually best held 
 in the lap of an adult, as the mother, with head resting upon her breast and 
 the ear to be examined turned toward the physician. One arm passes around 
 the child's waist from behind and holds the hands, while the other is ready to 
 steady the head or meet any other requirement. Some throwing back and 
 twisting of the head may be expected ; but the physician's hand in drawing 
 and holding the auricle outward, backward, and down or up, as the config- 
 uration of the parts may demand, can take points of counter-pressure for his 
 hand upon the child's head and do much to steady it. In mopping and other 
 manipulations the movements of the child should be followed as closely as 
 possible, especially if the ear is painful, for much roughness and restraint may 
 be thus avoided. The active struggles and screaming of a child cease most 
 acceptably in many instances as the applicator actually enters the ear, and 
 perfect quiet is maintained until it is withdrawn, as though the child, in 
 anticipation of something awful, were reserving its powers to do justice to the 
 occasion. With older children quiet can often be obtained by allowing them 
 to stand or sit free, while the examination is directed first to the unaffected 
 ear, the nose, and the throat, and they are plied with questions, jesting as well 
 as serious. Moderate stillness yielded spontaneously is generally better than 
 that which can be enforced by the efforts of three or four strong adults, and 
 considerable patience in winning confidence and obedience will usually prove 
 good policy ; but if restraint has to be enforced, it should be as overwhelming 
 as possible, so as to demonstrate the futility of resistance and the real gentleness 
 of the treatment, for it is generally fright or wilfulness, rather than pain, that 
 is the disturbing element. Facility in the measures of examination and 
 treatment, especially without instrumental aids, counts for a great deal, since 
 every speculum, tongue-depressor, or other instrument may be an object of 
 terror as well as a probable source of discomfort. The unaided view into a 
 canal may be restricted and incomplete, yet if the light spot can be seen and 
 no redness is visible along the handle of the malleus, tympanic inflammation 
 may be excluded ; and flakes of epidermis, etc. along the walls may then be 
 let alone, which would be pushed up before a speculum and require removal 
 before any view could be obtained. 
 
 Affections of the External, Ear. 
 
 The external ear, although tangible and prominent, is far less important for 
 our consideration than the middle, and furnishes hardly 25 per cent, of aural 
 work ; and the labyrinth suffers so rarely that less than 10 per cent, of ear 
 diseases affect it, leaving the mucous membrane of the tympanum to bear the 
 responsibility of quite two-thirds of all aural disorders. Yet access to the 
 
1160 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 deeper structures is partly through the auditory canal, and the disorders and 
 study of this portion may best be first considered. 
 
 The auricle, as a skin-covered projection of fibro-cartilage, is open to ready 
 inspection and palpation for its study, and its position exposes it to trauma as 
 well as to various cutaneous affections. Its congenital malformations of distor- 
 tion, reduplication, or defect are of interest rather as curiosities than as path- 
 ological conditions, and, except for appearance' sake, rarely concern the aural 
 surgeon. Supernumerary auricles or auricular appendages may be removed 
 if conspicuous ; the persistence of the branchial cleft, as the so-called " aural 
 fistula," may call for a tiny plastic operation to close it; huge auricles may be 
 brought to more reasonable dimensions by the excision of a wedge-shaped seg- 
 ment, or very prominent auricles may be fastened more closely in by excising 
 a crescentic flap behind them. These are mere matters of surgical common 
 sense. Minuteness of the auricle or absence, congenital or traumatic, may 
 tempt the surgeon to plastic efforts ; but it must be remembered that without 
 cartilaginous framework any semblance of an auricle is quite hopeless, and that 
 transplanting of cartilage, except from the adjacent meatus, has always proven 
 a failure. Upon the hearing, these conditions are practically without influence, 
 and any rash experimentation is unjustifiable. 
 
 The habit of piercing the ears for ear-rings is responsible for some of the 
 lesions of the auricle, aside from the tearing of the lobules from traction upon 
 them; for the services of an itinerant vender of ear-rings are sometimes followed 
 by a surprising group of cases of abscess of the lobule, apparently affecting in 
 a neighborhood every little girl who had not previously been subjected to the 
 rather barbarous custom. Although usually limited and without diffused infec- 
 tion, these abscesses deserve some surgical care, for their healing may be slow 
 and disfiguring. The infiltration may be of less passing nature, and there may 
 result a fibroid or so-called keloid tumor, which tends to grow rather persist- 
 ently and to recur after removal. These are rather uncommon, except in the 
 negro. The malignant tumors are too rare, even in adult life, to demand notice. 
 Dermoid cysts, probably congenital, may occur in the sulcus behind the auricle, 
 and cyst-like perichondritic effusions or haematomata may fill the concavities of 
 its anterior aspect as the result of trauma. 
 
 The inflammatory lesions of the auricle are almost always of an eczematous 
 character. Herpes is rarely met and hardly distinguished with certainty, except 
 by the occurrence of severe pain for hours or days before the visible lesions. 
 True erysipelas is very rare, though not infrequently simulated by a severe 
 eczema. Specific lesions may take almost any form, though generally pustular 
 or rupial. 
 
 Eczematous Inflammations. — These are usually secondary to some irri- 
 tant, such as an excoriating purulent discharge from the tympanum ; and the 
 main measure of treatment is protection from the cause, which should be re- 
 moved if possible. The eczema is generally marked in the furrow back of 
 the auricle, where Assuring may be deep and inveterate, and cicatrization 
 may bind the auricle tightly down upon the mastoid ; but fissures of the 
 lobule and intertragus notch may be deep and disfiguring. The dyscrasia, 
 conveniently though vaguely termed " strumous," is apt to underlie and 
 strongly influence the condition ; and similar lesions of eyelids, nares, and lip 
 are apt to be present, with swelling or suppuration of the adjacent glands. For 
 its cure eczema often demands long, varied, and laborious treatment. Internally 
 such tonics as cod-liver oil, hypophosphites, and iodide of iron are called for, 
 with close attention to the hygienic surroundings. The diet must be regulated, 
 the perversions of appetite, which have often been encouraged by giving cakes 
 

 DISEASES OF THE EAR. 1161 
 
 and candy to still the fretful child, must be corrected, tea, coffee, and other 
 inappropriate food forbidden, and simple but generous nourishment given. 
 Locally, cleansing to the verge of meddling is called for as often as the lesions 
 become crusted, since healing is generally tardy or absent beneath the inspis- 
 sated discharge. Alkaline solutions or peroxide of hydrogen will soften the 
 crusts and permit their removal with little violence, and while all rude hand- 
 ling is detrimental, it is generally less so than permitting the pathological tissue 
 to remain bathed in pus and protected from medication beneath its incrustation. 
 Any of the many lauded measures may prove promptly successful or largely 
 futile, but a routine treatment, with a bland calomel ointment (gr.xx-xl, ad 
 vaseline aj), has usually served me excellently. In the very moist forms free 
 painting with silver nitrate may make a better beginning, and drying powders, 
 such as boric acid, may be used on the eczema, as well as in the suppurating 
 tympanum from which the irritation has often proceeded. The ichthyol oint- 
 ment has decided value in reducing the swollen lymph-glands, and may be well 
 used upon the infiltrated aural surfaces, especially after visible lesions are about 
 gone, yet there remains a rigidity, which is often a useful diagnostic sign. 
 
 Furuncle. — Circumscribed inflammation of the external canal is less 
 common in children • than in adults, who are more inclined to scratch the irri- 
 tated and itching surfaces caused by eczema. Yet it is met at times, as is a 
 similar lesion of the auricle. Its painfulness raises its importance beyond any- 
 thing due to its influence upon the function, although it may close the canal by 
 swelling in a way to muffle hearing and to conceal and possibly seriously 
 obstruct a deeper suppuration. Diagnosis may remain uncertain, and call for 
 treatment as though a tympanic lesion were certainly present. Cleansing with 
 hydrogen peroxide, rubbing in of a salve of the yellow oxide of mercury, and 
 firm pressure by a conical cotton pledget, will generally secure prompt resolu- 
 tion ; but sometimes this cannot be borne, and must be substituted by the 
 rather agreeable and pain-relieving hot douche. The poultice or moist warmth 
 in any form is to be deprecated, and the warmth or actual heat furnished by a 
 salt-bag or hot-water bottle must be relieved of any macerating effect by the 
 thorough drying of the ear after douching. No single measure is as valuable 
 in aural treatment as this hot douche, serving as it does to clean away secre- 
 tion, to reduce swelling by relieving stasis, and to soothe the pain ; and it is as 
 applicable to the acute tympanic inflammation as it is to the external suppura- 
 tion of the canal, ind is especially appropriate in the mixed cases. Any sort 
 of syringe, gently used, will serve, the bulb and nozzle of soft rubber being 
 often best ; but a medicine-dropper or a teapot will do nearly as well, and the 
 temperature should be as high as the patient can be induced to bear. Careful 
 use of the cotton-carrier, under illumination by the forehead mirror, should 
 follow, if possible, in order to remove the moisture, to press out secretion from 
 any open furuncle, to disclose and possibly dislodge any cerumen mass or un- 
 suspected foreign body (recent or long present) which may be hidden beyond 
 the swelling, and, as a probe, to demonstrate the most swollen and tender point 
 as a preliminary to incision. It can also seek for uncovered bone beneath a 
 discharging opening ; for it must not be forgotten that the furuncle may lead 
 to caries of the wall of the canal ; and, still more important, that burrowing 
 of pus from deeper localities, in antrum or attic, may appear externally as fur- 
 uncle-like lesions. The knife may shorten treatment and is indicated to release 
 pus, but, without prejudice to the result, it can often be dispensed with, to the 
 patient's great mental relief. When used, the smaller and sharper the blade 
 the better, a cataract knife-needle being admirably suited to this and similar 
 incisions, which may be almost painless when pointing is well marked. A 
 
1162 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 series of furuncles is to be expected, and prognosis and treatment given accord- 
 ingly. Whether to be ascribed to dyscrasia and demanding tonics, or regarded. 
 as a matter of microbic auto-inoculation to be combated by rigid antisepsis, 
 both local and general measures are indicated to forestall or control this 
 tendency. 
 
 Cerumen Impaction. — This is also much less common in the child than 
 in later life, associated as it so often is with a chronic tympanic catarrh. It is 
 almost invariably a sign of lessened, not increased, secretion of wax, with change 
 in its consistency, so that it tends to mass in dark scales or lumps instead of 
 passing constantly out in tiny, light, unnoticed flakes. Those who suffer are 
 often victims of misplaced efforts at cleanliness, for Nature is given no chance 
 to displace the material as it forms, but meddlesome attempts to hasten the 
 process push back and pack inward the emerging masses. The epithelium 
 seems to grow most rapidly at the centre of the drumhead, and to tend to push 
 outward from this point to the margins and then along the meatus walls ; so an 
 outward march of the lining skin and all that rests upon it is generally discern- 
 ible, the slow progress of which is aided, as the exit is approached, by the 
 movements of the jaw. Many have probably felt at times a little tickling in 
 the ear, and found that a wax-flake had been ejected by the spring of hairs 
 upon which it had been pressed. The movements of the auricle, also, whether 
 accidental or by its own muscles, serve to dislodge any clinging masses. Formed, 
 as the cerumen is, only in the outer two-thirds of the canal, it can only by 
 interference be pressed into the deeper parts, although the epidermal debris 
 which serves to increase the collection can arise in the neighborhood of the tym- 
 panic membrane. So long as the mass does not absolutely occlude the canal, 
 sound-waves may pass through an invisible crevice and the hearing remain 
 perfect ; but the hygroscopic mass can easily swell, if only through atmospheric 
 moisture, and thus give rise to sudden deafness. If there has been displace- 
 ment of the mass, as in the movements of the head upon the pillow, pressure 
 upon the drumhead or other sensitive point may also be suddenly caused, with 
 most varied and possibly severe, reflex attacks of vertigo, coughing, or symp- 
 toms of more remote and inexplicable character. The unsuspected presence of 
 these masses should never be forgotten, and both ears looked into, not only in 
 aural patients, but in all nasal and many other obscure cases. 
 
 Treatment. — This consists in syringing away the collection with hot water. 
 Previous instillations of oil or glycerin are to be deprecated as rarely useful and 
 not always harmless ; and medicinal additions to the syringing fluid do little, if 
 anything, to increase its efficiency. Plain water is about as good a solvent of 
 cerumen as can be found, and its value increases with its temperature. At the 
 same time, the dizziness or faintness which syringing oftener than other aural 
 manipulations is apt to cause is less probable or severe if the fluid be warm. 
 The water must be thrown with wel] -controlled and well-directed force ; so the 
 canal must be straightened by traction, illuminated with the forehead mirror, 
 and the stream directed along one wall, especially up and back, in the attempt 
 to insinuate it beside the mass. The syringe is to be emptied with gently 
 increasing force, and after the first ounce or so, the fluid ought to be stained 
 with dissolved cerumen, the softened lumps should follow, and soon the re- 
 sidual mass, softened and reduced in size, appears in the exit, and may be 
 hastened out, if it clings there, by a touch of the probe. If fair employment 
 of the syringe has not been thus successful, with good illumination and a steady 
 hand the mass may be touched with a probe, such as the cotton-carrier, and 
 gently loosened, when the syringing will probably succeed. When the epidermal 
 element is large and the solubility correspondingly small, considerable instru- 
 
DISEASES OF THE EAR. 
 
 1163 
 
 mentation may be needful ; but it takes a skilful hand to employ forceps or 
 curette safely or effectively. A small sharp spoon is a most useful instrument, 
 for with it a channel can be excavated in the centre or side of the mass, por- 
 tions displaced so as to be easily grasped and withdrawn by the forceps, or the 
 whole engaged and adroitly extracted. Yet it is decidedly dangerous, and the 
 
 Fig. 1. 
 
 The Aural Syringe in Use. 
 
 blunt ear-spoons more so than the sharp ones, since the operator is apt to pre- 
 sume upon the supposed innocuous character of the former. First and last, and 
 often between-times, the syringing is to be relied upon as the really appropriate 
 measure ; and, well used, it will rarely need much help in securing complete 
 removal of impacted cerumen at the first sitting. On clearing the canal some con- 
 gestion of the walls and drumhead is usually seen, with excoriation, perhaps, 
 if the pressure of the mass has been ill borne or the manipulation rough in re- 
 moval. The canal should be gently dried with absorbent cotton on the cotton- 
 carrier, any excoriated surfaces lightly dusted with boric acid, and the exit 
 filled with a flake of cotton in order to exclude the dust and too rapid move- 
 ment of the air. A repeated visit should be called for, to make sure of prompt 
 restoration to normal ; while any tympanic catarrh should be appropriately 
 treated at the first as well as later visits. 
 
 Foreign Bodies in the auditory canal owe their importance almost solely 
 to the utter misapprehension with which they are regarded and the maltreat- 
 ment to which the ear is often subjected on their account. They are rare, 
 and generally of no importance if let alone ; but the panic with which they are 
 frequently regarded by patient and parent is too often fostered by the almost 
 breathless haste with which the physician undertakes heroically to remove them. 
 
1164 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Placed in the canal with little pressure, kept in place often only by the force 
 of gravity, the foreign body may be ready to fall out spontaneously as soon as 
 the ear is directed downward so as to permit it. Shaking or jarring of the 
 head may greatly aid this, and rotary rubbing in front of the tragus will often 
 serve to coax an intruder out. The jaw condyle presses upon the canal and 
 narrows it, so the mouth should hang open, and the meatus should be drawn 
 outward and back to straighten it. The syringe, with warm water, is the 
 proper instrument for the removal of the great majority of foreign bodies, not 
 excepting seeds and such bodies as will swell if long soaked. Swelling of 
 the canal-walls through irritation or injury in rash attempts at removal ina;y 
 preclude prompt success by this means : if so, the hot irrigation will be of 
 value to reduce it. The canal may be dried with absorbent cotton and the 
 body dehydrated with alcohol or glycerin if maceration or germination is feared, 
 a drying powder, such as boric acid, dusted in, and, unless urgent symptoms 
 should arise, further intervention delayed until a more favorable occasion. 
 It is important, however, to preface any attempt with an explanation of the 
 intention to do only a limited amount of intervention because of the danger of 
 overdoino- ; for this will come with better grace and find readier acceptance 
 before a non-success. The temperature and general condition must be closely 
 watched if expectancy is attempted and brain-symptoms looked for ; but if 
 great violence has been done, delay is both safe and advisable. Nearly half 
 of the foreign bodies noted as found in our clinics have been present longer or 
 shorter times without the knowledge of patient or friends. 
 
 Accurate diagnosis is of course a prerequisite to any intervention, a,nd this will, 
 as usual, be much aided by inspection of the fellow-ear. Thus we can learn the 
 probable size and form of the canal, the pre-existence of eczema or other irrita- 
 tion which may have led to the introduction of the foreign body, and other 
 valuable points. Not very infrequently a foreign body is really present in the 
 fellow-ear, either because one has been placed in each ear, or because, in the 
 panic over the case, its true location has been forgotten. The cases are far too 
 numerous where harsh or destructive efforts at extraction have been blindly 
 made in the wrong ear or in one from which the intruder had alreadv fallen 
 out. The presence and the nature of a mass to be removed must, therefore, 
 be decided, although in some instances blood or swelling in a maltreated ear 
 may preclude certainty of diagnosis. The hearing should be tested by speak- 
 ing or whispering questions or commands into each ear, better with the other 
 one closed with a finger-tip ; since retention of good hearing is of good omen 
 as to the incompleteness of impaction and the uninjured condition of the tym- 
 panum — points of great prognostic importance. The 
 Fig. 2. syringe should be used gently at first, and so directed 
 
 as to seek a passage past the body if visible and local- 
 ized, the upper back wall of the canal being gener- 
 ally the best along which to throw the stream. Much 
 ingenuity has been wasted in trying to float up with 
 mercury a foreign body too heavy to be readily lifted by 
 the stream of water, when the mere inclining the ear 
 downward while syringing would have far more effect- 
 
 Metal Cast of the Audi- ,, ,. , . J ; , & & mi . . . . , 
 
 tory canal of a child, ually enlisted the aid oi gravity, lnis position is awk- 
 
 sho wing the marked flex- j j -j , i , * i . n . ,-i 
 
 ure usually found at junc- ward and need not be attempted at first, until syringing 
 
 tooV^^oSrand^flfe has been vainl 7 tried in the ordinary fashion." Here, 
 
 inclination of the drum- as i n all syringing, work under good illumination with 
 
 head. Although quite ,, „ , J , & . »' . L . ° . . .. „ 
 
 movable in the canal, the the ioreneacl mirror is strongly advisable ; lor synng- 
 Sy%io\enuractiou! n on y ing may wholly fail when blindly used, though perfectly 
 
DISEASES OF THE EAR. 1165 
 
 competent if intelligently employed, and the well-straightened canal is as neces- 
 sary for success as in inspection. When well seen, yet immovable by a strong 
 and well-directed stream of water, a gentle touch of the probe may do good 
 service, if the patient is quiet and tractable ; for much may thus be learned 
 as to the impaction, and perhaps the body rotated into better position or dis- 
 engaged. 
 
 If space beside the body can be seen and vigorous syringing has failed to 
 move it, a delicate wire-loop may be passed beyond it and serve as an efficient 
 yet gentle tractor. But all use of instruments is dangerous, even in hands 
 well accustomed to precisely these manoeuvres, and should rarely be attempted 
 except under ether, and then with great caution. Almost no form of forceps 
 is to be commended, since they are apt to injure the walls and push the body 
 deeper in the attempt to grasp it ; and slipping, as they so often will, even 
 when fairly and firmly placed, they are almost sure to drive the intruder 
 deeper. Yet some wholly unsuitable pair of forceps, thrust into the canal of 
 an unansesthetized and struggling child, on the mere suspicion of a foreign 
 body, without aid of illumination, is rather generally the first resort of the 
 practitioner who has little experience in aural work, and scarcely enough 
 knowledge of the anatomy not to share the "lay" fear that the body, unless 
 removed at any cost, may work its own way into the brain. The risk of brain 
 lesion is indeed great when the ear is subjected to such an attack, for there 
 may be no foreign body there to be encountered, and the ossicles or any other 
 normal structures may fall victims to the heroic resolve not to retire empty- 
 handed. If present, the body will probably be driven through the drum- 
 head into the tympanum, with more or less destruction of the ossicles ; and the 
 numerous fatal results on record give ghastly but incomplete evidence of the 
 seriousness of the situation. If such an impaction in the tympanum has oc- 
 curred, and the air-douches through the Eustachian tube and syringing 
 through the meatus both fail, little place remains for expectancy or gentle 
 measures. Only in cases with no fever or disquieting symptoms can the 
 brush of glue be allowed to attach itself to the mass, or delicate skilful trac- 
 tion by instruments be tried in the effort to dislodge the body. It is actually 
 safer and simpler to dissect the auricle and cartilaginous canal forward, and 
 work with free view in the short, broad bony canal, chiselling away the upper 
 back wall if greater space is needed, than to do unknown and more serious 
 damage to the deeper structures in the effort to work through the natural pas- 
 sage. The fact that this operation has not been more often done since it was 
 proposed argues little for the manual skill of aural and other surgeons, and 
 much against their wisdom and judgment. 
 
 Caries of the Wall of the Auditory Canal may occur apparently idio- 
 pathically, and cause much enlargement through loss of tissue. The granulation 
 tissue formed is sometimes redundant, and the healing process may cause fibrous 
 stenosis or division of the canal by a membranous septum across it. Bony 
 outgrowths may also arise, congenital, perhaps, in origin, yet increasing later, 
 and may narrow and close the canal. 
 
 Congenital Atresia, or defect of the meatus, may be met, with or with- 
 out malformation of the auricle. Operation may, with difficulty, secure patu- 
 lency in cases where the closure is by soft tissues ; but the formation or freeing 
 of a canal closed by bone is a serious and often unsuccessful measure. Good 
 bone-conduction must be present as evidence of a useful labyrinth ; and the 
 hearing by way of the Eustachian tubes may be as good as the case admits 
 of; so these passages are to be kept in as open a condition as possible. The 
 proper location of the auditory canal is to be determined by the mastoid process. 
 
1166 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 for the auricle may be widely displaced ; and as absence of the tympanum may 
 render nugatory all efforts, drilling or such procedures can be attempted only 
 with great caution. 
 
 Affections of the Middle Ear. 
 
 Inflammation of the Middle Ear, arising, as it generally does, from a nasal 
 origin by way of the Eustachian tube, may involve any or all portions of the 
 tract, from the pharyngeal mouth of the tube to the remotest cells of the mas- 
 toid. It is readily distinguished into acute and chronic, with a few interme- 
 diate forms, and the types of catarrhal and suppurative, which are distinct and 
 strongly contrasting in the chronic inflammations, are with less certainty dis- 
 tinguishable in the acute. Localized subdivisions can be made, a fortiori, as 
 the brunt of the attack falls on the tube, drumhead, or mastoid, or the disease 
 tends to cling there, as salpingitis, myringitis, or mastoid periostitis, etc. ; yet 
 such nomenclature can be strictly applied in few cases, and rarely with profit, 
 especially if taken to mean that adjacent parts are free from implication. The 
 gravity of all the severer middle-ear inflammations lies in the facts of the prox- 
 imity of very important structures like the labyrinth, the meninges, and the 
 great blood-vessels, and that to a large extent the lining mucous membrane is 
 practically the periosteum, and readily causes the dependent bone to share its 
 inflammation or its destruction. What would elsewhere in the air-passages be 
 a mere superficial mucous ulcer may here lay bare the bone to carious or necrotic 
 process. The intricacy of the tract also hampers the escape of the secretions 
 and degenerated products ; and retention of these maintains and increases the 
 disease at the focus, often gives rise to most excruciating suffering, and may 
 lead to penetration of septic material in most dangerous directions. 
 
 Acute Simple Inflammation of the Middle Ear. — This usually origi- 
 nates in a coryza by an extension of the process up the Eustachian tube ; for as 
 this entire tract is essentially a part of the upper-air passages, its involvement is 
 as natural as that of the pharynx. Bathing, especially in the surf, with penetra- 
 tion of the water into the naso-pharynx and tubes, is responsible for many cases, 
 some of which are ascribed to the action of the cold water in the external canal ; 
 and the improper use of the nasal douche or syringe is fairly blamed for a fur- 
 ther series of cases, sometimes disastrous. Intranasal surgery has not infre- 
 quently such a sequence, and all too often the aural inflammation takes on the 
 suppurative character. All of the exanthemata, including typhoid, are very 
 apt to give rise to it, and its symptoms are likely to be ascribed to the general 
 condition or be masked by it ; so routine investigation of the ears is called 
 for in such cases. The prime symptom is usually earache ; and the prevalent 
 error of regarding this as an entity instead of a symptom, and combating it by 
 narcotics instilled into the ear, instead of striking at the underlying inflamma- 
 tion, is responsible for many unhappy results. Neuralgias of the ear are rare, 
 and while points of reflex irritation may be suspected and sought in teeth, ton- 
 sils, and other neighboring structures, it is only after careful investigation, prov- 
 ing the uninflamed condition of the aural tract, that a painful condition should 
 be set down as otalgia. Usually in children some fever is present, there is ten- 
 derness elicited by pressure on the tragus or traction on the auricle, and inspec- 
 tion will show a congested and perhaps distended condition of the drum- 
 head. 
 
 It is important here to correct misapprehensions as to the drum-mem- 
 brane in childhood, which have been fostered by some of the authorities. 
 
 The tympanic membrane and the annulus in which it is set are upon the sur- 
 
DISEASES OF THE EAR. 
 
 1167 
 
 Fig. 3. 
 
 
 Schematic Vertical Section of Adult Ear, showing direction of the 
 auditory canal and the length of the bony portion. 
 
 face of the skull in infancy, open to view when the soft structures have been 
 removed, and revealing the nearly horizontal inclination of the drumhead : 
 hence the impressions that the tympanic membrane is more superficial and more 
 horizontal in infancy. Neither is true ; for the canal is about thirty millimetres 
 long, as in the adult, with a membranous portion where the tympanic scroll 
 later forms the bony canal ; and removal of the bony canal in adults shows that 
 
 the two drumheads main- 
 tain identically the same 
 inclination to each other 
 as in infants. Much as is 
 the growth of the temporal 
 bones and their separation 
 by the occipital, the plane 
 of the tympanic mem- 
 brane, like its size, is 
 unaltered after birth. An 
 anatomical point which 
 lends color to the error 
 has much practical im- 
 portance. The direction of 
 the adult canal is upward 
 as it passes inward, while 
 the auricle falls downward 
 and forward, and must be 
 drawn up and back to 
 straighten the cartilagin- 
 ous portion (Fig. 3). In infancy the auricle is above the tympanum, 
 and the flaccid canal is pressed against the upward-curving surface of 
 the squama, and can be straightened only by drawing it down and out 
 (Fig. 4). Long, narrow, and readily collapsing, the infant meatus gives 
 but a poor view of the drumhead, even when correctly straightened ; and 
 the distinction between back wall and drum- 
 membrane is unrecognized, unless shown by 
 the normal coloration. In an inflamed ear 
 the practised eye is often puzzled to find land- 
 marks or make a certain diagnosis, and one 
 less expert is apt to make insufficient attempt 
 to discern details — too soon discouraged be- 
 cause the picture is not unmistakable. Yet 
 the triangular light spot on the lower ante- 
 rior portion of the drumhead ought to be visible 
 in every healthy ear, and from its absence or 
 alteration valuable data can be easily obtained 
 as to the position and surface. The malleus 
 handle ought to be distinguishable, and any 
 congestion will show first and last in the plexus 
 along its posterior margin. Distention of the 
 tympanic membrane generally shows up and back, and the color indicates the 
 character of the collection, being generally greenish if filled with serum or 
 mucus — yellowish, if purulent ; while the thinness of the sac usually reveals 
 whether only a bleb or the whole thickness is protruded. Inflation of the 
 tympanum, if successfully accomplished, generally alters the appearances: thus 
 giving evidence of the patulency of the Eustachian tube and a new view of the 
 
 Fig. 4. 
 
 Schematic Vertical Section of the Ear of 
 an Infant, showing the usual direction 
 and length of the auditory canal. 
 
1168 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 tympanic condition, with a clear surface line to the contained fluid, perhaps^ 
 or bubbles moving in it. The pneumatic speculum may do similar service 
 in clearing obscure details, whether inflation succeeds or fails. 
 
 Congestion, serous exudation, and hypersecretion of mucus are the usual 
 stages of the affection ; and imperfect drainage by the Eustachian tube consti- 
 tutes a cause for retention and pressure. In the absence of septic infection 
 and consequent suppuration, there is little danger, except to the hearing, in 
 adults ; but with children the barriers are too thin and imperfect to protect the 
 meninges and other important structures from involvement, and most severe 
 brain-svmptoms, which are not always merely reflex, may arise in cases where 
 the collection is simply mucus. Stupor, hemiplegia, convulsions, opisthotonos, 
 and other indications of meningeal or cerebral inflammation may occur, with 
 little to direct attention to the ear ; and marvellous improvement may be gained, 
 as though by magic, from relief of the pressure, either by freeing the Eusta- 
 chian tube or by incising the tense drumhead. For diagnosis, as well as treat- 
 ment, therefore, the nares should be sprayed free of any mucus, the pharynx 
 vault and tube-mouths mopped with the curved cotton-carrier passed above the 
 velum, and the inflation tried with the Politzer bag. If no voluntary aid 
 be given by the child in puffing out the cheeks, saying " Huck," or swallowing, 
 a cry will often be as helpful ; and often the short, wide, flaccid tube opens 
 readily without special assistance. A quick, spontaneous movement of the 
 hand to the ear will often tell of the passage of air to the tympanum ; and as 
 this, may be painful, its first employment should be gentle, with force increased 
 when needed. No harm is likely to result, even should the increased pressure 
 cause rupture of the tympanic membrane, for this can happen only when it is 
 about to occur spontaneously. 
 
 Exit of the secretion by its normal drainage-channel may be impossible 
 because of tubal swelling or from the tenacious character of the mucus, and 
 incision of the drumhead may be demanded in order to give relief. This 
 should be a simple and harmless measure, yet its pain is often severe enough to 
 forbid its needless performance. It may cause injury to the stapes or the inner 
 tympanic wall if done with a stab, and has been known to open the head of 
 the jugular; and it may convert a non-suppurating into a septic inflammation 
 if all the requirements of asepsis are not secured and maintained. It must be 
 done, of course, under good illumination, and should generally be preceded by 
 delicate use of the probe in order to let touch assist sight in getting the true 
 relations. The most protruded portion of the membrane should usually be 
 chosen, and the needle-point inserted for a distinct cutting motion, avoiding 
 any contact with the ossicles or inner wall. The oblique position of the drum- 
 head must be clearly borne in mind, and a hand skilled in aural procedures is 
 generally requisite. Inflation of the tympanum should follow, if possible ; and 
 hot syringing of the canal will remove the blood and evacuated secretion, allay 
 the pain, and serve to favorably stimulate the inflamed tissues and inaugurate 
 resolution. The canal should then be gently dried and protected by a flake 
 of cotton or wool, and a pad of the same laid on outside in unfavorable weather. 
 The same result can commonly be gained without incision, and, unless the 
 symptoms are urgent, the little operation had better be delayed. The hot 
 syringing can impress the tympanum, controlling the pain and other symptoms, 
 about as fully and favorably with the drumhead intact. Nasal treatment, 
 aided by the shrinking effect of cocaine, can generally free the Eustachian tube 
 and fairly maintain its patulency ; and dry heat, as by a hot-water bottle, can 
 increase the comfort and further the cure. The hot douching should be fre- 
 quently employed, and if drying be done with reasonable care, no undue mace- 
 
DISEASES OF THE EAR. 1169 
 
 ration need be feared. Greatly distended drumheads can thus be brought back 
 to normal condition with perhaps greater safety and promptness than by more 
 radical intervention. 
 
 The habit of treating "earache " by instilling sedatives is not to be com- 
 mended. Any fluid introduced should be warm, and is efficient in proportion 
 to its heat rather than to its ingredients. A tincture, such as laudanum, is apt 
 to be irritating ; oils and glycerin are more apt to harm than help ; and cocaine, 
 except in strong solution, has less value than atropine or morphine. More 
 than would be a full dose by the mouth had better not be instilled, lest it find 
 penetration and cause poisoning. Poultices are apt to macerate, and are gen- 
 erally inferior, in convenience and directness of application, to hot douching or 
 fomentations. They should be used very hot, if at all, and removed before 
 they have cooled to the body temperature. They are so liable to improper use 
 that their employment is not to be commended. Leeching is advisable only 
 during the rise or acme of the inflammation, and is rarely well borne by chil- 
 dren. As it is generally impossible to determine at first whether the acute 
 tympanic inflammation will prove suppurative and serious, the prognosis should 
 be guarded and the treatment include rest in bed, with regulated diet and anti- 
 febrile medication — matters easier to regulate in children than in adults. After 
 improvement has begun, protection against renewed or increased cold-taking is 
 still very important, and covering of the ear-region is advisable in inclement 
 weather. Tonics and alteratives may be necessary as well as advisable — 
 cod-liver oil probably serving better than almost any other. Chloride of 
 ammonium and syrup of iodide of iron are each very useful in its place. 
 Quinine, which is often taken to " break up a cold," has been vigorously con- 
 demned by some aurists because it stimulates the circulation in the ears as well 
 as elsewhere. Yet stasis is worse than active congestion, and the facts by no 
 means fully support the contention as to its counter-indication. 
 
 One form or phase of acute tympanic inflammation deserves a word in pass- 
 ing. The most inflamed and distended portion of the drumhead is sometimes 
 its upper flaccid portion, especially the part above the short process of the mal- 
 leus. This indicates collection in the upper tympanic cavity, or attic, and the 
 rather isolated pouches of this region, largely independent of the condition else- 
 where. Rupture may give exit to a single drop of fluid with relief and prompt 
 resolution ; but the perforation may remain as a pinhole opening — the so-called 
 "foramen of Rivinus" — claimed to be a congenital defect of development, 
 although less often seen in children than in adults. 
 
 Acute Suppurative Inflammation of the Middle Ear differs little from 
 the catarrhal form in its onset, although apt to be more severe in its febrile and 
 painful symptoms. It is specially characterized by the rupture of the drum- 
 head and more persistent flow of secretion, which generally contains pus and 
 the pyogenic bacteria. The perforation is less often the mere pushing apart of 
 the tissues, although frequently assuming a pouting, nipple-like form, for there 
 is generally some loss of substance ; and in the cases due to scarlatina and 
 diphtheria the destruction of the membrane may rapidly be extensive or total. 
 Ulceration of the inner surface of the drumhead is only one indication of the 
 destructive influence of the inflammation or its products ; and as the attic and 
 antrum are generally involved, as well as the tympanum proper, the dangers to 
 meninges, blood-vessels, and mastoid are real and great. Paracentesis may be 
 promptly called for, either to make or enlarge an opening, if the symptoms 
 point to retention of secretion ; and the temperature should be carefully 
 watched for evidence of extension or exacerbation of inflammation. Tender- 
 ness of the mastoid and other neighboring parts is to be frequently sought ; 
 
 74 
 
1170 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Fig. 5. 
 
 and it, with or without swelling, redness, or oedema, calls for redoubled pre- 
 cautions. The position of the auricle should be critically compared with that 
 
 of the other side, especially by study 
 from directly behind the head (Fig. 5), 
 for displacement is almost invariably 
 present if there be any surface involve- 
 ment of the temporal. The size and 
 form of the auditory canal should be 
 noted, so as to detect any bagging, es- 
 pecially of the upper back wall, by re- 
 tained secretion. The position of the per- 
 foration is probably of small importance, 
 unless it be in the flaccid membrane, as 
 an indication of suppuration partly or 
 wholly isolated in the cavities of the 
 attic ; and its form depends principally 
 on its size. The opening at the apex 
 of a pouting, nipple-like protrusion has 
 importance, however, since it is in itself 
 
 an evidence of incomplete relief of pres- 
 sure, is rather prone to clogging, and 
 serves as a valve to exclude all medicinal 
 applications. It may readily be mistaken 
 for a polyp, and attacked with the snare ; 
 and while this, used only to cut, is not 
 the pin-hole opening, any traction may 
 
 Swelling of the Mastoid Region, 
 auricle out and forward 
 
 the 
 
 very bad as a method of enlarging 
 be very injurious. 
 
 Incision should be free, and maintained, if made at all ; for it has a tendency 
 to heal quickly, and even close what little exit was present. Dilatation with a 
 conical pledget is generally better, if practicable. The distinctly unfavorable 
 meaning which the pouting perforation has in adults does not obtain in children ; 
 although the muco-purulent secretion, which is its usual concomitant, is in youth 
 almost as dangerous as the more destructive pus. It is most often in such cases 
 that the use of dry boric powder has been charged with dangerous sequences, and 
 caution is necessary, although its contra-indication is not proven. A standing 
 rule may be made for all insufflations, that free use of insoluble powder always 
 brings danger of clogging the outflow; and boric acid is but slightly soluble in 
 mucus. Hot douches are more valuable in these than most cases, since the 
 heat can penetrate to the inflamed tissues when drugs cannot, and the effect 
 upon actual or imminent involvement of the mastoid cells may be most valuable 
 and grateful. In other respects the treatment is much the same as that in 
 catarrhal inflammation — the naso-pharyngeal spraying and mopping, Politzer 
 inflation after such cleansing, and the syringing through the canal for the 
 maintenance of the utmost possible cleanliness of the tympanum. A course 
 of several weeks is usual, and early cessation of the discharge is to be looked 
 upon with suspicion, and evidences of retention carefully sought. The hearing 
 may be much impaired, to improve but slowly; and the termination of the 
 discharge may leave the auditory apparatus unduly dry and stiff, with a tem- 
 porary decline of the hearing in consequence. It is best to prognosticate this, 
 for patients often retain the old idea that it is dangerous to check all such 
 flows, and may be alarmed or discouraged. 
 
 Chronic Suppuration of the Middle Ear. — This condition is almost 
 always the result of a neglected acute attack, although debility may invalidate 
 
DISEASES OF THE EAR. 1171 
 
 the very best treatment and cause the maintenance or recurrence of the condition. 
 Its symptoms are often inconspicuous, and neglect is quite frequent, especially 
 under the impression that u it will get well of itself." Histories in such matters are 
 apt to be wholly untrustworthy, and perforations, cicatrices, losses of the bony 
 parts, massive chalk deposits, or collections of' exfoliated epithelium or 
 inspissated discharge may be present in one or both ears which are declared 
 to have been always sound. A tuberculous affection is occasionally insidious 
 and painless in its onset, and may be characterized by multiple perforations, 
 which probably represent broken-down tubercles of the drum-membrane. 
 The exanthemata are responsible for a large number of cases, sometimes 
 following doubtful or unrecognized attacks ; while more often the illness of 
 the patient masks the ear disease or overshadows it in apparent importance. 
 The spontaneous cure for which many physicians look, as well as the laity, 
 is often obtained, but may prove temporary and incomplete ; and treatment is 
 called for in all cases as lessening the danger to hearing and life, mitigating 
 the annoyance to patient and companions due to the discharge, and tending to 
 hasten and complete the cure. 
 
 The character of the discharge deserves attention. If fetid, it tells of 
 retention and neglect ; if bloody, polypoid growths are probably present ; if 
 ichorous, search should be scrupulously made for dead bone ; if stringy from 
 mucous admixture, subacute involvement of the antrum and mastoid cells is 
 probable, and a slow, obstinate case may be anticipated. As cleanliness is the 
 prime factor in restraining evil tendencies and securing resolution, the character 
 and source are noteworthy as bearing on the means required to remove secre- 
 tion. The syringe remains the best cleanser here, and the heat which its fluid 
 can so well convey can have efficacy little short of that in the acute conditions. 
 Frequently, isolated cavities, into which ordinary syringing hardly penetrates, 
 need cleansing, and intratympanic injections are needed. A steady hand can 
 make these in a quiet patient with almost any long, fine canula introduced, 
 under good light, to the precise point requiring it ; but where these requisites 
 are lacking, the auditory canal should be filled with fluid — best the peroxide of 
 hydrogen — and pressure exercised by finger-tip or Politzer bag to force it into 
 every opening; and it can often be thus carried down into the pharynx. In 
 some obstinate cases syringing through the Eustachian catheter proves very 
 efficient, though this cannot so often be used in children. Drying should follow 
 cleansing, and all epidermal flakes or similar material removed as perfectly as 
 possible, even to the verge of meddling. It is never safe to form a diagnosis 
 of the precise condition until the whole accessible tract has been studied by the 
 eye, and perhaps with the probe. Polyp masses or other protrusions often show 
 most characteristically when standing out as reddish islands, surrounded by 
 whitish pus ; so study before cleansing is important : and many conditions need 
 probing for their comprehension, for which the cotton-carrier, guarded with a 
 tip of cotton of appropriate size, is best adapted. In seeking for bare bone and 
 Toughnesses, the fibres catch upon these, and may not only reveal but remove 
 them. The mopping is an excellent means of cleansing, independent of syring- 
 ing, and should always follow it to remove the remaining fluid. It also affords 
 valuable instruction and practice in aural, and especially intratympanic. manip- 
 ulation, preparing the physician for the more delicate measures, such as para- 
 centesis. Often a flake of cerumen-like material clings closely to some part of 
 the wall or fundus, and its removal is requisite in order to learn whether or not 
 a sinus or other lesion lurks beneath. These leathery crusts are common near 
 the short process, and frequently indicate an attic inflammation, with a per- 
 foration in the flaccid membrane, and all too often caries of ossicles or adja- 
 
1172 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 cent walls. Backward, too, there may be an opening into the antrum or 
 its communicating cells sometimes with polypoid granulations surrounding it. 
 
 " Polyp of the ear" is no sufficient diagnosis. Although usually a symptom 
 of chronic suppuration of the tympanum, its real cause should be determined 
 as soon and accurately as possible, and its removal regarded as essential to a 
 fair beginning of treatment. In rare cases polyps arise in furuncles, generally 
 after poulticing ; but most of them come from the tympanum. When seated 
 upon the canal-wall they generally indicate a carious condition, and call for 
 scrupulous study and care. Their removal is rarely worth considering an ope- 
 ration, since it can often be done without the knowledge of the patient and the 
 probable consequent increase of difficulty. Mere rotation with the probe will 
 often " wring the neck" of a polyp, or it can be bitten off with forceps or 
 snare. The new tissue is generally insensitive, and it is the traction on its 
 base or adjacent parts which is felt more or less painfully. Complete removal 
 is desirable, and chromic-acid or other cauterization of the stump ; but the 
 mere drying effect of boric or alum powder often suffices for those not arising 
 from inflamed bone. General anaesthesia may be required for proper explora- 
 tion and removal, and the arrangements should be made beforehand to carry 
 through at once any requisite operation on the bone. Caries of small extent 
 can often be sufficiently treated by rubbing vigorously with the cotton-carrier, 
 or may be curetted with the small sharp spoon. The ossicles can be excised 
 if considerably involved, since their usefulness is generally gone, and they 
 remain as obstacle to treatment and often to hearing. Yet such intervention 
 is far from sure to give either prompt or lasting relief if confined to cases really 
 demanding it; for it may fairly be claimed in the majority of cases of limited 
 caries of the ossicles that healing can be secured as quickly and surely without 
 excision, and that with it prompt cure can be expected in only some 60 per 
 cent, of the apparently appropriate cases. The operation of Stacke, in which 
 the tympanic attic, and often the antrum, is at the same time laid freely open 
 by removal of all wall intervening between it and the canal, is called for in 
 many of these cases ; and the turning forward of the auricle and cartilaginous 
 canal, by incision behind it, greatly favors thoroughness and safety, while not 
 increasing the risk of operation. 
 
 Chronic suppurations commonly resist any treatment which parents or 
 nurses can give, and the physician who treats them with no more insight rarely 
 succeeds better. Yet a single thorough cleansing, with insufflation of boric 
 powder, will often cut short a case that has been trifled with for years. Such 
 prompt drying had better be distrusted, for recurrence is probable. Foci of 
 trouble often are unreached, and the exciting causes in nares and tubes 
 generally remain. Hearing may be temporarily lessened by reason of the stiff- 
 ness of the parts, no longer even duly moist ; and perforations in the drum- 
 membrane may be retained by repression of the reparatory inflammation. Yet 
 these charges against the dry treatment are rarely justly condemnatory, and 
 proper maintenance of naso-pharyngeal treatment, with inflation of the tym- 
 panum, will generally secure all that any other measures can do, and with real 
 gain in time and safety. Serious secondary conditions, like mastoid empyema or 
 caries may thus be averted ; but there is no evidence that they are not rather 
 lessened, and they are not so apt to be masked by the t}^mpanic condition. 
 
 Aside from the dangers to hearing, a number of perils surround both the 
 acute and chronic forms of tympanic suppuration. The bony walls are every- 
 where more or less dependent for their nutrition upon the mucous membrane, 
 and caries of ossicles and other parts can readily take place, with occasionally 
 extensive necrosis. Yet without this, extension of inflammation, even when 
 
DISEASES OF THE EAR. 
 
 1173 
 
 not septic, may involve the meninges, the great blood-vessels or the labyrinth ; 
 and from any of these serious Fig. 7. 
 
 or fatal cerebral lesions may 
 arise. Brain-abscess depends, in 
 most cases, upon aural suppura- 
 tion, and subdural abscess and 
 septic thrombosis are still more 
 frequent in children (Fig. 7). 
 Suppuration in the labyrinth gains 
 ready access to the intracranial 
 cavity through the internal audi- 
 tory canal, and the basilar men- 
 ingitis resulting is usually fatal. 
 This is noteworthy, for the lep- 
 tomeningitis due to caries or ne- 
 crosis of the temporal bone is 
 often salutary, and builds a de- 
 fence against serious invasion for 
 the more important structures. 
 (See Figs. 8 and 9). 
 
 Kecrosis may lead to exfolia- 
 tion of large portions of the tem- 
 poral bone, including the laby- 
 rinth and facial canal ; yet the 
 cranial contents may escape un- 
 harmed, in spite of loss of much 
 of the meningeal surface of the 
 bone, and the facial nerve may reorganize. Facial paralysis is not rarely met, 
 for the facial canal is frequently incompletely bony, and is always vulnerable 
 as it passes above the oval window. Bell's palsy in children is usually a part 
 Fig. 8. Fig. 9. 
 
 Portion of Base of Skull of Child of Three Years, showing 
 carious defect in the roof of left tympanum and the 
 overlying dura. Death resulted from a large brain- 
 abscess communicating with the suppurating tym- 
 panum. 
 
 Inner Aspect of the Temporal Bone of a Boy 
 of 2 x / 2 vears, showing caries of roof of 
 attic and antrum. Dural thickening effect- 
 ually protected the brain at this point, but 
 pus 'penetrated with fatal result through 
 the internal auditory meatus. 
 
 Outer Aspect of the same Bone, showing 
 destruction of mastoid cortex and meatus- 
 wall, throwing- into one open cavity the 
 canal and tympanic chambers. The oval 
 window is seen, as in life, to be empty ; 
 the facial canal above it is open and va- 
 cant, and a third opening is into the hori- 
 zontal semicircular canal. 
 
1174 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of an otitis media, although the aural symptoms may be slight and fleeting. 
 When the nerve is actually destroyed, restoration is not likely, and the canal 
 may prove a path for infection. (See Fig. 10). 
 
 Burrowing of pus may so easily take place out along the bone, instead of 
 through it, that its presence upon the surface should never be accepted as 
 proof of a bone-lesion, but the region must be carefully searched for sagging 
 
 of the wall? of the canal, es- 
 Fig. 10. pecially above, or other indi- 
 
 cations of subperiosteal bur- 
 rowing. Up and back, near 
 the drumhead, where but a 
 thin lamella separates the 
 antrum from the meatus, a 
 rounded protrusion, more gen- 
 erally of reddish color, may 
 be found as the result of pur- 
 ulent collection, which has 
 come around or through the 
 bony plate ; and the relations 
 of the Shrapnell membrane 
 are such that suppuration in 
 the attic may pass out along 
 the wall, instead of perforat- 
 ing the membrane. Bone- 
 lesion may, therefore, be ab- 
 sent ; but as the periosteum 
 is generally detached, super- 
 ficial caries is almost certain 
 to follow unless prompt relief 
 of the condition is obtained. Incision freely down upon the bone is called 
 for, in order to lay open the tract throughout as soon as it is detected, and 
 stimulating measures, especially the hot syringing, should be vigorously 
 employed. Weak acid solutions, best in 75 per cent, glycerin, have been 
 warmly advocated as capable of decalcifying and aiding to remove any dead 
 portions of bone, while energetically stimulating the growth of healthy 
 granulations. 
 
 Chronic Catarrhal Inflammation of the Middle Ear may remain as 
 the result of one or more acute attacks, but more frequently is an insidious and 
 progressive disease due to continuous nasal trouble, directly or indirectly acting 
 through the Eustachian tube. These slit-like canals are normally closed, yet 
 open readily in yawning, swallowing, or forced respiration, and serve to venti- 
 late the tympanum and maintain equality of pressure upon the inner and outer 
 surfaces of the drumhead. Nasal catarrh may lead to violent nose-blowing, 
 with undue distention of the tympanum ; but much oftener the swelling of the 
 mouth or lumen of the Eustachian tube both guards the ear against this and 
 also precludes the normal transmission of air. The unrenewed air in the drum- 
 cavity is absorbed, the tympanic membrane pressed in by the preponderating 
 external pressure, and swelling or hypersecretion of the lining mucous mem- 
 brane, or transudation through it, results from the partial vacuum. In still 
 other cases the tube is duly patulous, and nasal obstruction gives rise to suction 
 at every act of swallowing, just as in the "Toynbee experiment " with the nose 
 held closed. Whether thus medially, or through direct extension of inflamma- 
 tion by continuity, the tympanum becomes involved in a low grade of inflam- 
 
 Large Sequestrum, showing much of the outer surface of mastoid. 
 It comprises also much of the facial and semicircular canals, 
 the antrum, and its removal uncovered extensively the dura 
 and lateral sinus, but was followed by recovery, with deafness 
 and facial palsy of this side. The whole temporal bone is 
 sketched in to show the relations of the exfoliated portions. 
 
DISEASES OF THE EAR. 1175 
 
 mation tending toward sclerosis. So marked is this tendency that some cases 
 may well, from their start, be designated as sclerotic ; yet such are rarely recog- 
 nizable in early childhood, and the hypertrophic form is here the most import- 
 ant. Slight congestion of the whole tract is usually present, as indicated by 
 the distended vessels visible along the malleus handle ; infiltrations take place 
 in limited or diffused areas of the drumhead or other parts of the tracts, lead- 
 ing to fibrous or chalky deposits ; and, more important still, the ligaments of 
 the ossicles and the less constant reduplications of mucous membrane about 
 them undergo stiffening and contraction. The pull of the tensor tympani upon 
 the malleus handle may thus be exaggerated through the affection of its tendon 
 sheath, increasing the depressed or retracted condition of the drumhead ; and 
 the stapes, which is often surrounded by bands of tissue, becomes anchored 
 firmly in its niche or undergoes true ankylosis of its foot-plate in the oval 
 window. The effect of this in hindering the due transmission of aerial sound- 
 waves is evident, for the drum-membrane is stretched too tightly to respond 
 properly to the lower tones, the conduction through the chain of ossicles is hin- 
 dered, and the cardinal factor — the slight piston-like movement of the stapes — 
 is reduced or prevented. Pain of a neuralgic character is sometimes present, 
 possibly through the sharp pressing inward of the drumheads, and subjective 
 noise or vertigo is apt to be added to the deafness. 
 
 Even in childhood chronic tympanic catarrh may be very obstinate and 
 require long and persistent treatment. The naso-pharynx is to be put in the 
 best practicable condition, with reduction of turbinal hypertrophies, shrinkage 
 or destruction of "adenoid vegetations" of the vault of the pharynx, and 
 reduction of the tonsils by astringents, cauterization, or excision. My routine 
 nasal treatment is to spray clean the nares with a detergent alkaline solution, 
 such as Dobell's, mop the pharynx-vault with glycerole of iodine on the bent 
 cotton-carrier, give a protective spray with a 10 per cent, menthol-camphor 
 solution in alboline, and dust lightly with calomel. Inflation of the tympanum 
 can usually be satisfactorily done with the Politzer method, the patient aiding 
 by puffing out the cheeks or saying " Huck " at command. If water is given 
 to aid the swallowing effort, the sip should be small, the inflation made as the 
 larynx is seen to rise, and the physician will be wise to stand out of range of 
 the probable spluttering. If the collapse of the drum-membrane be consider- 
 able, its distention may be painful, even by gentle inflation ; and it is well to 
 have the fingers thrust into the ears to compress the air in the canals and miti- 
 gate the pressure. The air blown in may be advantageously medicated by 
 filling the bag from a bottle containing a little iodine or other stimulant. The 
 pneumatic speculum is of decided value, not only in studying the condition of 
 the drumhead, but also as an excellent means of using massage. Any fulness, 
 pain, or discomfort caused by inflation may be thus promptly relieved, tinnitus 
 and deafness much lessened, and a rational method of relieving the worst fea- 
 tures of the trouble readily inaugurated. Its effect can be continued and 
 increased by " tragus-pressure, " or pneumatic massage, done with the finger- 
 tip moving in and out while hermetically closing the canal. Valsalva infla- 
 tion had better not be taught, as it is very liable to be abused, but this other 
 measure is generally as useful and probably wholly harmless. 
 
 Affections of the Internal Ear. 
 
 Lesions of the internal ear are fortunately rather rare in children. Con- 
 genital defects are hard to prove during life, but may be assumed when other 
 malformations are present, with no evidence of disease and where no hearing 
 
1176 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 has ever been detected. When deafness is total, labyrinthine lesion is almost 
 certain, since disease of the conducting apparatus can hardly abolish the func- 
 tion of the organ. 
 
 Acquired Labyrinthine Deafness is usually syphilitic, except in the 
 cases of necrotic destruction or exfoliation as the result of tympanic suppuration; 
 and evidence of the inherited taint should be sought in the eyes and teeth. Even 
 when no sign of interstitial keratitis or other ocular syphilis is found, and the 
 teeth are well formed and spaced, the facies may have a pinched expression, 
 with precocious marking of the naso-labial lines, which is quite characteristic. 
 The loss of hearing is generally sudden, and, although considerable tympanic 
 trouble may be present to confuse the diagnosis, the routine treatment of the 
 middle-ear lesion will prove it to be too slight to be a probable cause of the 
 profound deafness, and alteratives will have distinct influence in improving the 
 hearing. Tuning-fork tests are not very reliable with young patients, even 
 when intelligent enough to understand what we wish to learn, and the objec- 
 tive methods are of uncertain value. It is claimed that through long stetho- 
 scopic tubes connecting the ears of patient and observer the tuning-fork on the 
 vertex can be better heard from the less-affected or normal ear if the lesion is 
 labyrinthine, but on the more affected side if tympanic. The contrary is 
 sometimes, if not generally, true. The Gal ton whistle is of value in testing 
 if any hearing be present, as it can be concealed in the hand and sounded at 
 various pitches in proximity to the ear without attracting any notice unless its 
 sound be heard. Yet the question of total deafness may remain undecided, 
 and the history throw little light upon diagnosis, especially in children who do 
 not talk. Sounds accompanied by concussion, even of the air, are apt to be 
 noticed, and calls and phrases may be comprehended in spite of abolition 
 of hearing; but any words spoken bej^ond accidental semblances of "ma-ma," 
 etc. may be taken as. proof that some hearing is or has been present. Cases 
 of labyrinthine deafness due to extravasation or sudden exudation, and 
 accompanied by the Meniere symptoms of vertigo, etc., are very rare in chil- 
 dren, and usually unilateral. It is still a question how far acute bilateral 
 otitis interna is mistaken for cerebro-spinal meningitis, the intracranial symp- 
 toms of which are merely reflex, and recovery takes place with surprising 
 promptness except for the persistence of total deafness. Such cases do occur, 
 but more often the lesion is doubtless in the floor of the fourth ventricle, with 
 destruction of the auditory tracts ; and any labyrinth lesions later found are due 
 to atrophic degeneration. 
 
 Whether syphilitic or not, the treatment of these disorders is about the 
 same. A full mercurial impression should be obtained with all possible prompt- 
 ness, and the alterative effect of this drug and iodine well maintained. Mer- 
 curial inunction is generally safest and most convenient in children, the oint- 
 ment being given in drachm or half-drachm pellets, of which one is to be 
 rubbed once or twice daily upon the belly and covered with a flannel band, a 
 new surface being taken each time till the waist is encircled. Pilocarpine has 
 some curative value, but is probably much less safe or certain than mercury. 
 
 When hearing is lost in early life, from whatever cause, speech is either not 
 learned or is very apt to be lost, and the child becomes a deaf-mute. Yet 
 some trace of hearing is present in the majority of those in the mute institu- 
 tions, since the deafness is usually tympanic ; and acquired, as it often is, after 
 some language has been learned, this only needs preservation and cultivation. 
 A considerable proportion can be taught to speak intelligibly and read the 
 lips of others with facility. The process is slow and difficult; so it should be 
 begun early and with rigorous exclusion of the easier but far less useful sign- 
 
DISEASES OF THE EAR. 1177 
 
 language. Any remnant of hearing may be of immense aid, and it should be 
 made as good as possible by treatment ; and the vocal apparatus should in like 
 manner be put in the best practicable condition, that it may add no needless 
 impediment to the acquisition of useful speech. 
 
 Mechanical aids to the hearing may be of value to the mute as well as to other 
 deaf persons, both for hearing the sounds of the words spoken to them and their 
 own voices in speaking. The appliances are of two principal forms — either a 
 trumpet to receive in the expanded mouth a larger number of sound-waves 
 than the ear itself could catch, and transmit them by air-conduction to the 
 auditory apparatus, or else of the "dentaphone" type — an elastic surface to 
 respond to the vibrations and convey them by bone-conduction. Each has its 
 limited value and its applicability to individual cases; and it is claimed that 
 they sometimes greatly facilitate that exercise of the auditory apparatus which 
 can occasionally work a slow but immense improvement in apparently hopeless 
 cases. A similar therapeutic idea has led to use of the phonograph as a means 
 of exercise or massage, especially by the believers in infinitesimals — perhaps 
 "proved" by the fact that the attenuated sounds of telephone and phonograph 
 can work harm to diseased ears. Numerous improved forms have been devised, 
 all promising wonders as soon as, like perpetual-motion machines, a missing 
 cog shall be adjusted. 
 
PART XIV. 
 
 DISEASES OF THE EYE 
 
 By G. E. de SCHWEINITZ, M. D., 
 
 Philadelphia. 
 
 In the following pages only those diseases of the eye are recorded which 
 the general practitioner of medicine and surgery is likely to encounter, and 
 which do not demand the use of instruments of precision for their detection 
 and study. 
 
 Diseases op the Lids. 
 
 Abscess and Furuncle of the Lid. — An abscess of the lid, sometimes 
 called phlegmon, appears as a localized red elevation, which may arise in debil- 
 itated children without ascertainable cause, and also results from exposure, 
 injury, or diseases of the orbit. The affection may terminate in the formation 
 of a slough or "core," and then receives the name "furuncle" and in sub- 
 jects of poor nutrition may be complicated with gangrene of the surrounding 
 integument. 
 
 Treatment. — Pointing should be favored by the application of moist 
 heat with compresses of lint steeped in hot, slightly carbolized solutions. 
 As soon as fluctuation is detected, or even earlier, the abscess should be incised 
 with a knife thrust through it parallel to the muscle-fibres, and the cavity kept 
 clean with a solution of bichloride of mercury or with peroxide of hydrogen. 
 Nourishing food and tonics, as quinine and iron, are indicated. 
 
 Hordeolum, or Stye, is a small furuncle on the margin of the lid caused 
 by a circumscribed inflammation of the connective tissue, or of one of the glands 
 of this region. 
 
 Ordinarily, the affection, though annoying, is trifling in character; the 
 swelling becomes invested with a yellow cap, indicating suppuration, and the 
 purulent contents are evacuated by spontaneous rupture or by incision. Some- 
 times, however, the appearances are similar to those of purulent ophthalmia, 
 from which it may be differentiated by observing the indurated portion of the 
 lid, the point of suppuration, and the absence of profuse purulent discharge. 
 
 Styes tend to recur or to come in " crops." They are excited by exposure to 
 dust and cold and the strain of uncorrected ametropia, especially hypermetropic 
 astigmatism. The repeated occurrence of styes always indicates some general 
 derangement — dyspepsia, constipation, and, in girls at the age of puberty, 
 menstrual disorders. 
 
 Treatment. — An attempt to abort a stye may be made by the repeated 
 application of compresses steeped in hot boric-acid solution, by rubbing the 
 
 1178 
 
DISEASES OF THE EYE. 1179 
 
 inflamed area with an ointment of yellow or red oxide of mercury, or by paint- 
 ing The surface with collodion. When suppuration occurs the swelling should 
 be incised by cutting through its base parallel to the lid. Constipation, dys- 
 pepsia, and menstrual disorders should be corrected, and in children of suitable 
 age refractive anomalies should be neutralized with appropriate glasses. Sul- 
 phide of calcium has some influence in preventing the recurrence of styes. 
 
 Exanthematous Eruptions are found upon the eyelids during the various 
 eruptive fevers, and in small-pox a pustule ma} 7 form, by preference at the com- 
 missure, leaving a disfiguring scar, or it may terminate in an ulcer of stubborn 
 character which is denominated post-variolous ulcer. Vaccine vesicles on the 
 free border of the lids have been reported by Hirschberg, Berry, and others, after 
 contact with vaccine. The affection receives the name vaccine blepharitis. 
 
 Blepharitis. — This term describes the various subacute and chronic inflam- 
 mations of the border of the lids, and the affection usually appears in a non- 
 ulcerated and an ulcerated form. 
 
 The non-ulcerated varieties manifest themselves as a simple hyperemia of 
 the lid margins, the "red eyes" of common parlance, characterized by swell- 
 ing, redness, and passive congestion of the superficial blood-vessels ; or in an 
 abnormal secretion of the sebaceous glands, characterized by the formation of 
 crusts and scales of hardened sebum (a similar process often affecting the eye- 
 brows at the same time) at the roots of the cilia, and lying upon a slightly 
 inflamed and occasionally abraded surface. Distinct ulcers usually are not 
 present. This form is always bilateral, and is known- as seborrhoea of the lid 
 border, blepharitis ciliaris, or squamous blepharitis. 
 
 The ulcerated varieties manifest themselves as a marginal eczema, which 
 resembles an aggravated form of the simple hyperemia ; or as a blepharo-adenitis, 
 characterized by the matting of a tuft of cilia in a crust which covers a dis- 
 tinct ulcer, and which often affects a single lid ; or as a pustular inflamma- 
 tion, characterized by the development of thick yellow crusts covering deep 
 ulcers that destroy the nutrition of the eyelashes, which are misshapen and 
 readily fall from their follicles. This type, called blepharitis ulcerosa, 1 often 
 affects all of the lid margins, and may lead to deformities, owing to the loss of 
 the cilia and the change in the shape of the ciliary border, which becomes 
 thickened, everted, and rounded ("lippitudo" or blear-eye). 
 
 Etiology. — Blepharitis in many of its forms is distinctly a disease of child- 
 hood, and is apt to attack children of blonde complexion and strumous habit. 
 It frequently follows in the wake of the exanthemata, but may arise in other 
 subjects in seemingly perfect condition. Not infrequently, affections of the 
 nares and naso-pharynx are present (various types of rhinitis, catarrh, and 
 adenoid vegetation), which probably act as causative factors. Eczema around 
 the nares and auricle is often present. Ametropia, especially hypermetropia 
 and astigmatism, as originally pointed out by Roosa, probably causes many 
 cases, and is responsible for the continuance of others. Abnormal shortness 
 of the palpebral fissure may originate blepharitis (Fuchs). 
 
 Treatment. — This depends upon the type of the disease, but in children 
 of suitable age refractive anomalies should always be corrected. The forms 
 described as hyperemias will often disappear by this means alone ; if not, the 
 lids may be washed frequently with warm water and castile soap, and an eve- 
 
 1 Eczema of the border of the lids, according to its manifestations, was formerly described 
 under several names — blepharitis ciliaris, blepharitis ulcerosa, psorophthalmia, lippitudo ulce- 
 rosa, tinea tarsi, sycosis tarsi, ophthalmia tarsi, etc. 
 
1180 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 douche may be employed, the water of which, at a temperature of about 60° F., 
 is conducted from a can held above the head through a tube to the end of which 
 a small rose is fitted, which distributes the fluid in fine, shower-like jets upon 
 the closed lids. Stimulating salves are not indicated in this variety. 
 
 In the seborrhceas the crusts should be removed with an alkaline solution, 
 bicarbonate of sodium (gr. viij-f^j), or biborate of sodium (gr. iv-fsj), and then 
 an ointment of milk of sulphur or of resorcin (2 or 3 per cent.) applied to the 
 lid margins. In the eczemas, after removal of all crusts, the yellow oxide of 
 mercury (gr. j-f^j) is the most useful application. In any type associated with 
 much ulceration all loose cilia should be removed with epilating forceps and the 
 ulcers touched with a solution of nitrate of silver. In place of the salves which 
 have been mentioned, boracic-acid ointment (10 per cent.), zinc ointment, or 
 aristol ointment (2 per cent.) may be used. The puncta and lachrymo-nasal 
 duct should be patulous, and any diseased condition of the nares and naso- 
 pharynx should be corrected. As constitutional remedies, cod-liver oil, lacto- 
 phosphate of lime, iodide of iron, and syrup of hydriodic acid will usually find 
 suitable indications. 
 
 Phtheiriasis of the Lids. — The pediculus pubis (crab louse) occasion- 
 ally infests the eyebrows and eyelashes. The parasites cause much irritation, 
 and the affection may be mistaken for ordinary blepharitis. 
 
 Treatment. — The margins of the lids should be rubbed with balsam of 
 Peru, mercurial ointment, or a solution of corrosive sublimate. 
 
 Syphilis oe the Eyelids. — A hard chancre may develop on any portion 
 of an area included by the lid borders and inner canthus, the tarsal conjunctiva 
 and the cul-de-sacs (De Beck), the inoculation usually taking place by con- 
 tact with the secretion from a syphilitic mouth. The affection begins as a 
 pimple which develops into a characteristic ulcer with indurated base. 
 
 A small papular syphilide has been noted upon the eyelids of infants the 
 subjects of hereditary syphilis a few weeks after birth, and madarosis (fall- 
 ing of the lashes), as well as a form of ulcerated blepharitis, has been ascribed 
 to the same cause. 1 
 
 Tumors and Hypertrophies. — Clear, small cysts, warts, and little masses 
 of granulations may occur on the margin of the eyelid, the last arising from the 
 mouth of a Meibomian duct. In addition to these attention is directed to the 
 following growths: 
 
 Ncevi (angiomas). — These are congenital growths, either small red spots 
 or cavernous structures analogous to those which occur elsewhere in the 
 body. They should be removed as soon as practicable. If small, excision 
 may be practised ; if large, they may be destroyed by galvano-cautery puncture. 
 
 Chalazion. — This is a small tumor arising in the tarsus, due to inflammation 
 of a Meibomian gland and its surrounding tissue; hence it is an adenitis or a 
 periadenitis, and not a true cyst. It occurs in children, but is much more com- 
 mon in adolescence. The exact cause is not known, although it is connected 
 with stoppage of the duct of a Meibomian gland, which in its turn may be caused 
 by inflammatory affections of the lid border. Chalazia are apt to occur in the 
 lids of those suffering with hypermetropia and astigmatism. 
 
 Treatment. — The lid should be everted and the discolored spot on the 
 tarsal conjunctiva, which marks the position of the chalazion, exposed. This 
 
 1 Those interested in this subject should consult De Beck, Hard Chancre of the Eyelids and 
 Conjunctiva, Cincinnati, 1886; and Alexander, Syphilis und Auge, Wiesbaden, 1889. 
 
DISEASES OF THE EYE. 1181 
 
 is incised and the contents scraped out with a small curette. Large chalazia 
 should be removed by cutaneous incision, the area of operation being enclosed 
 in a suitable clamp forceps (Snellen or Knapp). Resolvent ointments (yellow 
 oxide of mercury gr. j-3J) have some reputation, but usually their employ- 
 ment is a waste of time. 
 
 Sarcoma of any of the types occurs in the eyelids of children, both upper 
 and lower, as a primary growth. At first the growth is movable under the skin 
 and slightly elastic to the touch, but rapidly develops, and may be complicated 
 with ulceration of the overlying tissue. Thorough removal should be prac- 
 tised as soon as the diagnosis is established, but return and metastasis are likely 
 to take place. 
 
 Tarsitis. — This is a chronic (very rarely acute) inflammation of the tarsus, 
 often syphilitic in origin, and then consisting of a gummatous infiltration. An 
 idiopathic tarsitis also exists which resembles a chronic blepharitis, from which 
 it must be differentiated by observing the induration of the tarsal portion of 
 the lid. If it be syphilitic, the usual constitutional remedies are indicated ; if 
 idiopathic, the treatment of chronic blepharitis is suitable. 
 
 Blepharospasm. — This term comprises several varieties of involuntary 
 contraction of the whole of the orbicularis palpebrarum or of a few of the fibres. 
 It is either clonic or tonic in character. 
 
 Clonic Blepharospasm. — The most trifling type of the clonic variety con- 
 sists in the twitching of a few fibres of the muscle, sometimes spoken of as 
 " life in the eyelid," being significant of eye-strain or some loss of tone in the 
 nervous system, and correctible by removing the evident cause. Occasionally, 
 however, it becomes stubborn, and requires, in addition to suitable glasses, the 
 administration of antispasmodic remedies — gelsemium or conium. 
 
 That form of nervous disorder which Weir Mitchell has called " habit 
 chorea" manifests itself in undue winking of the eyelids and jerky movements 
 of the facial muscles, partaking of the nature of a grimace. It is very com- 
 mon in nervous school-children, and almost always refractive error, usually 
 hypermetropic astigmatism, follicular conjunctivitis, and blepharitis will be 
 found. Suitable glasses and the exhibition of iron and arsenic usually suffice 
 to cure the disease. 
 
 Tonic Blepharospasm appears as a more or less persistent cramp of the 
 orbicularis, and may be caused by foreign bodies in the conjunctival cul-de-sac 
 or in the cornea, by conjunctivitis, and by various types of keratitis. 
 
 In rare instances a persistent cramp of the lid occurs in children, generally 
 in those of poor nutrition, which continues for weeks and even months, and for 
 which there is no obvious cause. When the lids are finally opened, there may 
 be blindness, temporary in character and without changes in the fundus oculi, 
 or associated with definite lesions in the choroid and retina. In the one 
 instance the blindness is probably due to the long-continued exclusion of the 
 rays of light, and in the other to alteration in the coats of the eye from 
 pressure. 
 
 Treatment. — As the affection in the large majority of cases partakes of 
 the nature of a reflex originating from an irritation of the peripheral trigem- 
 inal fibres, the source of irritation — foreign body, phlyctenule, or fissure at 
 the commissure — must be removed. If the cramp continues, morphine, conium, 
 or gelsemium may be tried. In bad cases section of the supraorbital nerve 
 has been performed. 
 
1182 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Ptosis. — In this affection the upper lid droops over the eyeball, and more 
 or less perfectly covers it. It may be congenital or acquired, unilateral or 
 bilateral, and is usually divided into that form of ptosis which is caused by an 
 hypertrophy of the connective tissue or an excessive accumulation of fat, and 
 that variety which depends upon imperfect development of the levator palpe- 
 brarum or paralysis of this muscle. Ptosis may also be the result of paralysis 
 of the oculo-motor nerve, and can be caused by injury to the levator of the 
 upper lid. 
 
 Cases of constitutional origin — for example, from syphilis or rheumatism — 
 require the usual remedies. The treatment of congenital ptosis, either of the 
 hypertrophic variety or that due to imperfect muscular development, requires 
 an operation. 
 
 Lagophthalmos, or an inability to close the eyelids, may result from 
 paralysis of the facial nerve, and also when the globe is pushed forward by a 
 tumor of the orbit, or is prominent as the result of exophthalmic goitre, or pro- 
 tuberant on account of a staphyloma. The affection is referred to because, 
 under certain circumstances, the exposure which the cornea suffers may lead 
 to ulceration, especially if with the facial palsy there exists an involvement of 
 the trigeminal fibres. Under these circumstances the operation of tarsorrhaphy, 
 which consists in uniting the margins of the upper and lower lids in the neigh- 
 borhood of the external commissure, is indicated. 
 
 Symblepharon is really an affection of the conjunctiva, and consists of a 
 cohesion between the eyelids and the ball which may be partial or complete. 
 It generally follows an injury, particularly a burn of the conjunctiva with acid 
 or lime, and may also result from violent inflammations of the conjunctiva. It 
 occasionally occurs as a congenital defect. 
 
 Treatment. — If adhesions form, they should be broken down with a probe, 
 and their reattachment prevented by introducing between the lid and the ball 
 a piece of gold-beater's skin or by keeping the cul-de-sac packed with a pledget 
 of lint smeared with boric-acid ointment. If these simple measures fail, then 
 one of the many operations for the relief of symblepharon must be performed. 
 
 Trichiasis; Distichiasis. — Trichiasis is that affection in which the cilia 
 are turned inward and rub against the ball. It is most commonly caused by 
 chronic inflammation of the border of the lid — for example, blepharitis — and 
 by granular conjunctivitis. The cilia produce much irritation, and may cause 
 an ulceration of the cornea. 
 
 When incurved rows of supplementary eyelashes are developed from the 
 intermarginal part of the lid, the affection receives the name distichiasis. 
 Sometimes this is congenital, but it also arises under the same circumstances 
 which produce trichiasis. 
 
 Treatment. — If the misplaced lashes are not too numerous, they may be 
 removed with cilium forceps, and the procedure repeated when they grow again ; 
 but if the affection is extensive, some operation which consists in strangulating 
 or destroying the roots of the incurved lashes, or in which a single or double 
 transplantation of the entire margin of the lid is effected, must be performed. 
 
 Entropion. — With or without trichiasis there may be an inversion of the 
 lid. The organic variety follows long-continued granular conjunctivitis, atrophy 
 of the conjunctiva, and diphtheritic ophthalmia. A spasmodic entropion is com- 
 mon as the result of inflammation of the cornea or conjunctiva, or from the 
 
DISEASES OF THE EYE. 1183 
 
 presence of foreign bodies, and is sometimes a marked symptom shortly after 
 birth, owing to an undue activity of the orbicularis muscle. 
 
 Treatment. — Spasmodic varieties usually subside by removing the cause. 
 In the event of failure the inverted lid may be drawn outward and held in 
 place by a piece of adhesive plaster attached near the margin of the lid and 
 passing downward on the cheek, or by a piece of gauze fastened with collodion. 
 When there is organic entropion a formal operation must be undertaken for 
 its cure. 1 
 
 Ectropion. — This consists in an eversion of the lid, partially or completely 
 exposing the conjunctival surface. It may occur as an acute affection, espe- 
 cially in children with inflammatory affections of the conjunctiva and cornea. 
 In its organic form, however, the eversion is generally caused by an injury — 
 for example, the laceration of the lid with a sharp instrument — by cicatricial 
 contraction as the result of burns, by chronic disease of the margin of the lid, 
 and by caries of the orbital border or malar bone. A slight eversion of the lid 
 is practically always present in children with facial palsy. 
 
 Treatment depends entirely upon the type of the affection. The spas- 
 modic varieties get well with removal of the cause, associated with replace- 
 ment of the everted lids ; mild types are sometimes curable by dilating the 
 punctum lachrymale, but in the organic forms there is no remedy except a 
 formal operation. 
 
 Milium. — Milia are common on the eyelids about the age of puberty, and 
 consist of small, yellowish elevations which are due to a distention of the 
 sebaceous glands. They result from improper, care of the skin, but often indi- 
 cate disturbances in the alimentary canal, particularly dyspepsia and constipa- 
 tion. They may be removed by pricking each elevation with a needle and 
 evacuating the contents. 
 
 Molluscum Contagiosum, a disease of the sebaceous glands, perhaps of 
 the rete mucosum, and probably of parasitic origin, may develop upon the eye- 
 lids. It is generally seen in ill-nourished children, and in asylums sometimes 
 constitutes an epidemic. Each molluscum is a rounded papule about the size 
 of a pea, of a somewhat waxy color, and with a slight depression near its 
 centre. 
 
 The treatment consists in incising it and forcing out the contents. 
 
 Sebaceous Cysts, as well as Dermoid Cysts, may o.ccur in the eyelids, 
 but are more commonly seen in the upper portion of the eyebrows. Some- 
 times in the latter situation they adhere to the periosteum and may pass 
 deeply into the orbit. They should be removed by an ordinary dissection. 
 
 Injuries of the Eyelids. — The eyelids may receive an incised, lacerated, 
 or contused wound, depending upon the character of the implement which has 
 caused the injury. The treatment does not differ from that of similar injuries 
 elsewhere located, but it is of the utmost importance that scrupulous asepsis 
 should be followed, and accurate adjustment of the lips of the wound effected 
 with fine silk sutures. 
 
 Blows upon the lid may cause a simple oedema on account of the distention 
 of the cellular tissue with serum. 
 
 1 For the description of operations the reader is referred to systematic works on ophthalmic 
 surgery. 
 
 
118± AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 (Edema does not alone result from an injury, but independently of its com- 
 mon association with severe inflammations of the cornea and conjunctiva, 
 appears in renal and cardiac diseases ; and one variety, which has received the 
 name fugitive oedema, may occur in connection with migraine, and sometimes 
 arises in association with the establishment of the menstrual function, and, 
 again, spontaneously and apparently without cause. In one case which the 
 author has seen with Dr. Louis Starr, in a very young child, it depended upon 
 the circulatory disturbances associated with slight goitre. 
 
 In the non-constitutional varieties evaporating lotions — for example, lead- 
 water and laudanum — and removal of the cause, if possible, are the proper 
 remedies. 
 
 A burn of the eyelid, either by hot water, acid, or caustic, should be treated 
 upon general principles, care being taken to prevent adhesions between the 
 eyeball and lid. One of the very best preparations for soothing the pain of 
 burns is a lotion of carbonate of sodium. 
 
 Poivder-burns. — The bluish-black specks caused by the implantation of 
 the grains of powder in the skin should be picked out with a fine needle as 
 soon as possible after the injury, and recently Dr. Jackson, of this city, has 
 suggested that each grain may be removed by touching it with a finely-pointed 
 galvano-cautery needle. Afterward the ordinary applications for burns may 
 be applied. 
 
 Emphysema of the Lids generally indicates a fracture of the orbit, per- 
 mitting the escape of air into the cellular tissue through a communication with 
 the ethmoidal or frontal sinus. 
 
 If blood collects in the same situation, ecchymosis of the lid results. This 
 condition, commonly called " black eye," most frequently follows a blow. It 
 may also occur with fracture of the base of the skull, and occasionally appears 
 in an alarming fashion by the rupture of a small blood-vessel after a violent 
 paroxysm of whooping-cough. 
 
 Treatment. — Frequent applications of very hot water, tincture of arnica, 
 lead-water and laudanum, or diluted fluid extract of hamamelis, have some 
 effect in producing absorption of the effused blood. It is useless to attempt to 
 cause absorption of the blood by the application of leeches. 
 
 Affections of the Conjunctiva. 
 
 Inflammatory diseases of the conjunctiva are exceedingly common in chil- 
 dren, constituting about 40 per cent, of the eye cases in hospital practice. The 
 most important group is that described under the general term conjunctivitis, 
 which for purposes of description may be conveniently divided into six 
 varieties : 
 
 I. Simple Conjunctivitis, generally called catarrhal or muco-purulent 
 conjunctivitis, is characterized by hyperemia of the conjunctiva, loss of its 
 transparency, some dread of light, with a feeling of grittiness under the eyelids 
 and a muco-purulent discharge, which may be slight or profuse: 
 
 Etiology. — The disease readily passes from one eye to its fellow, and from 
 one subject to another, and in this sense is distinctly contagious. Bacteria are 
 probably the active agents of this contagion. The affection is common in 
 changeable weather, and is often seen in the spring and fall. It may attack 
 perfectly healthy children, but is more common in scrofulous subjects, and is 
 more likely to be implanted in a conjunctiva already hypersemic or studded 
 with swollen follicles. It may be associated with eczema, erysipelas, impetigo 
 
DISEASES OF THE EYE. 1185 
 
 contagiosa, naso-pharyngeal affections, bronchitis, and rheumatism, and com- 
 monly follows or attends the exanthemata. It may further arise from exposure 
 to dust or irritating substances, and is sometimes the result of eye-strain. One 
 form, common in the spring and fall, has received the singularly inappropriate 
 name "pink eye, ,? being really an epidemic catarrhal inflammation probably 
 due to a special micro-organism (Weeks). 
 
 Symptoms. — These are — swelling of the lids and slight oedema of their 
 margins ; mucous or muco-purulent discharge, which may excoriate the sur- 
 rounding skin; hyperemia of the conjunctiva and congestion of the posterior 
 conjunctival vessels, in bad cases associated with oedema of this membrane and 
 small hemorrhages ; and some photophobia, especially if small corneal ulcers 
 are present. The character of the discharge and appearance of the conjunc- 
 tiva, the free mobility of the iris and lack of change in its color, distinguish it 
 from iritis. 
 
 Prognosis is good, cure usually resulting in one or two weeks, but when 
 neglected or when occurring in homes or asylums conjunctivitis of this charac- 
 ter may spread with great rapidity and become a stubborn epidemic. 
 
 Treatment. — This should be as follows : Removal of the cause in so far as 
 this is practicable ; protection of the inflamed eyes with a pair of dark glasses 
 or a shade, but under no circumstances the application of a bandage or of a 
 poultice in the form of flaxseed, tea-leaves, bread and milk, or scraped potatoes ; 
 prevention of contamination with the discharge through any medium (in homes, 
 etc. the affected inmates should be isolated) ; scrupulous removal of the secre- 
 tion, which may be effected by washing the eyes frequently with tepid water 
 and castile soap and irrigating the conjunctival cul-de-sac with the following 
 collyrium : 
 
 1^. Boric acid gr. xv. 
 
 Table salt gr. ij . 
 
 Distilled water fgj.— M. 
 
 "When the discharge becomes profuse, the lids should be everted and carefully 
 painted with a small cotton mop or camel's-hair brush dipped in a solution of 
 nitrate of silver (gr. v-f^j). 
 
 The following collyria have also found favor with many surgeons : 
 
 Bichloride of mercury (1 : 10,000) ; alum (gr. iv-f^j) ; sulphate of zinc (gr. 
 ij-f5j) ; peroxide of hydrogen (diluted one-half or three-quarters) ; and creolin 
 (1 per cent.). Atropine is generally unnecessary. A saline laxative and tonic 
 doses of quinine are suitable remedial agents in cases which do not present spe- 
 cial therapeutic indications. 
 
 II. Purulent Conjunctivitis. — This affection, in so far as infants are 
 concerned, is generally described under the name " Ophthalmia Neonatorum." 
 
 Etiology. — The infecting material enters the eye from some portion of the 
 genito-urinary tract during the passage of the head of the infant through the 
 birth-canal, or inoculation may be effected shortly after birth ; in rare instances 
 it takes place in utero when there has been a rupture of the membranes. 
 
 The gonococci of Neisser are demonstrable in most of the cases and in all 
 severe forms, and bear the same relation to this disease that they do to gonor- 
 rhoea. There is, however, one non-specific variety in which this micro-organ- 
 ism is not present. Therefore a virulent vaginal discharge (gonorrhoea!) is not 
 a sine qua non of this affection, but it may arise from the introduction of any 
 muco-purulent discharge during birth, while careless bathing and the use oi 
 soiled towels or sponges after birth are evident sources of infection. 
 
 It is probable that injudicious intravaginal antisepsis with strong solutions 
 
1186 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 of bichloride of mercury may originate a vaginitis itself capable of inducing 
 one form of ophthalmia neonatorum, and the best obstetricians confine the 
 application of germicidal solutions in uncomplicated labors to the external 
 genitalia. The author is confirmed in this belief by a consultation with Prof. 
 B. C. Hirst. 
 
 Bo} r s are more apt to be affected than girls, and inoculation is more likely 
 to occur during retarded labors and with face presentations. 
 
 Symptoms. — Ophthalmia neonatorum usually begins on the third day after 
 birth, but may set in sooner, and when it results from secondary infection — for 
 example, from soiled clothes — it begins at a later date. Almost invariably both 
 eyes are affected. 
 
 At first there is a slight discharge, which gathers at the corners of the eye, 
 rapidly succeeded by intense injection and chemosis of the conjunctiva, great 
 swelling of the lids, and the free secretion of contagious pus. The swollen 
 lids are at first tense, and the serous infiltration of the bulbar conjunctiva 
 almost hides the cornea, sometimes forming a hard rim around it ; the discharge 
 increases and flows out underneath the lids, often being mixed with blood 
 and serum. During the earlier stages the conjunctiva is red and velvety 
 and often covered with flakes of lymph ; later it becomes dark red, rough, and 
 easily bleeds. In from six to eight weeks, if unattended, the disease gradually 
 declines and the relaxed conjunctiva is thick and granular-looking, and slowly 
 regains its normal appearance. 
 
 The intense chemosis of the conjunctiva strangulates the vessels which sup- 
 ply nutrition to the cornea ; hence the vitality of this membrane is threatened, 
 constituting the chief danger of the disease. Ulcers are likely to form, either 
 at the margin or centre, and their tendency is to spread and perforate; or the 
 entire corneal tissue becomes hazy. 
 
 The results of perforation are the formation of a partial or complete 
 staphyloma and adherent leucoma, or a pyramidal cataract. Even without 
 perforation the ulcers leave scars which, according to their density, are nebu- 
 lous or leucomatous. In extensive perforation there may be an inflammatory 
 involvement of all the coats of the eye, constituting panophthalmitis, which is 
 followed by shrinking and atrophy of the globe. 
 
 Some non-specific cases of ophthalmia neonatorum do not have so violent a 
 course, and present the appearance of an ordinary muco-purulent conjunctivi- 
 tis. Again, others are analogous to diphtheritic conjunctivitis, and the danger 
 of corneal destruction is even greater than is ordinarily the case. 
 
 Prognosis. — This is always grave, but under the guidance of competent 
 medical advice, if the eye be seen while the cornea is still clear, except in those 
 examples which assume the diphtheritic type, the case should be brought to a 
 successful termination. The chief fault lies in the indifference of attendants to 
 what seems to them at first a trivial inflammation. 
 
 Treatment. — The treatment should meet four indications : 
 
 (a) During the earlier stages, when the inflammatory swelling of the lids is 
 great, in addition to proper cleanliness the local application of cold is the most 
 useful agent. This should be applied as follows : Upon a block of ice, square 
 compresses of patent lint are laid, which, in turn, are placed upon the swollen 
 lids, and are as frequently changed as may be needful to keep up a uniform 
 cold impression. The length of time occupied with these cold applications 
 must vary according to the severity of the case. Sometimes they may be 
 almost continuously used, and sometimes frequently for periods of half an 
 hour. 
 
 (b) The discharge should be constantly removed, and, if possible, by a 
 

 DISEASES OF THE EYE. 1187 
 
 trained hand. In order to accomplish this, proceed as follows : Gently separate 
 the lids, wipe away the tenacious secretion with bits of moistened lint or absorb- 
 ent cotton, and irrigate the conjunctival sac freely with an antiseptic solution, 
 care being taken that the point of the pipette does not come in contact with 
 the cornea. For this purpose a saturated solution of boracic acid — which, 
 while it is not germicidal, is still feebly antiseptic and slightly astringent — is 
 the most useful. Bichloride of mercury, one grain to the pint, may also be 
 employed. 
 
 (c) As soon as the discharge becomes free and creamy, which is very early 
 in the disease, nitrate of silver should be employed; and this drug is facile 
 princeps of the local remedial agents. It must be applied as follows: Care- 
 fully evert the lids and secure complete exposure of the inflamed tarsal con- 
 junctiva ; remove all discharge and flakes of lymph by irrigating the surfaces 
 with the cleansing lotion, wiping away the adherent particles with moistened 
 cotton ; carefully touch the area thus prepared with a cotton mop or camel's- 
 hair brush which has been dipped in a solution of nitrate of silver, ten, or at 
 most twenty grains, to the ounce; neutralize the excess with a solution of com- 
 mon salt — a pinch of salt in a cup of water will suffice — and keep applying 
 the saline solution until a clean, red surface is secured; finally, return the lids 
 to their proper position and carefully inspect the cornea before leaving the case, 
 and see that this inspection is made at each dressing of the eye ; finally, grease 
 the margins of the lids with pure vaseline, some of which should be introduced 
 within the conjunctival cul-de-sac. 
 
 (d) Should the cornea become hazy or should a small ulcer form, eserine may 
 be employed in a strength varying from a sixth to a half grain to the ounce, 
 but cautiously, lest it produce iritis. Under the latter circumstance, or if the 
 ulcer be central, atropine is the better drug, and may be used in a strength of from 
 two to four grains to the ounce. Very good results usually follow the use of 
 eserine two, three, or four times during the day, according to the severity of the 
 corneal ulceration, and a drop or two of the atropine solution toward night, with 
 due caution lest the constitutional disturbance from these drugs arise in young 
 infants. If there is corneal haze, indicating low vitality of the membrane, the 
 cold compresses may be replaced by hot applications, which should consist of 
 squares of lint wrung out in a slightly carbolized solution of a temperature of 
 120° F. 
 
 The author has thus described the treatment which he has employed many 
 times with success. Among the other solutions which have found favor with 
 surgeons are the following: Alum (eight grains to the fluid ounce); 1 carbolic 
 acid (J to 5 per cent, solution) ; weak solutions of nitrate of silver ; alcohol 
 and bichloride-of-mercury solutions; creolin in 1 per cent, solution; peroxide- 
 of-hydrogen solution; permanganate of potassium (1:1000), employed in 
 copious irrigations ; cyanuret of mercury (1 : 1500), and aqua chlorinata. 
 Many others might be mentioned, but the evidence is not sufficient to warrant 
 their recommendation or even their trial. 
 
 While the author does not wish to condemn the use of a proper strength 
 (1 : 8000) of bichloride of mercury in the treatment of this disease, because it 
 has often served him to good purpose, he is convinced that in many instances 
 a sense of false security has arisen simply because the drug has been employed 
 and because of its vaunted germicidal properties. Strong solutions of sub- 
 limate may occasion cloudiness and even ulceration of the cornea. The success 
 of treatment depends largely upon seeing the case early while the cornea 
 
 1 This has recently received fresh endorsement from Mr. Brudenell Carter (^London Lancet, 
 December 10, 1892). 
 
1188 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 is still bright, upon the faithfulness of the attendants, and upon assiduous 
 attention to the details of the treatment. 
 
 Prophylaxis. — Inasmuch as ophthalmia neonatorum is one of the most 
 fruitful causes of blindness, prophylactic measures are of the utmost import- 
 ance. All things considered, Creole's method of treating the eyes of the new- 
 born child is the one which is followed by the best results. This consists in 
 the instillation of two drops of a 2 per cent, solution of nitrate of silver in the 
 eves of the new-born child, which, as soon as it is expelled from the maternal 
 passages and before the cord is cut, is placed upon its back in the bed, the eye- 
 lids carefully cleansed, then parted, and the drug introduced. This instilla- 
 tion, when there is reason to suspect gonorrheal contagion, should be repeated 
 on the second day. In the mean time, small compresses soaked in a solution 
 of salicylic acid are laid upon the closed lids. Sometimes the instillation of 
 the silver solution causes hyperemia, which disappears in a few days. In a 
 few instances smart conjunctival haemorrhage has followed this treatment. The 
 enormous value, however, of this prophylaxis far outweighs the few accidents 
 which have occurred after its use. 
 
 Numerous other methods have been employed in the prophylaxis of oph- 
 thalmia neonatorum, and most of the antiseptic fluids have had their advocates, 
 particularly carbolic acid, 1 per cent., bichloride of mercury, 1:5000, Yan 
 Swieten's solution (corrosive sublimate 1 part, alcohol 100 parts, water 900 
 parts), and aqua chlorinata, the last drug being especially recommended by 
 Schmidt-Rimpler. On the other hand, many obstetricians are content with 
 painstaking cleanliness during birth and also during childbed, believing that 
 this will reduce the possibility of the disease to a minimum. While this may be 
 true in private practice and in the absence of any suspicious secretion in the 
 maternal passages, Crede's method or an analogous one ought certainly to be 
 used in hospital practice always and whenever there is the least suspicion of 
 contagion. There is reason to hope that stringent legislative regulations will 
 be formulated to lessen this appalling cause of blindness, but in their absence 
 it is the evident duty of physicians, nurses, and directors of public charities to 
 disseminate among the poorer classes a knowledge of the dangers of this dis- 
 ease and the necessity for prompt treatment. When the disease has developed 
 and is monolateral, the unaffected eye may be protected with a bandage. 
 Attendants should be warned of the danger of contamination. 
 
 III. Diphtheritic Conjunctivitis. — This is an exceedingly contagious 
 conjunctivitis, which may arise from a similar case or during the course of a 
 purulent ophthalmia. It may appear in connection with eczema of the face or 
 accompany an acute illness, as scarlet fever or measles. The disease is also 
 seen during epidemics of diphtheria, when it is occasioned by direct inocu- 
 lation. A comparatively rare affection in America and England, it is common 
 in certain parts of France and in the north of Germany. It is most frequent 
 in children between the ages of two and eight. 
 
 Symptoms. — The chief symptoms are swelling of the lids, which become 
 exceedingly hard and board-like ; a dull, grayish, false membrane, either dis- 
 crete or confluent, covers the conjunctival surface. The membrane is often 
 deeply incorporated with the subjacent tissue. The cornea rarely escapes, and 
 destruction of this membrane may take place in twenty-four hours. Even 
 in the mild cases severe ulceration is common. 
 
 Treatment. — During the earlier stages cold compresses are proper, to be 
 substituted by hot affusions later on, especially if there be corneal ulceration. 
 The eyes should be frequently cleansed with boric acid or weak solutions of 
 bichloride of mercury, and atropine drops should be instilled if the ulceration 
 
DISEASES OF THE EYE. 1189 
 
 of the cornea is peripheral ; but in most instances eserine is the better drug. 
 French physicians warmly recommend the application of lemon-juice and citric- 
 acid ointment, and, on the recommendation of Tweedy, solutions of quinine 
 have been much employed. The internal treatment is that suited to a case of 
 diphtheria, and in the experience of the author, with the few cases which he 
 lias seen in the Children's Hospital of this city, the best results were obtained by 
 the administration of bichloride of mercury or calomel, associated with quinine 
 suppositories. 1 
 
 IV. Spring Conjunctivitis (Fruehjahrs Catarrh). — This curious form 
 of conjunctival disease is generally seen in children between the ages of five 
 and fourteen years. Its exact cause is unknown. One of the characteristics 
 of the disease is its return about April, and its subsidence in the fall and 
 winter, although sporadic cases are seen in almost every month of the year. 
 Sometimes it accompanies the disease known as hay fever. 
 
 Symptoms. — The chief symptoms are photophobia, mucous secretion, 
 hypertrophy of the tissues surrounding the limbus of the cornea in the form 
 of grayish nodules, and a pale, dull color of the palpebral conjunctiva, which 
 has been compared to the appearance of a thin layer of milk, together with 
 the formation of large flattened granulations covering the tarsal folds and 
 causing the eyes to droop and give the patient a peculiar, sleepy expression. 
 It must not be confounded with granular lids, from which it is distinguishable 
 by the flat appearance of the granulations and the absence of corneal compli- 
 cations. So far as vision is concerned, the prognosis is good, but the prom- 
 inent tendency of the disease to return with the early spring and warm weather 
 makes it a difficult disorder to manage. 
 
 Treatment. — The eyes should be protected with dark glasses, the con- 
 junctival cul-de-sac freed from the accumulated secretion, which is sometimes 
 quite free, with a lotion of boric acid and salt. When the granulations 
 are prominent the lids may be everted and their surfaces touched with a 20 
 per cent, solution of boroglyceride or with a strong solution of bichloride of 
 mercury (1:500), this application to be made once a day. In bad cases the 
 actual cautery may be employed to destroy the granulations, or these may be 
 crushed with roller forceps, as in the treatment of granular lids. Internally, 
 some form of arsenic is advisable, preferably Fowler's solution. 
 
 V. Follicular Conjunctivitis. — This, as its name implies, is an inflam- 
 mation in which numerous pinkish, round elevations appear in the conjunctiva, 
 chiefly in the retrotarsal folds, sometimes associated with the symptoms of an 
 ordinary catarrhal conjunctivitis of mild degree. These bodies are tumefied 
 lymphatic follicles, and disappear under treatment without leaving cicatricial 
 changes in the conjunctiva, and the cornea is not involved — points which dis- 
 tinguish the affection from true granular lids. Some authors regard it as an 
 early stage of granular conjunctivitis. The evidence is in favor of a separate 
 classification. 
 
 It occurs usually in children and young people, and in its aggravated forms 
 arises under the influence of bad hygienic surroundings in overcrowded schools 
 and asylums. A mild form is common in school-children under good con- 
 ditions. When neglected, it may become a serious and epidemic disorder. 
 
 Treatment. — This consists of improvement of the surroundings, building 
 up of the general health if this is below par, and, locally, boric-acid solution 
 
 1 There is also a true croupous conjunctivitis which occasionally attacks children between the 
 first half year of life and the fourth year. It is not contagious, and the cornea generally escapes, 
 and although membrane forms upon the conjunctiva, the lids remain pliant. It is a rare dis- 
 ease, and the distinction between it and true diphtheria of the conjunctiva is not always main- 
 tained by authors. 
 
1190 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 or sublimate collyrium, a salve of sulphate of copper (J gr. to 3j), or dusting 
 upon the retrotarsal folds iodoform, aristol, or equal parts of subnitrate of 
 bismuth and calomel. Refractive errors should be corrected. If the disease 
 is at all stubborn, the swollen follicles should be destroyed, preferably with 
 Knapp's roller forceps. 
 
 VI. Granular Conjunctivitis (Trachoma). — This is a serious form of 
 inflammation in which rounded granulations 1 (trachoma-bodies) form in the 
 conjunctiva, resulting in cicatricial changes in the lids and vascularization and 
 ulceration of the cornea. The disease may be acute or chronic. It is dis- 
 tinctly contagious. 
 
 Although not nearly so common in childhood as in adult life, many cases 
 occur among children, especially of the poorer classes. It is most frequent 
 among the Jews, Irish, Italians, Indians, and inhabitants of the East, but, 
 except in rare instances, is unknown among the pure negroes. Inhabitants of 
 low and damp regions are more liable than those who live on high ground, an 
 altitude of one thousand feet conferring comparative immunity. This pre- 
 disposition to granular lids is also encouraged by residence in badly-ventilated 
 homes and asylums, where the disease may become epidemic, and by imperfect 
 nutrition, but there is no known constitutional disorder at the bottom of the 
 disease. The essential characteristics of the affection are the " granulations" 
 (trachoma-bodies), sometimes called "follicles," which differ from those seen in 
 follicular conjunctivitis because they may be regarded as pathological new 
 formations. It is probable that the active agent in the production of trachoma 
 and its dissemination is a special micro-organism, the trachoma-coccus, but its 
 identity is' not clearly established. 
 
 Symptoms.— In acute granular conjunctivitis, in addition to the phe- 
 nomena of a violent conjunctivitis, associated with great dread of light, free 
 lachrymation, and later a muco-purulent discharge, the conjunctival papillae 
 become hypertrophied and there is a liberal growth of roundish granulations 
 in this membrane. This acute type must be distinguished from the exacerba- 
 tions which are common in the chronic variety of the disease. 
 
 In chronic granular conjunctivitis there may be a stage of acute inflamma- 
 tion, such as has just been described, but most frequently it appears without 
 such preceding condition. The grayish-white, semi-transparent granulations, 
 often in rows and sometimes resembling the spawn of frogs, develop chiefly in 
 the retrotarsal folds. The most important types are (a) papillary trachoma, 
 (6) follicular trachoma, and (<?) mixed or diffuse trachoma. In the papillary 
 and mixed varieties, in addition to the granulations, there is much hypertrophy 
 of the conjunctival papillae. At first there is little discharge, but as the develop- 
 ment of the follicles increases a softening process takes place and the secretion 
 becomes abundant and is extremely contagious. Gradually the stage of cica- 
 trization is reached, which results in the formation of scar-tissue, the cicatrices 
 often lying in characteristic parallel lines, while the lids become indurated and 
 their borders inverted, resulting in conditions which have already been described. 
 In bad oases there is a practical drying up, or xerosis, of the conjunctiva, 
 with obliteration of the sulcus. 
 
 Sequelae. — The most important sequels of granular lids have been referred 
 to, with the- exception of the vascularization of the cornea, or p annus, which 
 is really a form of vascular keratitis. It always begins under the upper lid by 
 the development of blood-vessels in the superficial layers of the cornea, often 
 associated with ulceration and opacification of that membrane. This pannus is 
 
 1 These should not be confounded with the granulations of wounds. 
 

 DISEASES OF THE EYE. 1191 
 
 partly due to the mechanical effect of the granulations, and partly to a special 
 implantation of the disease in the cornea, 
 
 Treatment. — Acute granular conjunctivitis must be managed on the 
 principles already laid down in connection with an acute inflammation of 
 the conjunctiva. 
 
 In chronic granulations the object is to promote absorption of these with 
 the least cicatricial change, and consequently the application should never be 
 so caustic as to create scars, which would be worse than those resulting from 
 the natural subsidence of the disease. It would be impossible in this brief 
 description even to refer to the numerous applications which have been made, 
 and the author will hence recommend those which in his own practice he has 
 found most efficacious- — namely, (a) nitrate of silver, 10 grains to the ounce, 
 during any stage of granular lids when there is much discharge, to be applied 
 in the manner already described ; (b) strong solutions of bichloride of mercury 
 (1 : 300 or 1 : 500), applied to the everted lids with a cotton mop, associated with 
 frequent irrigation of the conjunctival cul-de-sac with a tepid solution of the 
 same drug, 1 grain to the pint ; suitable in practically any stage of granular 
 lids, but especially when there is decided development of the follicles ; (c) sul- 
 phate of copper in the form of a smooth crystal, which is rubbed over the 
 everted lids and well across the retrotarsal folds, useful in any stage except 
 that in which there is much discharge, and particularly valuable in the later 
 periods of the disease ; (d) boro-glyceride, 20 or 50 per cent., applied in the 
 usual manner to the affected conjunctiva, most valuable after cicatrization has 
 begun. In mild cases an excellent remedy is a solution of tannin and glycerin, 
 20 or 30 grains of tannic acid to the ounce of glycerin. 
 
 Generally, pannus will disappear with the subsidence of the granulations. 
 If it does not or if exacerbations are present, it must be treated after the man- 
 ner suited to keratitis. (See page 1197.) 
 
 Operative interference, except in the acute cases, yields the most satisfac- 
 tory results in the treatment of granular lids. The best method is expression 
 of the granulations by means of forceps, and of those thus far devised, the one 
 advocated by Knapp, which works on the principle of a roller, is the most val- 
 uable. After the lids have been thoroughly rolled the local treatment must be 
 continued, and generally the sulphate-of-copper crystal will then be found use- 
 ful. The roller forceps, however, are not sufficient in cases of diffuse trachoma. 
 Then the operation called " grattage " is much practised. This consists essen- 
 tially in deep scarifications and rubbing out the trachoma-bodies with a stiff 
 brush which has been dipped in a solution of bichloride of mercury. This last- 
 named method is a vigorous means which should be utilized in selected cases, 
 and for a description of which, and of the many other methods, the reader is 
 referred to systematic treatises on diseases of the eye. 
 
 Ecchymosis of the Conjunctiva, which consists of an escape of blood 
 into the meshes of the connective tissue, is particularly interesting in children 
 as the common result of a violent paroxysm of whooping cough, although it 
 may arise under any straining effort. It is also seen with girls at the begin- 
 ning of the menstrual epoch. The entire conjunctiva may become blood-red. 
 The blood disappears without treatment, although hot compresses seem to hasten 
 its subsidence. 
 
 Chemosis of the Conjunctiva is common in various types of conjunc- 
 tivitis, but it is also a symptom of deeper diseases of the eve : for example, 
 inflammatory affections of the uveal tract. Sometimes it occurs without appa- 
 
1192 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 rent cause. The oedema may be very great, and the conjunctiva appear like a 
 huge bleb and protrude between the lids. Usually the oedema subsides under 
 the influence of hot compresses and an astringent lotion ; for example, a weak 
 solution of alum. If it be very severe, the swollen tissues may be incised. 
 
 Tumors and Cysts of the Conjunctiva. — Several varieties of benign 
 tumors and cysts (dermoids) have been described, and among the malignant 
 tumors in children should be mentioned sarcoma, which develops usually at the 
 limbus, and is generally pigmented. The benign growths and cysts can easily 
 be removed. If a sarcoma appears, it may be necessary to extirpate the entire 
 eyeball. 
 
 Tubercle of the Conjunctiva, under rare circumstances, occurs as a 
 primary affection in the form of uneven ulcers beset with grayish-red nodules, 
 in which a decisive diagnosis could be made by bacteriological examination. 
 
 Pemphigus may attack this membrane. There is a curious form of atrophy 
 of the conjunctiva in which the membrane dries up entirely and the borders of 
 the lid become fixed to the ball. This is probably a form of pemphigus, but it 
 has also been described as essential shrinking of the conjunctiva. Ordinary 
 atrophy of the conjunctiva following granular lids and diphtheritic conjuncti- 
 vitis has been referred to. 
 
 Injuries of the Conjunctiva. — Burns, especially with lime and acid, 
 are to be feared mostly on account of the symblepharon which they are likely 
 to produce. After a lime-burn the alkali may be neutralized with a weak acid, 
 but usually it is best to speedily flood the eye with a rapid stream of water — 
 for example, from a spigot — and pick off any pieces which the water fails to 
 wash away. Iced compresses may then be applied. Atropine drops should be 
 instilled if there is corneal involvement, and the conjunctival cul-de-sac should 
 be frequently cleansed with a solution containing boric acid and common salt. 
 An acid burn is treated on the same principles, an alkaline wash composed of 
 carbonate of sodium being at first employed. It is usually recommended 
 to drop olive oil on the conjunctiva after a burn, and certainly it can do no 
 harm. A good plan is to incorporate with liquid vaseline- some atropine 
 (gr. iv-lj) and freely introduce this substance. 
 
 Phlyctenular Kerato-conjunctivitis {Phlyctenular Ophthalmia, Stru- 
 mous, Pustular, and Vesicular Keratitis and Conjunctivitis). — It is customary 
 to describe phlyctenular conjunctivitis and phlyctenular keratitis as two dis- 
 tinct affections, but as both cornea and conjunctiva are associated in the inflam- 
 mation, and as the lesion is the same in both cases, it is better to include them 
 under one name. 
 
 The disease is characterized by the formation on the bulbar conjunctiva, at 
 the corneal margin, or on the cornea, of small, grayish -white elevations, often 
 called vesicles or pimples, and usually classified under the generic term phlycte- 
 nules, associated with injection, lachrymation, and dread of light. 
 
 Etiology. — It usually occurs in children before their tenth year, and most 
 frequently in those of strumous constitution. Eczema of the face is frequently 
 present. The use of unwholesome food (sweetmeats, pastry, tea, and coffee), 
 and consequent derangements of the alimentary canal, are predisposing causes : 
 the conjunctival form follows in the wake of scarlet fever and measles. All 
 varieties are more common and more aggravated in warm and moist weather. 
 
DISEASES OF THE EYE. 1193 
 
 There is a direct relation between this disease and various lesions in the nasal 
 fossae and naso-pharynx (rhinitis, congested turbinals, and adenoid vegeta- 
 tions). It is probable that astigmatic eyes are more liable than those with 
 refractive conditions approaching emmetropia. Several varieties of micro- 
 cocci have been described, but no definite causal relation has been established. 
 
 Symptoms. — In the conjunctival variety the phlyctenules form on the 
 bulbar conjunctiva and especially affect the margin of the cornea. There may 
 be only one or two of them (single form), or they maybe numerous and scattered 
 everywhere over the membrane (multiple form). At first translucent, they 
 soon become turbid and break down. The conjunctival vessels are freely 
 inj ected. 
 
 In the corneal types the phlyctenules, about the size of a millet-seed, 
 appear near the corneo-scleral junction or encircle the margin (marginal kera- 
 titis), or a single one develops near the border and creeps across the face of 
 the cornea, followed by a leash of blood-vessels (fascicular keratitis). There 
 are, in addition, conjunctival hyperemia, free lachrymation, and intense pho- 
 tophobia. Soon the phlyctenules grow yellow, break down, and ulcers (phlyc- 
 tenular ulcers) are formed, which at first are superficial and may remain so; or, 
 in the more aggravated varieties, they will grow deeper, the surrounding cornea 
 become infiltrated, and perforation may ensue. This is especially apt to occur if 
 a large yellow phlyctenule (pustular for ni) develops just at the margin of the 
 cornea. Relapses are frequent ; new phlyctenules form, fresh ulcers result, and, 
 unless the process is checked, the epithelium of the cornea becomes roughened, 
 opaque, and vascular, and phlyctenular pannus arises. Almost invariably 
 there is an irritating rhinitis, causing an acrid secretion to flow from the nose 
 and excoriate the lip, while frequently patches of eczema appear around the 
 nares, on the face, or at the auricle. 
 
 Treatment. — The extreme photophobia makes it difficult to properly apply 
 local remedies. For this reason the child's head should be taken between the 
 surgeon's knees, while an assistant holds the hands and body. The lids are 
 then separated and the cornea can be gradually coaxed into view. A lid-elevator 
 may be employed, and in very bad cases it is sometimes needful to use ether or 
 chloroform before the necessary inspection of the eye is possible. Cocaine will 
 temporarily relieve the photophobia, but it should never be employed as a con- 
 stant application where corneal ulceration exists. If the child is of sufficient 
 age, the eyes may be protected with goggles, and under all circumstances the 
 little patient should be encouraged not to bury its head in the bed-clothes or 
 hide in dark corners of the room. Photophobia may be allayed by douching 
 the eyes with cold water, and search should always be made for a fissure at the 
 external commissure, which is apt to keep up the dread of light ; if this be 
 present it may be touched with a crystal of blue-stone or the fibres of the 
 orbicularis divided at this point with a sharp knife. 
 
 The best possible hygienic surroundings, with strict regulation of the diet, 
 out-door exercise in good weather, and frequent sponge baths with salt water 
 are advisable. Atropine drops, 4 grains to the ounce, should be used until 
 complete mydriasis is obtained, and this dilatation of the pupil should be kept 
 up as long as there is irritation. If there is much discharge, boric-acid drops, 
 with or without the addition of common salt, may be used. In severe ulcera- 
 tion of the peripheral type, eserine (gr. J or J to the fluidounce) is useful, and 
 may be employed during the day, a drop or two of the atropine solution being 
 instilled at night. After the irritation has subsided yellow oxide of mercury, 
 1 grain to the drachm, should be employed as a local application, or in its 
 place finely-powdered calomel may be dusted into the eye, provided the patient 
 
1194 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 is not taking iodide of potash or any preparation of iodine, under which 
 circumstances such practice will result in a violent inflammation of the con- 
 junctiva. 
 
 Internally, after the alimentary canal has been prepared by a course of 
 calomel, the most useful drugs are cod-liver oil, iron, quinine, and arsenic. 
 
 It is essential in all these cases to treat the nasal conditions which have 
 been described, an excellent routine practice being to spray the parts with 
 Dobell's solution or listerine, and insufflate powdered iodoform, or a mixture 
 composed of camphor, boric acid, and subnitrate of bismuth, or finely-pul- 
 verized chlorate of potassium. If, however, adenoid vegetations or hyper- 
 trophied turbinated bodies are present, these must be treated on the principles 
 known to nasal surgery. In stubborn cases and with ulcers tending to per- 
 forate the measures to be described for treating corneal ulcers will be required. 
 After the subsidence of the disease suitable glasses should be ordered, if the 
 corneal astigmatism is of such character that it can be corrected. 
 
 Diseases op the Cornea. 
 
 Ulcers of the Cornea. — When the stage of infiltration which accom- 
 panies an inflammation of the cornea, or a keratitis, fails to end in absorption, 
 and the corneal tissue disintegrates, an open lesion or an ulcer results. In 
 children the majority of corneal ulcers which are of primary origin result from 
 the disease which has just been described, and are hence known as phlyctenular 
 ulcers. Systematic writers have described a number of other types of ulcer, 
 among which the following varieties may be mentioned : 
 
 (a) Simple Ulcer. — This, sometimes called "pimple ulcer" when it arises 
 from a phlyctenule, is a small gray infiltration, and may develop from an injury. 
 Frequently it appears right in the centre of the cornea, and as a slightly cone- 
 shaped, gray-white opacity, without much irritation, and is then known as the 
 small central ulcer of childhood. It heals, leaving a small scar directly in the 
 axis of vision. It is seen in poorly-nourished children of the strumous habit, 
 and probably represents one of the results of imperfect nutrition. It may 
 heal quickly or develop into a deep ulcer. 
 
 (b) Deep or Purulent Ulcer. — This is practically described in its title, 
 and is a more aggravated form of the type just described, of yellowish appear- 
 ance with infiltrated margins, and a tendency to penetrate the layers of the 
 cornea. It may be the result of injury, or may follow certain conjunctival 
 inflammations, or arise because a simple ulceration has been neglected. It 
 heals with a dense white scar. 
 
 (c) Indolent Ulcers. — Several varieties of these have been described. 
 One is apt to occur in the centre of the cornea — a small shallow lesion with a 
 slightly turbid base and not much injection of the surrounding tissues (shallow 
 central ulcer). It is often seen accompanying granular lids. Another variety 
 is called gouged-out ulcer, almost without any injection accompanying it, its 
 most common situation being near the corneal margin. These ulcers heal with 
 less dense scars, sometimes only a faint opaque facet remaining (facetted ulcer). 
 They are common in aneemic and scrofulous patients, and evidently depend 
 upon failure in the nutrition of the cornea. 
 
 (d) Sloughing Ulcer. — A sloughing or infecting ulcer is the representa- 
 tive of purulent keratitis, and is a more serious grade than the deep or purulent 
 ulcer already noted. This is not so common in children as in elderly people ; 
 but at the same time very violent and serious ulcers, which are serpiginous or 
 creeping in type, arise in children as the result of injury, because the abrasion 
 
DISEASES OF THE EYE. 1195 
 
 thus produced has been infected, probably, with a special form of micro-organ- 
 ism. Not only is there extensive purulent infiltration of the cornea, but also 
 the iris is involved and pus forms in the anterior chamber, and hence the disease 
 is called hypopyon keratitis. In like manner, instead of an open ulcer of this 
 character, the pus may be confined within the layers of the cornea, and an 
 abscess results, or its superficial layers may burst and there is an open lesion. 
 This also is due to the fact that the area has been inoculated with pathogenic 
 micro-organisms. Some of the most typical examples of abscess of the cornea 
 and hypopyon keratitis occur not only from injuries and neglected ulcers, but 
 with small-pox, scarlet fever, measles, typhus, and typhoid fever. 
 
 Treatment. — Everything which tends to improve the surroundings of the 
 patient and to build up his nutrition is indicated. Proper protection of the 
 eyes with goggles is important ; whenever possible, out-door exercise is advis- 
 able. The remedies already suggested with phlyctenular keratitis are usually 
 needed, care being taken to inquire into possible etiological conditions, which 
 should be met with suitable measures. 
 
 Search should always be made for the presence of a foreign body and for 
 irritating, misplaced cilia. The lachrymal passages should be explored to see 
 if they are patent, and the teeth should be examined, and if they are carious 
 the services of a dentist should be secured. The nasal passages and the naso- 
 pharynx should be carefully examined and treated. 
 
 In mild cases of simple ulcer atropine drops for a few days, to be followed 
 later by a salve of yellow oxide of mercury (gr. j-3J), usually suffice. In 
 severe cases atropine drops may be employed, provided the ulcer is central and 
 if there is any hyperemia of the iris ; if not, eserine in the strength already 
 mentioned may be dropped into the eye three or four times a day, with one 
 or two drops of the atropine lotion at night. The conjunctival cul-de-sac 
 should be frequently irrigated with a mild antiseptic lotion, a saturated solu- 
 tion of boric acid, a weak solution of bichloride of mercury (1:10,000), or 
 aqua chlorinata. These drugs are particularly indicated if there is an asso- 
 ciated conjunctivitis with muco-purulent discharge, which should then be treated 
 also on the principles already laid down. 
 
 If the ulcer is sluggish, it may be stimulated to heal by the introduction 
 of the yellow-oxide salve. In sloughing ulcers, in addition to the measures 
 already "indicated it may be necessary to curette the surface, touch it gently 
 with a solution of nitrate of silver, 10 grains to the fluidounce, or dust upon 
 it finely-powdered iodoform. In many cases the most effectual treatment is the 
 cautery, the point of a galvano- or a thermo-Cautery being applied gently but 
 thoroughly to the involved area. In hypopyon keratitis or in abscess of the 
 cornea, paracentesis of the cornea or the section of Ssemisch is sometimes neces- 
 sary. In any case in which rupture is impending, and there is no contraindi- 
 cation — as, for example, associated catarrhal conjunctivitis — much good may be 
 done by a carefully applied compressing bandage. In any type of corneal ulcer- 
 ation hot compresses are often invaluable, as they aid in healing and preserve 
 the nutrition of the cornea. 
 
 The Results of Corneal Ulceration. — Every ulcer is followed by a scar, 
 which may be a mere haze, -or nebula, a more pronounced spot, or macula, or a 
 dense white scar, or leueoma. If the cornea has ruptured, the anterior cham- 
 ber is evacuated, and the iris falls forward and is entangled in the opening. 
 This, then, is an anterior synechia, and the scar on the cornea is an adherent 
 leueoma. Sometimes an eye of this character becomes quiet : sometimes, how- 
 ever, it cannot resist the intraocular tension and the area bulges forward, form- 
 ing a staphyloma. If there has been an extensive rupture of the cornea and 
 
11^ AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 complete matting of the prolapsed iris with the inflamed and broken-down 
 corneal tissue, the whole cornea protrudes as an opaque elevation, forming a 
 complete staphyloma. 
 
 Treatment of Sequels. — Slight corneal scars and nebulas may be influ- 
 enced beneficially by massage of the cornea, aided by the previous introduction 
 of a small particle of Pagenstecher's ointment (yellow oxide of mercury, 1 gr. 
 to the drachm). The dense white leucomas, however, are not thus influenced. 
 If they are central and clear cornea remains at the side, an optical iridectomy 
 may be performed and the scar tattooed with India ink to improve its appear- 
 ance. After the perforation of an ulcer and prolapse of the iris it is sometimes 
 possible, when recent, to disentangle this with the aid of an instrument and the 
 vigorous use of eserine or atropine, according to the situation of the ulcer. If 
 this fails, staphyloma should be prevented by the vigorous use of a compressing 
 bandage. If, in spite of this, staphyloma, either partial or complete, forms, 
 various surgical measures are indicated, according to the extent of the dam- 
 age — namely, iridectomy, the operation for partial staphyloma, or, in hopeless 
 cases, evisceration or enucleation. 
 
 Infantile Ulceration of the Cornea, with Xerosis of the Con- 
 junctiva (Kerato-malacia). — In certain anaemic and badly-nourished children, 
 sometimes after measles, scarlet fever, violent diarrhoea, and other illnesses with 
 great depression of nutrition, the cornea undergoes a rapid destructive ulcer- 
 ation, while the conjunctiva becomes greasy and dry, little flakes of cheesy 
 appearance forming upon its surface. Not only is the destruction of the sight 
 almost inevitable, but most of the infants — for it usually occurs during the first 
 year of life — die, generally of intercurrent pneumonia. 
 
 The usual treatment of corneal ulceration is indicated, with an attempt to 
 improve the general condition. 
 
 This disease should not be confounded with a type of conjunctival disease 
 known as xerophthalmos, in which the same cheesy flakes form and the mem- 
 brane becomes greasy and dry, and which sometimes occurs as an epidemic with 
 the curious symptom of night-blindness, especially in people who have long fasted. 
 
 Interstitial Keratitis [Syphilitic, Parenchymatous Keratitis). — In this 
 disease, which is an inflammation of the chronic type, a diffuse keratitis, prac- 
 tically always without ulceration, arises, and the cornea gradually becomes 
 thick with haziness until it resembles ground glass, while superficial and deep 
 vascularization accompanies the condition. 
 
 It is most often seen between the ages of five and fifteen, and is more fre- 
 quent in females than in males. A very large percentage of cases is due to 
 inherited syphilis, but it has also been attributed to rachitis, scrofula, malaria, 
 rheumatism, and depressed nutrition. In the syphilitic cases generally some 
 other mark of syphilis is present, particularly Hutchinson's teeth, or evidence 
 of this taint can be acquired from the family history. 
 
 Symptoms. — The disease begins with slight ciliary congestion, a few spots 
 of infiltration in the cornea, which speedily develop into the general haze 
 already described, the infiltration being in the interstitial tissue ; blood-vessels 
 become thickly set in the layers of the cornea, which in its upper part assumes 
 a dull reddish color. In some types this is so pronounced that a special variety 
 of it is denominated vascular keratitis. There are considerable pain and pho- 
 tophobia. Quite commonly iritis develops, and in many instances inflammation 
 of the deeper coats of the eye occurs. It requires from six months to a year 
 and a half before the disease passes through its various stages. Under proper 
 
DISEASES OF THE EYE. 1197 
 
 treatment clearing of the cornea usually takes place, but years afterward 
 careful examination will show traces of the disease, especially in the pres- 
 ence of minute channels through the corneal tissue, indicating the course of 
 the former vessels. 
 
 Treatment. — Any irritating application is distinctly contraindicated. 
 Hence it is proper to employ atropine to maintain dilatation of the pupil and 
 prevent iritis : this, if the photophobia be severe, may be combined with 
 cocaine. Hot compresses are agreeable and soothe the inflammation. The 
 eyes should be protected with goggles, and the child encouraged to have out- 
 door exercise in proper weather. The best general medication is mercury, 
 and, in the opinion of the author, inunction is the preferable method of admin- 
 istration, pushed to the point of tolerance, but never to that of salivation. 
 Subconjunctival injections of bichloride of mercury — two drops of a 1 : 1000 
 solution — have recently acquired a favorable reputation. After the mercurial 
 course iodide of potassium may be given. Later, bichloride of mercury com- 
 bined with the tincture of the chloride of iron is suitable, and, if the indi- 
 cations are present, the administration of cod-liver oil, arsenic, and quinine. 
 "When all irritation has subsided the remaining opacity may be treated by 
 massage with the yellow-oxide-of-mercury ointment. Iridectomy is sometimes 
 necessary to check the disease or to make a new pupil if a central opacity 
 remains. The disease is stubborn, subject to relapses, and nearly always 
 bilateral, although both eyes are not attacked at the same time, and a long 
 period may elapse between the two attacks. 
 
 Injuries of the Cornea. — The most important of these are the ordi- 
 nary wounds, burns, and scalds; and practically the directions which have 
 already been given in diseases of the conjunctiva are applicable, although, 
 naturally, a wound of the cornea is likely to result in much more serious dis- 
 aster than one confined to the conjunctiva, because the lens, iris, and even 
 deeper structures, are liable to injury. 
 
 After a wound of the cornea the most thorougn antisepsis is required. If 
 the iris is prolapsed, it may be seized and cut off and an antiseptic compress- 
 ing bandage applied. Traumatic iritis is best combated by the frequent use 
 of iced compresses. In severe cases the question of enucleation to prevent 
 sympathetic irritation must be considered. 
 
 Foreign Bodies Imbedded in the Cornea must be removed with a 
 spud after the eye has been rendered insensitive with cocaine. Avoidance of 
 much digging at the corneal tissue is desirable. It is necessary to locate small 
 bodies by means of oblique illumination, and much aid is often given by drop- 
 ping a fluorescine solution into the eye, which colors green the abraded cornea 
 and brings out in contrast the foreign body as a black spot. After the removal 
 of the foreign body it is desirable to thoroughly cleanse the conjunctival cul- 
 de-sac, lest the abrasion be infected and a serious corneal ulcer result. It is 
 equally necessary that the instruments used should be clean in the surgical 
 sense of the word. 
 
 Disease op the Iris and Ciliary Body ; Sympathetic Inflamma- 
 tion of the Eye. 
 
 Diseases of the iris and, indeed, of the entire uveal tract, are comparatively 
 rare in childhood. 
 
1198 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 Ikitis. — This may arise in utero, and is then called congenital iritis. The 
 child is born with occlusion of the pupil, and actual shrinking of the eyeball 
 may ensue. 
 
 It also develops, but infrequently, during the first few months of life 
 (from two to nine months), and in practically all instances is due to inherited 
 syphilis. The ordinary symptoms of iritis are present, but not usually in so 
 severe a type as in adults : fine pericorneal injection, discoloration of the iris, 
 sluggish or immobile pupil, abnormal reaction of the iris to a mydriatic, and 
 the formation of attachments between the pupillary margin of the iris and the 
 capsule of the lens, or posterior synechia?, — symptoms which are absent in con- 
 junctivitis, and hence should always serve as distinguishing features. 
 
 Iritis associated with inflammation of the ciliary body, opacity in the 
 vitreous and changes in the choroid, and the deposition of a triangular patch of 
 punctate exudations upon the posterior layer of the cornea {keratitis punctata, 
 serous iritis, serous irido-cyclitis) is also seen in young subjects, and, like the 
 preceding affection, may be due to inherited syphilis. Sometimes the iritis 
 which frequently accompanies interstitial keratitis is the most prominent 
 feature of the disease. 
 
 Gumma of the Iris and so-called gummatous iritis have occasionally been 
 seen in children of syphilitic parents (Alexander, Watson, Mules). 
 
 As the age of puberty is approached diseases of the uveal tract become 
 more frequent, and iritis, both plastic and serous, may be seen, the latter 
 especially in girls with disturbances attending the development of the men- 
 strual functions. In one form of iritis lardaceous deposits or nodules appear 
 in the iris, somewhat resembling the small yellowish bodies seen in so-called 
 gummatous (really papular) iritis, constituting the disease called scrofulous 
 iritis, which is seen in strumous and anaemic subjects. An insidious form of 
 iritis, associated with vitreous opacities, occurs in the children of gouty parents. 
 The author has seen several examples, and this taint should be suspected in 
 the iritis of boys near the age of puberty. 
 
 Tubercles may also appear in the iris (tubercular iritis) and constitute a 
 primary tuberculosis. 
 
 Finally, an iritis may arise from injury (traumatic iritis), and under the 
 influence of infection become purulent (purulent iritis) — a type of the disease 
 which has s also been described in connection with several infectious diseases 
 (recurrent fever, pneumonia, typhus and typhoid fever, and pyasmia). 
 
 Treatment. — This consists in ascertaining the cause and exhibiting suit- 
 able remedies, the most important of which are mercury and iodide of potassium. 
 Locally, atropine drops, sufficient to maintain mydriasis, are indicated in prac- 
 tically all cases. 1 In children of a proper age, if there be much pain and 
 inflammatory reaction, leeches may be applied to the temple. Hot compresses 
 are soothing. In traumatic iritis it is proper to employ iced applications, but 
 not in the other varieties of the disease. The ordinary astringent applications 
 are never needed unless there should be associated conjunctivitis. The speedy 
 detection of iritis and prompt use of atropine are important, lest the posterior 
 synechia become too strong to be influenced by the drug. 
 
 Injuries to the Iris and Ciliary Region ; Sympathetic Irrita- 
 tion and Sympathetic Inflammation. — Surrounding the cornea there is a 
 zone about one-quarter of an inch wide, which Mr. Nettleship has very properly 
 called "the dangerous area," and which indicates the ciliary region. Wounds 
 of this portion of the eye, when followed by plastic or purulent inflammation 
 
 1 There are a few exceptions to the rule in serous iritis if the intraocular tension rises. 
 
DISEASES OF THE EYE. 1199 
 
 of the ciliary body (cyelitis), are liable to cause functional disturbance of the 
 other eve {sympathetic irritation), or serious organic change, which manifests 
 itself as an iritis, irido-cyclitis, or choroido-retinitis, to which the general term 
 sympathetic inflammation or sympathetic ophthahnitis is applicable. The eye 
 primarily injured or diseased is usually spoken of as the excitor, and the one 
 which becomes involved in the manner just described as the symp>athizer . 
 Sympathetic inflammation may also be produced by a foreign body which is 
 retained within the eye, and less commonly by corneal ulcers which have rup- 
 tured and in which the iris has become entangled, and by shrunken eyeballs — 
 for example, after a panophthalmitis. 
 
 Sympathetic irritation is probably a neurosis, and manifests itself in the 
 form of blurred vision, photophobia, tenderness in the ciliary region, and con- 
 junctival hypememia. It may be the prodrome of sympathetic inflammation, 
 but this is not necessarily the case, as the latter may arise quite independently, 
 and sometimes insidiously, in one of the forms already noted. If sympathetic 
 irritation is pronounced, the exciting eye should be enucleated, or one of the 
 substitutes for this operation should be performed. This usually suffices to 
 cure the case. 
 
 If an eye is so injured that it is sightless and the dangerous region is 
 affected, and especially if a foreign body has entered, enucleation should be 
 performed in order to prevent sympathetic inflammation, because when this has 
 once begun enucleation is often without avail and both eyes may be lost ; or 
 indeed, the exciting eye may sometimes be the better one in the end, provided 
 the original injury was not so great as to destroy its sight. 
 
 It is impossible in the space here allowed to do more than refer to this most 
 important subject, and for the rules governing the treatment of injuries of the 
 ciliary region and sympathetic inflammation, the reader is referred to systematic 
 treatises on diseases of the eye. Sympathetic inflammation is more apt to occur 
 in children and young people than in adults, and may arise as early as two 
 weeks after the injury or be postponed for years. 
 
 Diseases of the Lachrymal Apparatus and Orbit. 
 
 Inflammation of the Lachrymal Gland [D aery o adenitis) is an un- 
 common affection, and may be either acute or chronic, a lobulated swelling 
 appearing at the upper and outer part of the eyelid, associated with che- 
 mosisof the conjunctiva. Sometimes suppuration occurs, and an abscess points 
 upon the skin or in the conjunctiva. The chronic form has been seen among 
 scrofulous children, and may follow an injury or diseases of the conjunctiva. 
 In acute cases warm applications should be applied to encourage suppuration, 
 and the pus evacuated by an incision through the conjunctiva. In chronic 
 cases appropriate internal remedies are the various preparations of iodine, and 
 locally iodide-of-cadmium ointment may be applied over the swollen gland. 
 
 Diseases of the Lachrymal Sac and Nasal Duct. — The universal 
 symptom of almost every form of disease of this region is an excessive secre- 
 tion of tears, or epiphora. Acute inflammation of the sac, which is not uncom- 
 mon in children, is known as dacryocystitis. The sac becomes distended with 
 secretion, which may be catarrhal or purulent, forming a little swelling in the 
 region of the lachrymal sac, pressure upon which causes the contained fluid to 
 exude from the puncta lachrymalia. Occasionally this inflammation is very 
 acute and assumes a phlegmonous type, the surrounding connective tissue 
 becoming infiltrated with purulent material, while a brawny swelling spreads 
 
1200 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 over the face. Usually the lachrymal abscess under these circumstances points 
 below the tendo oculi, where it may rupture and the opening become sur- 
 rounded by pouting granulations. Stricture of the nasal duct generally pre- 
 cedes these inflammations of the sac, but in many instances there is no true 
 stricture, but simply a swelling of the lining membrane. 
 
 A fistula of the lachrymal sac may be congenital or may result from the 
 failure of a rupture of the lachrymal sac to heal. The little opening which 
 generally leads into the sac appears about half an inch below the punctum or 
 further outward along the lower orbital border, and can generally be detected 
 by the presence of a drop of fluid at its mouth. 
 
 The causes of diseases of the lachrymal sac and duct are various. Dacryo- 
 cystitis has been noted a great many times in infants, sometimes shortly after 
 birth and apparently without cause. A great many cases are due to an inflam- 
 mation which starts in the nose or naso-pharynx, and hence it is not uncom- 
 monly seen after measles, scarlet fever, and small-pox. Other cases are due 
 to inherited syphilis and disease of the bones (periostitis and caries) and to 
 traumatism. 
 
 Treatment. — A lachrymal abscess, if it is pointing in the manner already 
 described, should be opened with a sharp scalpel, and the sac and abscess- 
 cavity frequently syringed with bichloride of mercury, peroxide of hydrogen, 
 or blue pyoktanin (1 : 1000). The cavity may be packed with iodoform gauze 
 and allowed to heal by granulation. Sometimes it is possible to effect a cure 
 by dilating the punctum and irrigating the sac through the natural passages. 
 If there is a stricture, positive and cicatricial, the canaliculus should be split, 
 the stricture divided, and probes passed ; but it is extremely desirable to 
 avoid mutilating the punctum and the canaliculus if it is possible to effect a 
 cure without it. Naturally, all cases require intranasal treatment on account 
 of the common association of disease in this region, particularly rhinitis, 
 hypertrophied turbinals, and deflections of the septum. A fistulous communi- 
 cation into the sac may be cured by freshening the edges and closing it or by 
 the use of the galvano-cautery. Generally, however, capillary fistulas may be 
 allowed to remain undisturbed. A judiciously applied pressure bandage will 
 sometimes permanently close up one of these openings. Internally, iron, cod- 
 liver oil, and mercury are indicated, according to the general conditions which 
 may be present. 
 
 Diseases op the Orbit. 
 
 Periostitis. — Either acute or chronic periostitis, which may be due to 
 syphilis, scrofula, tuberculosis, or injuries, sometimes attacks the margin of 
 the orbit, causing localized pain, injection and chemosis of the conjunctiva, 
 swelling of the lids, and protrusion of the eyeball. Caries of the orbit occurs 
 quite frequently in children, and is situated nearly always at the margin of 
 the orbit. It may be due to syphilis, scrofula, tuberculosis, or to an injury, 
 and presents practically the same symptoms as those which occur with peri- 
 ostitis. A probe will detect the carious condition of the bone. Great deformity 
 of the lid (ectropion) is not uncommon as the result of this disease. 
 
 Treatment. — The treatment consists in the use of the proper constitutional 
 remedies and the surgical measures which are suited to the treatment of peri- 
 ostitis and caries. 
 
 Cellulitis of the Orbit {Phlegmon of the Orbit). — Phlegmonous inflam- 
 mation of the cellular tissue of the orbit, producing in its acute variety 
 
DISEASES OF THE EYE, 1201 
 
 exophthalmos, limitation of the movements of the eye, swelling and oedema 
 of the lids, and considerable hyperemia and chemosis of the conjunctiva, 
 together with decided constitutional disturbances — chills and fever — may occur 
 in children from a variety of causes. The most common are caries of the 
 orbit, septic phlebitis, injuries, and inflammations of the eye which result in 
 panophthalmitis. Sometimes the disease occurs in infants a very short time 
 after birth. 
 
 Treatment. — In addition to proper supporting measures and frequently 
 changed hot compresses, an incision should be made, preferably from the 
 conjunctiva, which secures the evacuation of the pus at as early a moment as 
 possible. Proper drainage must afterward be secured, and the case treated 
 upon the general principles which govern the management of purulent inflam- 
 mations. 
 
 Morbid growths are not uncommon in the orbit, either because an intra- 
 ocular tumor (sarcoma or glioma) has ruptured and invaded the orbit, or as 
 primary growths — namely, the various forms of sarcoma. 
 
 Simple and compound cysts are also seen, and, under rare circumstances, a 
 pulsating exophthalmos due to arterio-venous aneurism. 
 
 Bleeding in the orbit has sometimes been observed in new-born children, 
 and also occurs in haemophilia, scurvy, and occasionally in violent attacks of 
 whooping-cough. 
 
 Congenital Cataract. 
 
 A certain number of infants are born with complete cataract^ which is 
 usually white or bluish-white in color, and may readily be detected even with- 
 out instruments of precision. The eye may be otherwise healthy, or there may 
 be associated with it other congenital anomalies and diseases of the choroid, 
 retina, or optic nerve. 
 
 Treatment. — The treatment of complete congenital cataract consists in 
 discission, and the patient is ready for operation after the completion of the 
 first dentition ; indeed, it is advisable to operate as early as possible, so that 
 the retina may receive the stimulus afforded by the rays of light, and that the 
 sense of sight may thus be educated. 
 
 In addition to the complete congenital cataracts, there are numerous varie- 
 ties of partial cataract which occur in infants and children, of which the most 
 important are : (a) Zonular or Lamellar Cataract ; (b) Central Cataract ; and 
 (c) Pyramidal or Polar Cataract. The acquired anterior polar cataracts which 
 develop in infancy are due, as has already been explained, to perforating corneal 
 ulcers, especially during ophthalmia neonatorum. 
 
 Treatment. — In some of these cases the treatment is practically without 
 avail ; in others, particularly in zonular cataract, either iridectomy, discission, 
 or sometimes extraction, may be practised. 1 
 
 The Refraction op the Eye in Childhood. 
 
 The most important study of the refraction of the human eye, made from 
 a careful study of the recorded examinations of the eyes of school-children, 
 
 1 Those interested in congenital cataract and its numerous varieties should consult Professor 
 Michel's article in Gerhardt's Handbuch der Kinderkrankheiten, Fiinfter Band, Zweite Abtheilung. 
 Tubingen, 1889; and Picque, Anomalies de Developpement et Maladies congenitales du Globe de 
 i'CEil, Paris, 1886. 
 76 
 
1202 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 
 
 was published by Dr. B. Alexander Randall in the American Journal of the 
 Medical Sciences, in 1884. From this author's investigations we know that 
 myopia scarcely ever occurs in infancy and is very infrequent before the 
 beginning of school-life ; that hypermetropia, or far-sightedness, is the prepon- 
 derating condition of refraction in infancy and early childhood, and that there 
 is but little reduction in this proportion even during the first years of school- 
 life; that astigmatism is common, and that a measurable degree of it is found 
 in the majority of ametropic eyes; and that the approximately emmetropic or 
 normal eye is infrequent at all ages, and probably at no time exceeds more 
 than 10 per cent. 
 
 The great frequency of hypermetropia and hypermetropic astigmatism in 
 children is responsible for a number of the inflammatory conditions which have 
 already been described, particularly blepharitis, and slight conjunctivitis, as well 
 as hyperemia of the external and internal coats of the eye. Moreover, it is 
 well established that fully 50 per cent., if not more, of the headaches of func- 
 tional origin which occur in school-children are due to eye-strain, which in its 
 turn is the result of the refractive anomalies which have been mentioned. 
 Not only is headache commonly caused by hypermetropia and astigmatism, 
 but they also contribute to the existence of a variety of so-called reflex neu- 
 roses — habit chorea, chorea itself, night-terrors, irritability of disposition, and 
 general nervousness. While the influence of eye-strain in these respects has some- 
 times been grossly exaggerated, in the sensitive organism of a growing child it 
 is very frequently one of many factors which foster and aggravate these affec- 
 tions, and the evident indication in the investigation of all functional head- 
 aches and nervous diseases is the proper examination of the eyes, and in chil- 
 dren of suitable age the prescription of glasses to neutralize the refractive 
 anomalies. 
 
 It is not always necessary to condemn a child to glasses for the remainder 
 of his life because he happens to be somewhat hypermetropic, and very often 
 a temporary use of spectacles will bridge him over until he has gained sufficient 
 strength to control the symptoms induced by slight accommodative strain. 
 Glasses should not be ordered unless proper examination has demonstrated 
 their real necessity. Judicious hygiene, quitting school, and perhaps the use 
 of tonics, will often relieve symptoms which are inaccurately ascribed to eye- 
 strain simply because emmetropia is not present. 
 
 Strabismus, or Squint. 
 
 In general terms, strabismus includes those conditions in which the visual 
 axis of one eye is directed away from the point of fixation. 
 
 Squint may be convergent — that is, the visual line of one eye deviates 
 inward and crosses that of the sound eye at some point nearer than the object 
 fixed; or divergent — that is, the visual line of one eye fixes the object, while 
 the visual line of the other eye fails to intersect that of its fellow at the point 
 of fixation. More rarely there is an upward or a downward squint. So far 
 as children are concerned and for the purpose of the present paragraph, con- 
 vergent strabismus is the most important. This may be either concomitant — 
 that is, the squinting eye is able to follow the movements of the other eye in 
 all directions, or paralytic — that is, there is limitation of movement in the 
 direction of the action of the affected muscle. 
 
 Concomitant Convergent Squint. — This is the ordinary "crossed eye" of 
 children, and usually begins between the third and fourth years of life. 
 It may be either permanent or periodic, and the last-named variety may 
 
DISEASES OF THE EYE. 1203 
 
 affect one eye alone or each eye in turn; that is, it is either monolateral or 
 alternating. 
 
 There are numerous causes of concomitant squint, to which only a brief 
 reference can be made. The most important of these is a disturbance of the 
 relation which exists between the power of accommodation of the eyes and 
 their power of convergence, which is caused by errors of refraction — in con- 
 vergent squint, usually by hypermetropia, in divergent squint, generally by 
 myopia. Squint may also be caused by a disparity in the length or thickness 
 of opposing muscles ; for example, the internal rectus muscle may be strong 
 and well developed, while the external rectus is flat and poorly developed. 
 Quite commonly the squinting eye is very amblyopic, and this has been regarded 
 as a cause of convergent squint. This amblyopia, according to one theory, is 
 due to lack of use on the part of the squinting eye, and, according to the other, 
 depends upon imperfect development of the visual centres ; that is to say, the 
 amblyopia in the squinting eye is congenital. There is a widespread popular 
 belief that convergent squint may be brought about by fright or by imitation or 
 by looking at some object hung in an oblique direction. These causes, of course, 
 never obtain. Squint, however, is quite commonly first noticed in children 
 after an acute illness — for example, scarlet fever, measles, diphtheria (which 
 may cause one form of paralytic squint), or very depressing illnesses — cholera 
 infantum and similar conditions. These, by weakening the system, determine 
 a strabismus, the conditions for the production of which are already present in 
 the eyes of the child. 
 
 Concomitant strabismus must be distinguished from a paralytic strabismus, 
 which may be caused by syphilis, rheumatism, diphtheria, poisons, and, especi- 
 ally in children, by diseases of the base of the brain — for example, tuber- 
 cular meningitis — by observing that in concomitant strabismus the squinting 
 eye follows the movements of the other eye in all directions ; that the second- 
 ary and primary deviations of the eye are equal ; that double vision is 
 extremely uncommon ; and that there are usually considerable degrees of 
 refractive error. In paralysis of an ocular muscle there is limitation of move- 
 ment of the affected eye in the direction of the paralyzed muscle ; the second- 
 ary deviation (i. e. the deviation of the sound eye, while the affected eye 
 "fixes" an object held about one foot from it) is greater than the primary 
 deviation ; double vision is the rule ; and there is no special relation to refrac- 
 tive errors. Many of the differential points are difficult to determine in young 
 children, although usimlly it is possible to elicit that which compares the move- 
 ments of the eyes. 
 
 Treatment of Concomitant Convergent Strabismus. — This may be 
 divided into the mydriatic treatment, the spectacle treatment, and the opera- 
 tive treatment. In very young children who begin to squint good results will 
 sometimes follow the use of a weak solution of atropine — for example, a half 
 or one grain to the fluidounce — continued for long periods of time, just suffi- 
 cient being introduced into the conjunctival sac to maintain mydriasis and 
 keep the ciliary muscle paralyzed. As soon as the child is of sufficient age 
 the refractive error should be carefully neutralized by means of spectacles. 
 In many instances of periodic squint properly adjusted spectacles will produce 
 a cure, and the effect of the treatment is in direct ratio to the youth of the 
 patient. In the event of failure the eyes may be straightened, either by 
 tenotomy of one or both internal recti, or tenotomy combined with advance- 
 ment of the external rectus. It is not advisable to operate upon a case of 
 convergent strabismus before the sixth year ; in fact, many of the cases do 
 better if the time of operation is postponed to a later period than the one 
 
1204 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN, 
 
 just mentioned. It is also never proper to operate upon children, even if 
 there is very considerable amblyopia of one eye, until the spectacle treatment 
 has been given a faithful trial. For the method of performing tenotomy and 
 the rules which govern the expediency and character of the operation the 
 reader is referred to systematic treatises on diseases of the eye. 
 
INDEX. 
 
 Abdomen, condition of, in ty- 
 phoid fever, 197 
 distention of, 14 
 causes of, 14 
 diagnosis of, 14 
 in ascites, 14 
 in peritonitis, 14 
 examination of, 13 
 in disease, 13 
 inspection of, 13 
 palpation of, 14 
 percussion of, 14 
 in health, 13 
 protuberance of, in rachitis, 
 
 326 
 scaphoid, causes of, 14 
 tenderness of, diagnosis of, 14 
 Abdominal pneumonia, 916 
 tenderness in variola, 164 
 Abscess after vaccination, 175 
 in hip-joint disease, 1072 
 
 treatment of, 1076 
 in Pott's disease, 1067 
 treatment of, 1071 
 ischio-rectal, 588 
 marginal, 587 
 of brain, 630 
 diagnosis of, 632 
 
 from meningitis, 632 
 duration of, 631 
 etiology of, 630 
 in etiology of headache, 
 
 722 
 pathology of, 630 
 prognosis of, 632 
 rupture of, 632 
 symptoms of, 631 
 treatment of, 632 
 of cornea, 1195 
 of eyelid, 1178 
 of lachrymal gland, 1199 
 of lachrymal sac, 1200 
 of liver. See Hepatitis, sup- 
 purative. 
 of lobule of ear, 1160 
 of lung, 924 
 after croupous pneumonia, 
 
 917 
 following broncho - pneu- 
 monia, 908 
 prognosis of, 923 
 rupture of, into bronchus, 
 
 923 
 surgical treatment of, 923 
 temperature in, 923 
 treatment of, 923 
 perinephritic. See Perineph- 
 
 ritic abscess. 
 perityphlitic, 509 
 retro-pharyngeal. See Retro- 
 pharyngeal abscess. 
 tuberculous periumbilical, 
 290 
 
 Abscesses, cutaneous, with ec- 
 zema, 1101 
 Abscission of tonsils, 423 
 Acarus scabiei, 1154 
 Accumulation, fecal, diagnosis 
 
 of, 14 
 Acetanilide. See Antifebrin. 
 
 in tuberculosis, 302 
 Acetone in diabetic urine, 1000 
 Aching of limbs in chicken- 
 pox, 156 
 Achorion Shoenleinii, 1149 
 Acid-lemonade in cholera, 244 
 Acne, 1093 
 
 Aconite in acute tubal nephri- 
 tis, 1015 
 in broncho-pneumonia, 912 
 in peritonsillar abscess, 421 
 in scarlet fever, 145 
 in variola, 168 
 Acromegaly, 690 
 
 diagnosis of, from gigantism, 
 692 
 from myxcedema, 692 
 from pulmonary osteo-ar- 
 thropathy, 692 
 pathology of, 692 
 symptoms of, 691 
 treatment of, 693 
 Acute ascending paralysis. See 
 Paralysis, Landry's. 
 gastritis. See Gastric catarrh, 
 
 acute. 
 nephritis in etiology of 
 chronic tubal nephritis, 
 1018 
 Adenitis, cervical, tubercular, 
 283 
 in scarlet fever, 140 
 Adenoid vegetations. See Naso- 
 pharyngeal adenoid hyper- 
 trophy. 
 Adenoma of umbilicus, 575 
 Adenomo-sarcoma of kidney, 
 
 1035 
 Adenopathy in chicken-pox, 
 
 159 
 JEstivo-autumnal fevers, 312 
 diagnosis of, 315 
 
 from tuberculosis, 315 
 parasites of, 307 
 Afanassiew's bacillus, 184 
 Age in etiology of acute endo- 
 carditis, 977 
 of chicken-pox, 156 
 of chlorosis, 362 
 of chorea, 756 
 of croupous pneumonia, 
 
 913 
 of diphtheria, 252 
 of erysipelas, 222 
 of intussusception, 518 
 of measles, 118 
 
 Age in etiology of progressive 
 pernicious anaemia, 365 
 of rheumatism, 351 
 of tuberculous meningitis, 
 
 610 
 of tumors of kidney, 1006 
 of typhlitis, 510 
 of whooping-cough, 183 
 in prognosis of rheumatism, 
 356 
 of tracheotomy. 294 
 of whooping-cough, 189 
 of occurrence of rachitis, 322 
 of onset of infantile cerebral 
 palsies, 650 
 Agenesis corticalis, 655 
 Agoraphobia, 704 
 Agraphia, 659 
 Air-passages, hypersemia of, in 
 
 chicken-pox, 157 
 Alse of nose, dilatation of, in 
 broncho-pneumonia, 906 
 Albinism, 1135 
 partial, 1135 
 Albumin in acute tubal neph- 
 ritis, 1011 
 in chronic interstitial neph- 
 ritis, 1026 
 in chronic tubal nephritis, 
 1019 
 Albuminoids in milk, 46 
 Albuminuria after epilepsy, 751 
 chronic, in etiology of amy- 
 loid kidney, 1024 
 in diabetes insipidus, 1005 
 in diabetes mellitus, 1000 
 in diphtheria, 256 
 in erysipelas, 225 
 in etiology of incontinence 
 
 of urine, 998 
 in malaria, 314 
 in simple atrophy, 506 
 in splenic anaemia, 369 
 in stone in bladder, 1009 
 Albuminuric retinitis in 
 chronic interstitial neph- 
 ritis, 1026 
 Alcohol. See Stimulants. 
 in bronchitis, 933 
 in broncho-pneumonia, 911 
 in cholera, 246 
 
 in chronic intestinal indiges- 
 tion, 471 
 in croupous pneumonia, 918 
 indications for, 36 
 iix diphtheria, 261 
 in epidemic cerebrospinal 
 
 meningitis, 213 
 in influenza, 219 
 in mucous disease. 459 
 in peritonitis, 567 
 in rheumatism, 357 
 in scarlet fever, 146 
 
 1205 
 
1206 
 
 INDEX. 
 
 Alcohol in variola, 169 
 Alcoholism in etiology of cir- 
 rhosis of liver, 558 
 of hvsteria, 729 
 Alexia, 659 
 
 Algid stage of cholera, 240 
 state in acute milk infection, 
 476 
 Alkalies in diabetes mellitus, 
 1004 
 in mucous disease, 461 
 in rheumatism, 357 
 Allingham's method in pro- 
 lapse of rectum, 591 
 Alloxuric bodies as a cause of 
 litheemia, 94 
 excretion of, 95 
 Almond-flour in diabetes, 1002 
 Alopecia areata, 1136 
 diagnosis of, 1136 
 
 from ringworm, 1136 
 etiology of, 1136 
 prognosis of, 1136 
 syphilitic, 112 
 treatment of, 1137 
 Alternate heart-beat, 988 
 Altitude in etiology of granular 
 conjunctivitis, 1190 
 in tuberculosis, 300 
 Alum in ophthalmia neonato- 
 rum, 1187 
 Alveolar sarcoma of kidney, 
 
 1035 
 Amaurosis in hydrocephalus, 
 
 604 
 Amblyopia in erysipelas, 227 
 
 in hysteria, 734 
 American gout, 94 
 Ametropia in etiology of bleph- 
 aritis, 1179 
 Amimia, 659 
 
 Ammonia in functional affec- 
 tions of heart, 989 
 Ammoniaco - magnesian - phos- 
 phate calculus, 1038 
 Ammonium carbonate in bron- 
 cho-pneumonia, 911 
 in diphtheria, 261 
 in malignant measles, 128 
 chloride in bronchitis, 931 
 in cirrhosis of liver, 560 
 in congestion of liver, 
 
 551 
 in jaundice, 548 
 in measles, 128 
 salicylate in rheumatism, 356 
 urate calculus, 1038 
 Amoeba coli, 490 
 dysenteriae, 490 
 dysenterica in pus from liver, 
 542 
 Amussat's operation, 580 
 Amygdalitis, follicular. See 
 
 Follicular amygdalitis. 
 Amyl nitrite as a cause of 
 haematuria, 992 
 in asthma, 961 
 in epilepsy, 753 
 Amyloid changes in Pott's 
 disease, 1067 
 disease of kidney, 1024 
 etiology of, 1024 
 morbid anatomy of, 1024 
 prognosis of, 1024 
 treatment of, 1025 
 Anadenia of stomach, 447 
 Anaemia, 360 
 
 Anaemia as a cause of inconti- 
 nence of urine, 1027 
 definition of, 360 
 following acute nephritis, 
 1017 
 rheumatism, 354 
 in acute endocarditis, 978 
 in chronic tubal nephritis, 
 
 1019 
 in functional heart affections, 
 
 treatment of, 989 
 in heart-disease, treatment 
 
 of, 984 
 in hereditary syphilis, 110 
 lymphatic, 370 
 diagnosis of, 372 
 
 from pseudo-leukaemia, 
 
 372 
 from tubercular adenitis, 
 372 
 etiology of, 370 
 morbid anatomy of, 371 
 prognosis of, 372 
 symptoms of, 370 
 treatment of, 372 
 progressive pernicious, 364 
 diagnosis of, 367 
 etiology of, 365 
 morbid anatomy of, 366 
 prognosis of, 367 
 symptoms of, 365 
 treatment of, 367 
 secondary, 360 
 diagnosis of, 361 
 from chlorosis, 361 
 from pernicious anaemia, 
 
 361 
 from splenic anaemia, 361 
 etiology of, 360 
 prognosis of, 361 
 symptoms of, 361 
 treatment of, 361 
 splenic, 368 
 
 diagnosis of, 369 
 
 from amyloid infiltration 
 
 of spleen, 369 
 from enlarged kidney, 
 
 370 
 from leukaemia, 369 
 etiology of, 368 
 morbid anatomy of, 368 
 prognosis of, 370 
 spleen in, 369 
 symptoms of, 369 
 treatment of, 370 
 Anaemias, primary, 362 
 Anaemic headache, 723 
 
 murmurs in chronic tubal 
 nephritis, 1019 
 Anaesthesia dolorosa, 802 
 in acromegaly, 602 
 in acute spinal leptomenin- 
 gitis, 780 
 in cerebro-spinal meningitis, 
 
 211 
 in hereditary ataxia, 818 
 in hysteria, 733 
 in Raynaud's disease, 821 
 in tumors of spinal cord, 
 802 
 Anaesthetics in tracheotomy, 
 
 877 
 Analgesia in tumors of spinal 
 
 cord, 802 
 Anastomosis, lateral, in con- 
 genital malformations 
 of intestines, 577 
 
 Anastomosis, lateral, in intus- 
 susception, 523 
 Anatomy of urinary organs in 
 
 children, 1045 
 Anderson's dusting powder, 
 
 1095 
 Angina in rubella, 154 
 
 in scarlet fever, 136, 139 
 Angioma of rectum, 593 
 pigmentosum et atrophicum. 
 See Kaposi's disease. 
 Animal broths in subacute 
 
 milk infection, 483 
 Animals, experimental pro- 
 duction of rachitis, in 324 
 Ankle, tuberculous disease of, 
 
 1079 
 Ankle-clonus in hereditary 
 
 ataxia, 817 
 Ankle-joint disease, 1079 
 diagnosis of, 1079 
 operative treatment of, 1080 
 prognosis of, 1079 
 symptoms of, 1079 
 treatment of, 1079 
 Ankylosis following tuberculo- 
 sis of joints, treatment 
 of, 1081 
 Anomalies of auriculo-ven- 
 tricular orifices, 970 
 of valve-segments, 972 
 Anorexia, hysterical, 735 
 in chicken-pox, 156 
 in measles, 120 
 in typhoid fever, 197 
 in vaccinia, 174 
 Anterior fontanelle, ossifica- 
 tion of, 13 
 region of neck, anatomy of, 
 872 
 Antifebrin in diabetes insipi- 
 dus, 1006 
 in diabetes mellitus, 1004 
 in tuberculosis, 302 
 Antihygienic conditions in eti- 
 ology of rachitis, 323 
 Antipyretics, dangers of, 36 
 in erysipelas, 229 
 in measles, 129 
 in tuberculosis, 302 
 in typhoid fever, 206 
 in variola, 169 
 Antipyrine, caution in the use 
 of, 36 
 in acute follicular tonsillitis, 
 
 422 
 in diabetes insipidus, 1006 
 in diabetes mellitus, 1004 
 in epilepsy, 753 
 in migraine, 720 
 in pyrexia of broncho-pneu- 
 monia, 912 
 in tuberculosis, 302 
 in whooping-cough, 192 
 Antisepsis in treatment of 
 
 new-born, 75 
 Antiseptic alkaline solution, 
 
 416 
 Antiseptics in dysentery, 494 
 in subacute milk infection, 
 
 483 
 intestinal, in pernicious an- 
 aemia, 368 
 Antitoxines of diphtheria, 266 
 Anuria, 995 
 
 intermittent, in hydrone- 
 phrosis, 1030 
 
INDEX. 
 
 1207 
 
 Amis, diphtheria of, 587 
 diseases oi, 584 
 fissure of. 5S6 
 occlusion of, complete, 578 
 stricture of, 587 
 syphilitic affections of, 584 
 vegetations or warts of, 585 
 Aorta, stenosis of, 972 
 Aortic obstructive murmur, 982 
 regurgitant murmur, 983 
 regurgitation, 983 
 prognosis of, 984 
 stenosis, 982 
 prognosis of, 984 
 Apex-beat, altered position of, 
 in disease, 15 
 position of, in infant, 15 
 Apex pneumonia, 914 
 Aphasia, 659 
 
 during acute gastric catarrh, 
 
 444 
 etiology of, 660 
 from hereditary syphilis, 661 
 in infantile cerebral palsies, 
 
 651 
 in typhoid fever, 200 
 Aphonia due to ascarides, 527 
 
 in hysteria, 735 
 Aphtha, 309 
 Aphthae, Bednar's 400 
 
 in simple atrophy, 505 
 Aphthous ulcer, 400 
 Apncea, physiological, 76 
 Apomorphine in broncho-pneu- 
 monia, 910 
 Apoplexy neonatorum, 74 
 
 pulmonary, in new-born, 75 
 Apparatus for hot-air bath, 1014 
 Appendicitis, 509 
 
 operation for, after conva- 
 lescence, 516 
 operations for, 514 
 Appendix, diseases of. See 
 Csecum and Appendix. 
 in congenital hernia, 516 
 Appetite in chronic gastric ca- 
 tarrh, 449 
 in chronic intestinal indiges- 
 tion, 468 
 in chronic peritonitis, 568 
 in simple atrophy, 505 
 in tuberculous meningitis, 
 
 611 
 in typhoid fever, 206 
 Arrhythmia, 988 
 Arrow-root, value of, 22 
 Arsenic bromide in diabetes 
 mellitus, 1004 
 in childhood, 36 
 in chorea, 763 
 
 in chronic intestinal indiges- 
 tion, 471 
 in chronic malaria, 318 
 in convalescence from vari- 
 ola, 170 
 in diabetes mellitus, 976 
 in eczema, 1105 
 in leukaemia, 376 
 in lymphatic anaemia, 372 
 in pernicious ansernia, 367 
 in psoriasis, 1113 
 in pulmonary emphysema, 
 
 954 
 in purpura hemorrhagica, 
 
 383 
 in secondary ansernia, 362 
 in splenic anaemia, 370 
 
 Arsenic in tuberculosis, 301 
 Arterial tension, increased, in 
 chronic interstitial neph- 
 ritis, 1026 
 trunks, transposition of, 972 
 Artery, external carotid, liga- 
 tion of, 427 
 Arthritis in scarlet fever, 140 
 Arthropathies in syringomy- 
 elia, 813 
 Arthrospores of Hiippe, 233 
 Artificial feeding, 21 
 
 in etiology of chronic in- 
 testinal indigestion, 
 468 
 of gastric catarrh, 441 
 foods, chemistry of, 47 
 Asafcetida in constipation, 500 
 in croupous pneumonia, 918 
 in whooping-cough, 191 
 Ascaris lumbricoides, 524 
 diagnosis of, 528 
 habitat of, 525 
 in cystic and common bile- 
 ducts, 527 
 methods of infection by, 526 
 ova of, 525 
 symptoms of, 526 
 treatment of, 528 
 Ascites, 571 
 
 diagnosis of, 572 
 etiology of, 571 
 in cirrhosis of liver, treat- 
 ment of, 561 
 pathology of, 572 
 physical examination in, 572 
 prognosis of, 573 
 symptoms of, 572 
 treatment of, 573 
 Asphyxia from delayed labor, 76 
 local, 821. See, also, Ray- 
 naud's disease. 
 of the new-born, 75 
 causes of, 76 
 complications of labor 
 
 causing, 76 
 electricity in, 80 
 oxygen in, 80 
 prognosis in, 77 
 prophylaxis of, 77 
 recovery after, 77 
 symptoms of, 76 
 tracheotomy for, 80 
 treatment of, 77 
 partial, causes of, 82 
 Aspiration in hydronephrosis, 
 1031 
 in pleural effusion, 946 
 Astasia-abasia, 734 
 Asthenia in tuberculous menin- 
 gitis, 611 
 Asthma, bronchial, 956 
 diagnosis of, 959 
 from bronchitis and 
 
 pneumonia, 959 
 from cardiac asthma, 960 
 from emphysema, 960 
 from obstructive dysp- 
 noea, 959 
 from pleuritic effusion, 
 
 960 
 from pulmonarv oedema, 
 
 960 
 from spasm of dia- 
 phragm, 960 
 from ursemic dyspnoea, 
 9(50 
 
 Asthma, bronchial, etiology of, 
 956 
 pathology of, 957 
 physical signs in, 959 
 prognosis of, 959 
 symptoms of, 958 
 theories regarding nature 
 
 of, 957 
 treatment of, 960 
 Miiarii, 
 rachiticum, 
 
 thymicum Koppii. See Lar- 
 yngismus stridulus. 
 ureemic, treatment of, 1023 
 Astigmatism, 1202 
 
 in etiology of phlyctenular 
 k e r a t o-conjunctivitis, 
 1193 
 Astringents in subacute milk 
 
 infection, 483 
 Astrophobia, 704 
 Ataxia, hereditary, 815 
 diagnosis of, $19 
 etiology of, 815 
 morbid anatomy of, 817 
 symptoms of, 817 
 treatment of, 819 
 with tumors of spinal cord, 
 803 
 Atelectasis during bronchitis, 
 926 
 in whooping-cough, 187 
 post-natal, 899 
 diagnosis of, 901 
 from acute miliary tu- 
 berculosis, 902 
 from pleuritic effusion, 
 
 902 
 from pneumonia, 901 
 etiology of, 899 
 pathology and morbid 
 
 anatomy of, 899 
 physical signs of, 901 
 prognosis of, 902 
 symptoms of, 900 
 treatment of, 902 
 Athetoid affections in idiots 
 
 and imbeciles, 694 
 Athetosis, 694 
 diagnosis of, 696 
 
 from post-hemiplegic cho- 
 rea, 696 
 etiology of, 695 
 in infantile cerebral palsies, 
 
 654 
 pathology of, 695 
 prognosis of, 696 
 symptoms of, 694 
 treatment of, 695 
 Atresia ani urethralis, 583 
 vaginalis, 582 
 vesical is, 582 
 congenital, of auditorv me- 
 atus, 1165 
 of pulmonary orifice and 
 artery, 971 
 Atrophies of skin, 1135 
 Atrophy in acute spinal lepto- 
 meningitis, 780 
 in knee-joint disease. 1077 
 muscular, in hereditary 
 
 ataxia, 818 
 of conjunctiva. 1198 
 simple, ?>0o 
 
 bathing in, 507 
 diagnosis of, 506 
 from syphilis, 506 
 
1208 
 
 INDEX. 
 
 Atrophy, simple, diagnosis of, 
 from tubercular menin- 
 gitis, 506 
 from tuberculosis, 506 
 etiology of, 503 
 morbid anatomy of, 504 
 prognosis of, 506 
 symptoms of, 505 
 treatment of, 507 
 Atropine in atelectasis, 903 
 in interstitial keratitis, 1197 
 in night-sweats, 302 
 in ophthalmia neonatorum, 
 
 1187 
 in phlyctenular kerato-con- 
 
 junctivitis, 1193 
 in simple corneal ulcer, 1195 
 Attenuants, dextrinized, 50 
 
 in artificial feeding, 25 
 Attenuation, barlev-water in, 
 50 
 gelatin in, 50 
 oatmeal water in, 50 
 of milk, 50 
 Attic, tympanic inflammation 
 
 of, 1169 
 Attitude in pseudo-hyper- 
 trophic paralysis, 769 
 Auditory canal, caries of wall 
 of, 1165 
 direction of, in infancy, 
 1167 
 Aura in epilepsy, 749 
 
 in hysteria, 730 
 Auricle, congenital malforma- 
 tions of, 1160 
 lesions of, from ear-piercing, 
 
 1160 
 minuteness of, 1160 
 position of, in diagnosis of 
 mastoid involvement, 
 1170 
 supernumerary, 1160 
 Auriculo-ventricular orifices, 
 
 anomalies of, 970 
 Auscultation of chest, 15 
 in emphysema, 15 
 in pleurisy^ 15 
 in pneumonia, 15 
 of heart, 16 
 Auvard's incubator, 80 
 
 Bacilli in meconium, 472 
 
 of pseudo-diphtheria, 253 
 Bacillus in bronchitis, 926 
 
 in measles, 118 
 
 of cholera. See Spirillum 
 cholerx Asiatics. 
 
 of Eberth, 195 
 
 of foot-and-mouth disease of 
 cattle, 399 
 
 of Friedlander in croupous 
 pneumonia, 914 
 in broncho-pneumonia, 904 
 
 of influenza in croupous 
 pneumonia, 914 
 
 of Klebs-Loffler, 252 
 
 of Letzerich, 373 
 
 of Lustgarten in syphilis, 103 
 
 of tuberculosis in tuberculous 
 meningitis, 610 
 
 of typhoid fever, 195 
 
 parotidis, 178 
 
 scarlatinse, 134 
 
 tuberculosis, 271 
 
 anatomical changes pro- 
 duced by, 277 
 
 Bacillus tuberculosis, biology 
 of, 272 
 distribution of, 272 
 in broncho-pneumonia, 904 
 in fibroid phthisis, 964 
 in lupus vulgaris, 1139 
 in pleural effusion, 940 
 in urine, 281 
 method of staining, 271 
 tussis convulsive, 184 
 Backache in variola, 164 
 Backward children, 668 
 Bacteria, absence of, in milk, 
 39 
 in acute milk infection, 475 
 in diarrhoea, varieties of, 454 
 in stomatitis gangrenosa, 405 
 in stool of healthy infant, 454 
 multiplication of, in milk, 39 
 presence of, in milk, 39 
 toxicogenic, in milk infec- 
 tion, 472 
 Bacterium coli commune, 454 
 in normal stools, 472 
 fcetidum in bromidrosis, 1093 
 in parotitis, 178 
 lactis aerogeu es, 454 
 
 in normal stools, 472 
 Ball's incision, 580 
 Bandage, abdominal, for in- 
 fants, 34 
 Barley-water, preparation of, 
 
 23 
 " Barrel-shaped " chest, 472 
 Basham's mixture in ascites, 
 
 573 
 Bath, permanent, Winckel's, 
 80 
 temperature of, in childhood, 
 33 
 in infancy, 33 
 the cold, 33 
 the cooled, 33 
 the hot, 33 
 Bathing, 18 
 
 frequency of, 32 
 
 hour for, 33 
 
 in chronic gastric catarrh, 
 
 450 
 in hot weather, 33 
 in rachitis, 343 
 in simple atrophy, 507 
 Baths in broncho-pneumonia, 
 912 
 in croupous pneumonia, 918 
 in eclampsia, 745 
 in insanity, 708 
 in laryngismus stridulus, 863 
 in measles, 129 
 in Eaynaud's disease, 824 
 in variola, 169 
 Bath-tub, Winckel's, 80 
 Battledore-hands in acromeg- 
 aly, 691 
 Bednar's aphthse, 400 
 Bed-sores in acute myelitis, 785 
 in typhoid fever, 207 
 with tumors of spinal cord, 
 803 
 Bed-wetting. See Urine, incon- 
 tinence of. 
 in gravel, 1008 
 Beef-peptonoids in Pott's dis- 
 ease, 1008 
 Beef-tea. formula for, 25 
 Belladonna, administration of, 
 in childhood, 36 
 
 Belladonna in functional heart 
 affections, 990 
 in incontinence of urine, 997 
 in intussusception, 521 
 in peritonitis, 567 
 in pertussis, 191 
 in typhlitis, 513 
 Bell's palsy, 774 
 Benzoate of lithium in lith- 
 
 seruia, 101 
 Benzoic acid in alkaline lith- 
 
 iasis, 1010 
 Bichloride of mercury. See 
 Mercuric chloride. 
 for vaginal douche, 88 
 in chicken-pox, 161 
 Bigeminal pulsation, 988 
 Bilharzia hsematobia a cause of 
 
 hematuria, 993 
 Biliary cirrhosis, 558 
 Bismuth salicylate in cholera, 
 244 
 in typhoid fever, 206 
 subnitrate in chronic intes- 
 tinal indigestion, 471 
 in dysentery, 493 
 Bladder, distention of, diag- 
 nosis of, 14 
 paralysis of, in hydroceph- 
 alus, 626 
 with tumors of spinal cord, 
 804 
 peculiarities of, in children, 
 1045 
 Blaud's pill, 364 
 Bleeding in cerebral meningi- 
 tis, 603 
 Blepharitis, 1179 
 ciliaris. See Blepharitis. 
 etiology of, 1179 
 treatment of, 1179 
 ulcerosa, 1179 
 Blepharo-adenitis, 1179 
 Blepharospasm, 1181 
 tonic, 1181 
 treatment of, 1181 
 Blisters in cerebral meningitis, 
 604 
 in cerebro-spinal meningitis, 
 
 608 
 in diabetes insipidus, 1006 
 Blood after paroxysm of tertian 
 fever, 304 
 characteristics of, in new- 
 born, 359 
 examination of, in leukaemia, 
 374 
 in lymphatic anemia, 371 
 in malarial fever, 316 
 in pernicious antenna, 366 
 in splenic anemia, 369 
 in subacute purpura hein- 
 orrhagica, 381 
 in cholera, 238 
 in diphtheria, 254, 256 
 infections of, in new-born, 92 
 in hysteria, 737 
 Blood-cells, colorless, in in- 
 fancy, 359 
 nucleated red, 359 
 Boils after vaccination, 175 
 with subacute milk infection, 
 481 
 Bone, analysis of, 327 
 cancellous tissue of, 328 
 compact tissue of, 328 
 growth of, in rachitis, 330 
 
INDEX. 
 
 1209 
 
 Bone, minute anatomy of, 328 
 Bones in child and adult life, 
 
 327 
 Borax in diphtheria, 264 
 Boric acid in alkaline lithiasis, 
 1010 
 in gonorrhoea of mouth, 89 
 in vulvo-vaginitis. 1056 
 Bothriocephalus latus, 533 
 Bowels in typhoid fever, 199 
 primary tuberculosis of. 287 
 secondary tuberculosis of, 287 
 Bow-legs, braces for, 1089 
 
 treatment of, 1087 
 Braces for bow-legs, 1089 
 for knock-knee, 1089 
 for Pott's disease, 1070 
 Brachial plexus, obstetric in- 
 jury to. 83 
 Brachycardia, 988 
 Brachycephalic idiocy, 671 
 Bradycardia, 988 
 Brain, abscess of. See Abscess 
 of brain. 
 following chronic suppura- 
 tion of middle ear, 1173 
 chronic diffuse tuberculosis 
 of, 282 
 dropsy of, 624 
 in diphtheria, 255 
 in pernicious malaria, 308 
 in rachitis, 327 
 lesion of, in typhoid fever, 
 
 197 
 svmptoms in tvphoid fever, 
 200 
 Bran bread in diabetes, 1002 
 Brand method in tvphoid 
 
 fever, 206 
 Brandy in typhoid fever, 206 
 Breast-milk, characters of, 21 
 constituents of, 21 
 quantity of, 21 
 substitutes for, 21 
 farinaceous, 22 
 
 deleterious effects of, 22 
 Breath, ammoniacal, in uraemia, 
 8 
 catarrhal, 7 
 "feverish," 7 
 foetid, 7 
 
 gangrenous, in noma, 8 
 in acute gastric catarrh, 443 
 in chronic gastric catarrh, 
 
 447 
 in gangrene of lung, 922 
 of the child in disease, 7 
 
 in health, 7 
 sour, 7 
 Breathing, accelerated, causes 
 of, 10 
 embarrassed, with tumors of 
 
 spinal cord, 804 
 in Landry's paralysis, 799 
 labored, distinction of, from 
 laryngeal obstruction, 
 870 
 Breath-sounds in croupous 
 
 pneumonia, 917 
 Bright's disease, acute. See I 
 Nephritis, acute tubal. 
 chronic, 1018 
 Bromides in cerebral menin 
 gitis, 604 
 in diabetes mellitus, 1004 
 in epilepsy, 752 
 in rheumatism, 357 
 
 Bromidrosis, 1093 
 Bromoform in pertussis, 192 
 Bronchial catarrh in measles, 
 123 
 glands, chronic diffuse tuber- 
 culosis of, 282 
 Bronchiectasis, 927 
 Bronchitis, 924 
 acute, anatomical changes in, 
 
 926 
 capillary, 924. See, also, 
 
 Broncho-pneumonia. 
 chronic, anatomical changes 
 
 in, 927 
 classification of, 924 
 diagnosis of, 930 
 from pleural effusion, 931 
 from pneumonia, 931 
 etiology of, 924 
 in malaria, 314 
 in typhoid fever, 197, 193 
 in variola, 167 
 in whooping-cough, 187 
 mechanical causes of, 925 
 mode of drinking in, 6 
 morbid anatomy of, 926 
 prognosis of, 929 
 sea-air in, 63 
 subacute, in chronic heart 
 
 disease, 981 
 symptoms of, 927 
 treatment of, 931 
 Broncho- adenitis, diagnosis of, 
 from tuberculosis, 929 
 in etiology of asthma, 955 
 
 of bronchitis, 926 
 treatment of, 931 
 Bronchophony in pleural effu- 
 sion, 942 
 Broncho-pneumonia, 904 
 acute tuberculous, 292 
 
 morbid anatomy of, 293 
 pneumococci in, 293 
 staphylococci in, 293 
 streptococci in, 293 
 symptoms of, 294 
 diagnosis of, 909 
 
 from croupous pneumonia, 
 
 909 
 from pleurisv with effu- 
 sion, 909 
 duration of, 909 
 etiology of, 904 
 in etiology of fibroid phthisis, 
 963 
 of secondary pleurisy, 937 
 in scarlatinal nephritis, 142 
 in typhoid fever, 198 
 in variola, 167 
 in whooping-cough, 187 
 morbid anatomy of, 905 
 physical signs of, 908 
 prognosis of, 909 
 symptoms of, 906 
 treatment of, 910 
 Bronchus, compression of, by 
 
 cheesy glands, 276 
 Bruit of fontanelle, 339 
 Buelau operation. See Siphon- 
 age. 
 Buhl's disease, 92 
 Bullous svphiloderm, 1144 
 Bum of eyelid, 1184 
 Burns of conjunctiva, 1192 
 Burrow of itch-mite, 1154 
 Bush's extension in hip-joint 
 disease, 1074 
 
 Butyric acid, presence of, in 
 acute gastric catarrh, 443 
 
 Cachexia of malaria, 313 
 
 strumipriva, 684 
 Caecitis, 509 
 
 Caecum and appendix, inflam- 
 matory affections of, 
 509 
 diagnosis of, 511 
 from enteritis, 511 
 from hip disease, 512 
 from iliac abscess, 511 
 from internal strang- 
 ulation, 511 
 from intussuscep- 
 tion, 511 
 from psoas abscess, 
 511 
 etiology of, 510 
 exciting causes of, 510 
 morbid anatomy of, 509 
 prognosis of, 512 
 
 after perforation, 512 
 symptoms of, 510 
 treatment of, 513 
 Caffeine in migraine, 720 
 Calamine-and-zinc lotion, 1095 
 in eczema of ears, 1109 
 of face, 1109 
 Calcification of fangs of teeth, 
 410 
 of tubercle, 278 
 Calcium - carbonate calculus, 
 
 1038 
 Calcium - phosphate calculus, 
 
 1038 
 Calcium sulphide in furuncu- 
 
 lus, 1124 
 Calculi, impacted, in ureters, 
 1007 
 mode of formation of, 1007 
 Calculus, vesical. 1038 
 classification of, 1038 
 diagnosis of, 1043 
 etiology of, 1039 
 examination for, in females, 
 
 1044 
 in children, varieties of, 
 
 1038 
 operative treatment of, 1046 
 in females, 1052 
 relative frequency of, 1040 
 solvent treatment of, 1044 
 symptoms of, 1042 
 treatment of, 1044 
 Callus, spurious, 85 
 Calomel and soda in lithsemia, 
 101 
 in acute gastric catarrh. 445 
 in acute milk infection, 478 
 in constipation, 500 
 in pleurisy, 946 
 in typhlitis, 513 
 in typhoid fever, 206 
 sublimed, in diphtheria. 265 
 vapor in diphtheria. 260 
 Camphor in diphtheria. 261 
 Canal iculi of bone. 328 
 Cancer of omentum. 570 
 Caucrum oris. See Stomatitis 
 
 gangrenosa. 
 Cane-sugar. 46 
 
 Cannabis indica in pertussis. 191 
 Cantharides as a cause of 
 
 hematuria, 992 
 Caput Medusae, 572 
 
1210 
 
 INDEX. 
 
 Caput succedaneum, 68 
 abscess in, 69 
 mechanism of, 68 
 pathology of, 69 
 treatment of, 69 
 Carbohydrates in breast-milk, 
 21 
 in subacute milk infection, 
 483 
 Carbolic acid as a cause of 
 hematuria, 992 
 in diphtheria, 265 
 in eczema, 1106 
 in ophthalmia neonatorum, 
 
 1187 
 in whooping-cough, 192 
 Carbolic-acid injections in 
 treating erysipelas, 229 
 Carcinoma, encephaloid, of kid- 
 ney, 1035 
 of peritoneum, 570 
 Carcinomata of brain, 636 
 Cardiac impulse, extended, sig- 
 nificance of, 15 
 neuroses. 983 
 Caries of orbit, 1200 
 of wall of auditory canal, 
 1165 
 Carpopedal spasms in laryngis- 
 mus stridulus, 861 
 Caseation in tubercle, 278 
 Casein in breast-milk, 21, 46 
 in cow's milk, 21, 46 
 in human milk, 21, 46 
 Casselberry's forceps, 433 
 staphylorraphy-needle, 436 
 tonsillotome, 424 
 Castor oil in acute intestinal 
 indigestion, 466 
 in constipation, 499 
 Casts in acute tubal nephritis, 
 1012 
 in chronic interstitial neph- 
 ritis, 1026 
 in first stage of chronic tubal 
 
 nephritis, 1019 
 in second stage of chronic 
 
 tubal nephritis, 1019 
 in third stage of chronic tubal 
 nephritis, 1019 
 Catalepsy, 732 
 Cataract, congenital, 1201 
 complete, 1201 
 
 treatment of, 1201 
 partial, treatment of, 1201 
 Catarrh, acute gastric. See 
 Gastric catarrh, acute. 
 bronchial, in measles, 123 
 gastro-intestinal, in cirrhosis 
 
 of liver, 558 
 intestinal, in measles, 123 
 nasal, sea-air in, 63 
 objections to use of the term, 
 
 442 
 pharyngeal, sea-air in, 63 
 Catarrhal headache, 722 
 
 nephritis, acute. See Neph- 
 ritis, acute tubal. 
 chronic. See Nephritis, 
 chronic tubal. 
 pneumonia. See Broncho- 
 pneumonia. 
 in stomatitis gangrenosa, 
 406 
 symptoms of measles, 120 
 of rubella, 154 
 Catarrhs in rachitis, 325, 341 
 
 Catarrhs of larynx and bronchi 
 in etiology of laryngis- 
 mus stridulus, 859 
 Cathartics in acute myelitis, 
 786 
 in chronic tubal nephritis, 
 1023 
 Cautery in haemorrhage after 
 
 tonsillotomy, 426 
 Cautions in syringing in audi- 
 tory canal, 1164 
 Cavernous tumors of skin, 
 
 1137 
 Cellulitis of neck in scarlet 
 fever, 140 
 suppuration or gan- 
 grene in, 140 
 of orbit, 1200 
 Central cataract. See Cataract, 
 
 congenital. 
 Cephalalgia. See Headache. 
 
 in typhoid fever, 200 
 Cephalhematoma, 69 
 bony ring in, 70 
 diagnosis of, 70 
 from aneurism, 72 
 from encephalocele, 72 
 from hernia cerebri, 72 
 from tumors due to vio- 
 lence, 72 
 etiology of, 71 
 false, 69 
 intracranial, 70 
 in utero, 71 
 multiple, 71 
 pathology of, 70 
 treatment of, 72 
 true, 69 
 Cephalic index, 671 
 Cerebral complications in per- 
 tussis, 188 
 lesions following scarlatinal 
 
 nephritis, 143 
 pneumonia, 916 
 
 and typhoid fever, differ- 
 ential diagnosis of, 204 
 symptoms in pleurisy, 941 
 in rheumatism, 352 
 Cerebro-spinal meningitis, epi- 
 demic, 203 
 bacteriology of, 208 
 complications of, 211 
 definition of, 208 
 diagnosis of, 212 
 from scarlatina, 212 
 from tubercular men- 
 ingitis, 212 
 from typhoid fever, 212 
 etiology of, 208 
 history of, 208 
 pathology of, 209 
 prognosis of, 212 
 prophylaxis of, 212 
 relation of, to influenza, 
 
 209 
 sequel® of, 211 
 symptoms of, 209 
 synonyms of, 208 
 treatment of, 212 
 simple. See Meningitis, 
 simple cerebro-spinal. 
 Certified milk, 39 
 Cerumen impaction, 1162 
 
 treatment of, 1162 
 Cervical glands, enlargement 
 
 of, in rubella, 154 
 Chalazion, 1180 
 
 Chalazion, treatment of, 1180 
 Chalybeate tonics after acute 
 tubal nephritis, 1017 
 in chronic interstitial 
 
 nephritis, 1026 
 in chronic tubal nephritis, 
 1022 
 Champagne in peritonitis, 566 
 Chancre of eyelids, 1180 
 Chemistry of artificial foods, 47 
 Chemosis of conjunctiva, 1191 
 Chenopodium against ascarides, 
 529 
 against seat-worms, 531 
 Chest, auscultation of, in in- 
 fants and children, 15 
 characteristics of, in em- 
 physema, 15 
 in infants, 15 
 in pleural effusion, 15 
 in rickets, 15 
 contraction of, in fibroid 
 
 phthisis, 964 
 examination of, 14 
 in disease, 15 
 posture for, 14 
 inspection of, 15 
 palpation of, 16 
 percussion of, 16 
 retraction of, 15 
 Chest-wall, retraction of, after 
 
 pleurisy, 945 
 Cheyne-Stokes respiration, 10 
 in cerebro-spinal menin- 
 gitis, 210 
 Chicken-pox, 156 
 
 change of air in, 161 
 complicating other diseases, 
 
 159 
 complications of, 158 
 course of, 158 
 diagnosis of, 160 
 from vaccinia, 160 
 from variola, 181 
 from variola and varioloid, 
 eruption of, 156 
 erysipelas in, 159 
 formation of pits, 158 
 history of, 156 
 hoarseness in, 157 
 hyperemia of air-passages in, 
 
 157 
 incubation of, 156 
 laryngeal irritation in, 157 
 nephritis in, 159 
 " pockmarks " in, 157 
 profuseness of eruption in, 
 
 159 
 prognosis of, 161 
 quarantine of, 182 
 recurrence of, 158 
 scarlatiniform ervthema in, 
 
 159 
 secondary infections in, 159 
 sequele of, 158 
 sore throat in, 157 
 spasm of the glottis in, 159 
 suffocative laryngitis in, 159 
 symptoms of, 156 
 treatment of, 161 
 vesicles of, 157 
 Chilblain, 1096 
 Child, anatomical peculiarities 
 
 in, 492 
 Child-crowing, 744 
 Childhood, diet in, 32 
 diet-tables for, 32 
 
INDEX. 
 
 1211 
 
 Childhood, duration of, 1 
 Children, general management 
 
 of. IS 
 Chill. See Chilliness and Chills. 
 in acute spinal leptomenin- 
 gitis, 779 
 in acute tubal nephritis, 1011 
 in croupous pneumonia, 914 
 in epidemic cerebro-spinal 
 
 meniugitis, 208 
 in erysipelas, 2*25 
 in pleurisy, 940 
 in typhlitis, 510 
 Chilliness in measles, 119 
 in scarlet fever, 136 
 in small-pox, 164 
 Chills in cerebro-spinal menin- 
 gitis, 209 
 in influenza, 216 
 in peritonitis, 565 
 in pyonephrosis, 1032 
 in simple cerebral menin- 
 gitis, 59S 
 in typhoid fever, 197 
 in variola, 164 
 Chloral in asthma, 960 
 in broncho-pneumonia, 912 
 in chorea, 763 
 in eclampsia, 745 
 in pertussis, 191 
 iu rheumatism, 357 
 in scarlet fever, 145 
 in variola, 168 
 Chloride of iron in acute fol- 
 licular tonsillitis, 420 
 in diphtheria, 262 
 in erysipelas, 228 
 in scarlet fever, 145 
 in variola, 169 
 Chlorodyne in cholera, 244 
 Chloroform in cerebral menin- 
 gitis, 604 
 in eclampsia, 745 
 in paroxysm of asthma, 960 
 in tracheotomy, 878 
 in uraemic convulsions, 1016 
 Chlorosis, 362 
 diagnosis of, 363 
 from pernicious anaemia, 
 364 
 etiology of, 362 
 morbid anatomy of, 363 
 prognosis of, 364 
 symptoms of, 362 
 treatment of, 364 
 Choked disk in brain abscess, 
 632 
 in cerebral meningitis, 601 
 Cholera Asiatica, 231 
 
 conditions of infection in, 
 
 235 
 definition of, 231 
 diagnosis of, 242 
 etiology of, 231 
 foudroyant attacks of, 241 
 modes of infection in, 234 
 non-contagious attacks of, 
 
 236 
 personal hygiene during 
 
 epidemics of, 249 
 prognosis of, 243 
 prophylaxis of, 248 
 secondary septic fever in, 
 
 241 
 special complications of, 242 
 special phases of, 241 
 symptoms of, 236 
 
 Cholera Asiatica, symptoms of, 
 in algid stage, 240 
 in period of reaction, 
 
 240 
 in period of serous evac- 
 uations, 237 
 in prodromal period, 237 
 treatment of, 243 
 in algid stage, 248 
 in period of reaction, 
 
 248 
 in prodromal period, 244 
 in stage of serous diar- 
 rhoea, 245 
 infantum. See Milk infection, 
 
 acute. 
 infectiosa epidemica. See 
 
 Cholera Asiatica. 
 sicca, 242 
 Choleriform diarrhoea, 475 
 
 See Milk infection, acute. 
 Chorea, 754 
 after influenza, 217 
 description of, 754 
 diagnosis of, 760 
 from habit-spasm, 761 
 from maladie des tics con- 
 
 vulsifs, 760 
 from paramyoclonus mul- 
 tiplex, 761 
 from p o s t-hemiplegic 
 hemichorea, 761 
 due to ascarides, 527 
 duration of, 755 
 etiology of, 756 
 in etiology of incontinence 
 
 of urine, 997 
 in hereditary syphilis, 647 
 major, 732 
 minor, 754 
 pathology of, 759 
 prognosis of, 762 
 relation of, to endocarditis^ 
 758 
 to rheumatism, 756 
 treatment of, 762 
 with rheumatism, 353 
 Choreic idiocy, 673 
 
 insanity, treatment of, 709 
 Choreiform movements in in- 
 fantile cerebral palsies, 
 652 
 Chronic catarrh after diph- 
 theria, treatment of, 266 
 joint-disease, 1071 
 Chrysarobin in favus, 1150 
 in psoriasis, 1113 
 in tinea tonsurans, 1153 
 Chyluria, 995 
 
 in elephantiasis, 995 
 Circumcision, 1059 
 
 tuberculosis after, 98 
 Cirrhosis of liver, 558 
 hypertrophic, 558 
 in diabetes nielli tus, 999 
 in the etiology of ascites, 
 571 
 of lung. See Phthisis, fibroid. 
 Claustrophobia, 704 
 Clavicle, changes in, in rachi- 
 tis, 335 
 fracture of, at birth, 85 
 Clavus, 730 
 Cleft palate, 433 
 
 etiologv and pathologv of, 
 
 434 
 operative treatment of, 435 
 
 Cleft palate, palliative treat- 
 ment of, 435 
 prophylaxis of, 435 
 symptoms of, 434 
 Clemens's solution, 1004 
 Climate, change of, in asthma, 
 962 
 in whooping-cough, 190 
 in etiology of vesical calcu- 
 lus, 1040 
 Clinical investigation of dis- 
 ease, 1 
 inspecting the child in, 3 
 physical examination in, 
 
 9 
 questioning the attend- 
 ants in, 2 
 Clothing, 34 
 
 in chronic heart disease, 984 
 Clubbing of fingers and toes in 
 
 fibroid phthisis, 965 
 Club-foot, 1083 
 etiology of, 1083 
 fasciotomy in, 1084 
 from paralysis, 1086 
 pathological anatomy of, 1083 
 plaster-of- Paris bandage in, 
 
 1084 
 prognosis of, 1083 
 shoe for, 1085 
 symptoms and diagnosis of. 
 
 1083 
 tenotomy in, 1084 
 treatment of, 1083 
 varieties of, 1083 
 Coagulable lymph in periton- 
 itis, 564 
 Coal-oil in pediculosis, 1156 
 Cocaine in pertussis, 192 
 Coccus of vaccinia, 173 
 Cocoanut against taenia, 537 
 Codeine in acute tubal nephri 
 tis, 1015 
 in diabetes mellitus, 1004 
 in phthisis, 302 
 Cod-liver oil in broncho-aden- 
 itis, 934 
 in convalescence from var- 
 iola, 170 
 in convalescence of mu- 
 cous disease, 462 
 in lupus vulgaris, 1140 
 in pulmonary emphysema 
 
 954 
 in rachitis, 347 
 in simple atrophy, 507 
 in splenic anaemia, 370 
 in syphilis, 116 
 in tuberculosis, 301 
 in typhoid fevei\ 161 
 Cceliotomy in chronic periton* 
 itis, 570 
 in tumors of peritoneum, 
 571 
 Cohen's tracheotomy-tube, S76 
 Cold abscess in Pott's disease. 
 1007 
 applications in peritonitis. 
 
 567 
 douches in incontinence of 
 
 urine, 997 
 in acute spinal leptomenin- 
 gitis, 7S1 
 in cerebral meningitis. 604 
 in epidemic cerebro-spinal 
 
 meningitis, 213 
 in erysipelas. 229 
 
1212 
 
 INDEX. 
 
 Cold abscess in etiology of acute 
 peritonitis, 563 
 of chronic tubal nephritis, 
 
 1018 
 of croupous pneumonia, 913 
 of pleurisy, 938 
 in ophthalmia neonatorum, 
 
 1186 
 in peritonsillar abscess, 421 
 in Eaynaud's disease, 825 
 in variola, 169 
 sore. See Herpes simplex. 
 Colic intussusception, 517 
 Collapse of lung following 
 broncho-pneumonia, 908 
 Colles's law, 104 
 Collvria in simple conjunctivi- 
 tis, 1185 
 Color-fields, narrowing of, in 
 
 hysteria, 734 
 Colostrum, 18 
 
 Coma in cerebro-spinal menin- 
 gitis, 209 
 in malignant measles, 123 
 in pernicious malaria, 314 
 in scarlet fever, 137 
 in tuberculous meningitis, 
 
 611, 617 
 urjemic, 1011 
 Comedo, 1092 
 
 treatment of, 1092 
 Comma bacillus, 231. See Spi- 
 rillum cholerse Asiaticse. 
 Compensation, failure of, in 
 chronic heart disease, 981 
 in heart-disease, 981 
 Compensatory emphysema. See 
 Emphysema, compensatory. 
 Concealed gout, 94 
 Concepts, 703 
 Condensed milk, 49 
 analysis of, 49 
 disadvantages of, 22 
 food value of, 49 
 for temporary use, 22 
 in etiologv of scorbutus, 
 389 
 Condiments in diabetic diet, 
 
 1003 
 Condvlomata, treatment of, 
 
 1147 
 Congenital affections of heart, 
 968 
 dislocation of hip, 1082 
 iritis, 1198 
 malformations, 84 
 Congestion of lungs in typhoid 
 
 fever, 198 
 Conium in clonic blepharo- 
 spasm, 1181 
 Conjunctiva, atrophy of, 1192 
 diseases of, 1184 
 ecchymosis of, 1191 
 in jaundice, 543 
 injuries of, 1192 
 pemphigus of, 1192 
 tubercle of, 1192 
 tumors and cysts of, 1192 
 xerosis of, 1196 
 Conjunctival congestion in ru- 
 bella, 155 
 Conjunctivitis. See Conjunc- 
 tivitis, simple. 
 chronic granular, types of, 
 
 1190 
 diphtheritic. 1188 
 symptoms of, 1188 
 
 Conjunctivitis, diphtheritic, 
 treatment of, 1188 
 follicular, 1189 
 
 treatment of, 1189 
 granular, 1190 
 sequels? of, 1190 
 symptoms of, 1190 
 treatment of, 1191 
 in measles, 120 
 in variola, 167 
 
 muco-purulent. See Con- 
 junctivitis, simple. 
 purulent, 1185. See, also, 
 Ophthalmia neonatorum. 
 etiology of, 1185 
 non-specific variety of, 
 1185 
 simple, 1184 
 
 etiology of, 1184 
 prognosis of, 1185 
 symptoms of, 1185 
 treatment of, 1185 
 spring, 1189 
 
 symptoms of, 1189 
 treatment of, 1189 
 Constipation, chronic, 496 
 diagnosis of, 498 
 etiology of, 196 
 extrinsic causes of, 497 
 intrinsic causes of, 496 
 pathology of, 497 
 prognosis of, 499 
 symptoms of, 498 
 treatment of, 499 
 habitual, in etiology of typh- 
 litis, 510 
 in chronic gastric catarrh, 
 
 448 
 in diabetes mellitus, 1000 
 in diseases of nervous sys- 
 tem, 497 
 in infants, 497 
 in intussusception, 519 
 in invasion of variola, 164 
 in measles, 120 
 in tuberculous meningitis, 
 
 611, 613 
 in typhlitis, 511 
 in typhoid fever, 197 
 Contracted kidney. See Ne- 
 phritis, chronic interstitial. 
 Contractures in acute spinal 
 leptomeningitis, 780 
 in hysteria, 734 
 with tumors of spinal cord, 
 803 
 Conus arteriosus, stenosis of, 
 
 971 
 Convalescence from chicken- 
 pox, 182 
 from scarlet fever, 143 
 from variola, 170 
 in typhoid fever, 198 
 Convallaria in chronic heart 
 
 disease, 985 
 Convulsions. See Eclampsia. 
 due to ascarides, 527 
 in acute gastric catarrh, 444 
 in acute myelitis, 784 
 in acute spinal leptomenin- 
 gitis, 779 
 in brain abscess, 632 
 in brain tumors. 637 
 in cerebro-spinal meningitis, 
 
 209 
 in chicken-pox. 179 
 in croupous pneumonia, 914 
 
 Convulsions in erysipelas, 225 
 in hereditary syphilis, 645 
 in hydrocephalus, 626 
 in infantile cerebral palsies, 
 
 651 
 in invasion of variola, 164 
 in jaundice due to oblitera- 
 tion of bile-ducts, 546 
 in lithsemia, 97, 98 
 in malignant measles, 123 
 in measles, 124 
 in onset of pleurisy, 940 
 in pernicious malaria, 314 
 in scarlet fever, 137 
 in simple cerebral menin- 
 gitis, 598 
 in teething, 412 
 in tuberculous mengitis, 611, 
 
 613 
 in whooping-cough, 188 
 replacing chill in malarial 
 fever, 311 
 Cooled bath in diphtheria. 262 
 Copper sulphate in trachoma. 
 
 1191 
 Coprolalia, 661 
 Cord, spinal, in rachitis, 327 
 umbilical, prolapse of, 77 
 treatment of, 77 
 after birth, 86 
 Cornea, affections of, in simple 
 cerebro-spinal meningi- 
 tis, 606 
 danger to, in ophthalmia 
 
 neonatorum, 1186 
 diseases of, 1194 
 foreign bodies in, 1197 
 injuries of, 1197 
 ulcer of. See Ulcer of cornea. 
 ulceration of, in variola, 167 
 Corneal ulceration, results of, 
 1195 
 ulcers in ophthalmia neona- 
 torum, 1186 
 Corrosive sublimate. See Mer- 
 curic chloride. 
 for nsevus vascularis, 1139 
 Corvza in hereditary syphilis, 
 109 
 replacing sweating in mala- 
 ria, 314 
 Cosme's paste in lupus vulga- 
 ris, 1141 
 Coster's paint in tinea tonsu- 
 rans, 1153 
 Cotton jacket in bronchitis, 932 
 in broncho-pneumonia, 910 
 in croupous pneumonia, 918 
 Cough, character of, in bron- 
 chitis, 6 
 in laryngeal catarrh, 6 
 in pneumonia and pleu- 
 risy, 7 
 in spasmodic croup, 6 
 in true croup, 6 
 in bronchitis, 928 
 in broncho-pneumonia, 907 
 in croupous pneumonia, 915 
 in disease, 6 
 in measles, 120, 122 
 iu pleurisy, 940 
 in severe spasmodic laryn- 
 gitis, 852 
 in simple catarrhal laryngi- 
 tis. 846 
 in spasmodic laryngitis, 843 
 in typhoid fever, 198 
 
INDEX. 
 
 1213 
 
 Cough in whooping-cough, 136 
 region in -whooping-cough, 
 
 184 
 with broncho-adenitis, 929 
 Counter-irritation in acute my- 
 elitis, 786 
 in bronchitis, 932 
 in cirrhosis of liver, 559 
 Cowling's rule, 35 
 Cow-pox. See Vaccinia. 
 
 spontaneous, 171 
 Cow's milk, 21 
 
 characters of, 21 
 constituents of, 21 
 definition of, 33 
 effect of dilution of, 23 
 Cracked-pot sound in hydro- 
 cephalus, 626 
 in pulmonary tuberculosis, 
 296 
 Cramps in cholera, 238 
 Craniectomy in hydrocephalus, 
 629 
 in idiocy, 679 
 Craniotabes in rachitis, 332 
 relation of, to laryngismus 
 
 stridulus, 340 
 symptoms of, 339 
 syphilitic, 108 
 Cream and whole milk mixt- 
 ures, 56. 58 
 importance of, in diet, 345 
 strength of, 56 
 
 tables of dilutions with sugar 
 solution, 57 
 Creasote in broncho-adenitis, 
 934 
 in diabetes mellitus, 1005 
 in gangrene of lung, 923 
 in jaundice, 549 
 intrapulmonary injection of, 
 
 301 
 in tuberculosis, 301 
 Crede's method, 1188 
 Creolin for vaginal douche, 88 ' 
 in erysipelas, 229 
 in haemorrhages from mucous i 
 
 surfaces, 82 
 in mucous disease, 460 
 Crescentic bodies in aestivo- 
 
 autrumnal fever, 308 
 Cretinism, 680 
 diagnosis of, 683 
 endemic, 684, 685 
 etiology of, 682 
 pathology of, 683 
 prognosis of, 685 
 sporadic, 684, 685 
 symptoms of, 680 
 synonyms of, 680 
 treatment of, 680 
 Cretinoid idiocy, 685 
 Crisis in croupous pneumonia, 
 
 916 
 Critical period in chronic heart 
 
 disease, 983 
 Cross-legged progression in in- 
 fantile cerebral palsies, 
 652 
 Croton oil in tinea tonsurans, 
 
 1154 
 Croup, catarrhal. See Laryn- 
 gitis, spasmodic, severe. 
 spasmodic. See Laryngitis, 
 catarrhal. 
 Croupous nephritis, acute. See 
 Nephritis, acute tubal. 
 
 Croupous nephritis, chronic. 
 
 See Nephritis,chronic tubal. 
 
 pneumonia. See Pneumonia, 
 
 croupous. 
 
 in etiology of secondary 
 
 pleurisy, 937 
 
 Crust-formation in atrophic 
 
 rhinitis, 834 
 Cry, causes of the, 6 
 
 character of, in spasmodic 
 
 croup, 6 
 hydrencephalic, description 
 
 of, 6 
 in acute pleuritis, 6 
 in disease, 6 
 in epilepsy, 749 
 in intestinal pain, 6 
 in membranous croup, 6 
 in simple catarrhal laryn- 
 gitis, 846 
 nasal tone of, in swelling of | 
 nasal mucous mem- j 
 brane, 6 
 Crying during cough, indica- 
 tion of, 6 
 Curative effects of erysipelas, 
 
 230 
 Curetting in lupus vulgaris, 
 
 1142 
 Curschmann's spirals in asth- 
 ma, 957 
 Curvature of spine, lateral, 
 
 1063. See Scoliosis. 
 Curvatures of spinal column, 
 
 rachitic, 333 
 Cyanosis in acute endocarditis, 
 978 
 in broncho-pneumonia, 907 
 in chronic heart disease, 981 
 in pulmonary tuberculosis, 
 
 296 
 of face in lymphatic ansemia, 
 371 
 Cyclitis, 1199 
 Cyst of brain, 636 
 of omentum, 570 
 of orbit, 1201 
 paranephric, 1028 
 reual, 1027 
 Cysticerci in children, 535 
 Cysticercus cysts, 534 
 Cystic-oxide calculus, 1038 
 
 Dacryoadenitis, 1199 
 Dacryocystitis, 1199 
 Dactylitis in late hereditary 
 syphilis, 114 
 syphilitic, 107 
 diagnosis of, from tuber- 
 cular, 113 
 symptoms of, 111 
 Dairies, care of milk in, 39 
 hygienic conditions of, 33 
 inspection of, 38 
 Dance's sign in intussusception, 
 
 520 
 Davies-Colley method of sta- 
 
 phylorraphy, 437 
 " Dead finger," 821 
 Deaf-mutes, education of, 1176 
 Deaf-mutism, 662 
 Deafness, acquired labyrin- 
 thine, 1176 
 after parotitis, 180 
 in hysteria, 733 
 Death after tracheotomy, 
 causes of, 884 
 
 Death-rate at the sea-coast, 61 
 Deaver's retractor, 869 
 Debility in chronic tubal neph- 
 ritis, 1019 
 Decubitus in disease, 4 
 in diseases of liver, 540 
 in pericarditis, 974 
 in peritonitis, 565 
 in simple cerebro - spinal 
 
 meningitis, 606 
 in suppurative hepatitis, 554 
 in typhlitis, 510 
 Defect of ventricular septum, 
 
 969 
 Deficiency of phosphates in 
 etiology of cleft palate, 
 434 
 Deformities in mouth and 
 pharynx, 664 
 of trunk and limbs in idiocy, 
 
 675 
 old, from joint-disease, 1081 
 paralytic, 1086 
 rachitic, 1087 
 Deformity in hip-joint disease, 
 1072, 1073 
 in Potts' disease, 1068 
 Degeneration, acute fatty, of 
 
 new-born, 92 
 Delay in walking, causes of, 13 
 Delirium cordis, 988 
 in cerebro-spinal meningitis, 
 
 209 
 in chicken-pox, 156 
 in invasion of variola, 164 
 in rheumatism, 352 
 in scarlet fever, 136 
 in simple cerebral meningitis, 
 
 639 
 in simple cerebro-spinal 
 
 meningitis, 607 
 in tuberculous meningitis 
 
 611-616 
 in typhoid fever, 200 
 period of, in hysteria, 731 
 Delusions in typhoid fever, 200 
 Dental sac, 410 
 Dentine-germ, 410 
 Dentition, 409. See, also, 
 Teething. 
 delayed, phosphorus in, 411 
 
 relation of, to rachitis, 321 
 effect of rachitis upon, 333 
 in etiology of eclampsia, 743 
 of laryngismus stridulus, 
 859 * 
 primary, frequency of bron- 
 cho-pueumouia during, 
 904 
 retardedby chronic diarrhoea, 
 411 
 by rickets and syphilis. 411 
 Depletion in cirrhosis of liver. 
 
 559 
 Depurative disease. See Amy- 
 loid disease of kidney. 
 Dermatitis exfoliativa neona- 
 torum, 1119 
 sauunenosa infantum, 160. 
 U'20 
 treatment of. 1121 
 in rachitis, 341 
 Dermoid cyst of eyelid. 1183 
 
 cysts behind auricle. L160 
 Desquamation in measles. 121 
 in rubella. 153 
 in scarlet fever. 138 
 
1214 
 
 INDEX. 
 
 Desquamative nephritis, acute. 
 See Nephritis, acute tubal. 
 Development, general, 12 
 in health, 12 
 of new-born child, 12 
 of articulation, 665 
 of senses, 665 
 Dextrin, 45, 50 
 Dextrinized atteuuants, 50 
 
 analysis of, 50 
 Dextrose, 45 
 Diabetes insipidus, 1005 
 diagnosis of, 1005 
 etiology of, 1005 
 morbid anatomy of, 1005 
 prognosis of, 1005 
 symptoms of, 1005 
 treatment of, 1006 
 mellitus, 999 
 
 diagnosis of, 1000 
 etiology of, 999 
 hygienic treatment of, 1003 
 in etiology of chronic tubal 
 nephritis, 1019 
 of incontinence of urine, 
 998 
 morbid anatomy of, 999 
 prognosis of, 1001 
 symptoms of, 999 
 treatment of, 1002 
 Diacetic acid in diabetic urine, 
 
 1000 
 Diaphoresis in acute tubal 
 nephritis, 1003 
 in chronic tubal nephritis, 
 
 1023 
 in scarlatinal nephritis, 147 
 Diarrhoea, catarrhal, 481 
 chronic. See Indigestion, 
 
 chronic intestinal. 
 croupous, 481 
 during teething, 412 
 treatment of, 413 
 dysenteric, 481 
 in broncho-pneumonia, 907 
 in chronic peritonitis, 568 
 in invasion of variola, 164 
 in leukaemia, 374 
 in malarial fever, 314 
 in measles, 120, 122 
 in prodromal period of chol- 
 era, 237 
 in pulmonary tuberculosis, 
 
 296 
 in scarlet fever, 136, 140 
 in simple atrophy, 505 
 in tuberculosis, 286 
 in typhoid fever, 197, 198 
 simple. See Indigestion, acute 
 
 intestinal. 
 with constipation, 498 
 Diarrhceal diseases, 463 
 classification of, 463 
 Diathesis, scrofulous, 276 
 tuberculous, 276 
 characteristics of, 15 
 Diet in acute gastric catarrh, 
 446 
 in acute tubal nephritis, 1017 
 in asthma, 961 
 in broncho-pneumonia, 910 
 in chicken-pox, 161 
 in chronic gastric catarrh, 
 
 450 _ 
 in chronic intestinal indiges- 
 tion, 470 
 in chronic peritonitis, 569 
 
 Diet in chronic tubal nephritis, 
 1022 
 
 in cirrhosis of liver, 559 
 
 in croupous pneumonia, 918 
 
 in diabetes mellitus, 1002 
 
 in diphtheria, 261 
 
 in dysentery, 492 
 
 in eczema, 1104 
 
 in erysipelas, 229 
 
 in etiology of secondary 
 anaemia, 360 
 of vesical calculus, 1040 
 
 in functional affections of 
 heart, 989 
 
 in gonorrhoea, 1054 
 
 in influenza, 219 
 
 in jaundice, 547 
 
 in laryngismus stridulus, 864 
 
 in litheemia, 99 
 
 in lithiasis, 1010 
 
 in measles, 127 
 
 in peritonitis, 566 
 
 in prophylaxis of stone, 1044 
 
 in pulmonarv emphysema, 
 954 
 
 in rachitis, 344 
 
 in rheumatism, 356 
 
 in scarlet fever, 145 
 
 in simple atrophy, 507 
 
 in typhlitis, 513 
 
 in whooping-cough, 190 
 
 of infant in health, 29 
 tables of, 29, 30 
 water in, 30 
 Diffuse nephritis, chronic. See 
 Nephritis, chronic tubal. . 
 
 trachoma, 1190 
 Digestion of cow's milk, 46 
 Digitalis in acute endocarditis, 
 980 
 
 in acute tubal nephritis, 1017 
 
 in croupous pneumonia, 918 
 
 in chronic heart disease, 
 984 
 
 in chronic tubal nephritis, 
 1023 
 
 in diphtheria, 261 
 
 in functional heart affections, 
 989 
 
 in malignant measles, 128 
 
 in pericarditis, 976 
 
 in peritonitis, 567 
 
 in pleurisy, 946 
 
 in scarlatinal nephritis, 148 
 
 in typhoid fever, 207 
 Dilatation in treatment of ad- 
 herent prepuce, 1058 
 
 of heart in scarlatinal neph- 
 ritis, 143 
 Diphtheria, 250 
 
 antitoxines of, 266, 269 
 
 ascending, of trachea and 
 larynx, 258 
 
 bacteriology of, 252 
 
 complicated by parotitis, 178 
 
 complicating other diseases, 
 259 
 
 definition of, 250 
 
 diagnosis of, from catarrhal 
 and spasmodic larvngitis, 
 257 
 from other pseudo-mem- 
 branes, 255 
 from simple follicular 
 amygdalitis, 256 
 
 disinfection in, 260 
 
 etiology of, 250 
 
 Diphtheria, general disease the- 
 ory of, 251 
 incubation of, 253 
 in etiology of chronic tubal 
 
 nephritis, 1019 
 in typhoid fever, 199 
 intubation in, 267 
 Klebs-Loffler bacilli in, 266 
 laryngeal, 266 
 local pathological changes in, 
 
 254 
 local treatment of, 263 
 mode of infection and prop- 
 agation of, 253 
 mortality of, 260 
 nasal, in scarlet fever, 144 
 naso-pharyngeal, 266 
 of anus, 588 
 of bronchi, 259 
 of conjunctiva, 258 
 of larynx, 257 
 of nares, 257 
 
 of pharynx and mouth, 257 
 of tonsils, 256 
 prognosis of, 259 
 prophylaxis of, 260 
 sequelae of, 259 
 streptococci in, 266 
 symptoms and diagnosis of, 
 
 255 
 synopsis of treatment of, 268 
 treatment of, 261 
 
 of albuminuria of, 266 
 of anaemia following, 266 
 unfavorable prognostic signs 
 
 in, 260 
 with pertussis, 188 
 Diphtheritic sore throat, 418 
 Diplococcus in normal urethra, 
 
 1054 
 pneumoniae. See Pneumococ- 
 
 cus. 
 in pleurisy, 938 
 scarlatinae sanguinis 
 Diplopia, monocular, 
 
 teria, 734 
 Dipsomania, 703 
 Discharge in chronic 
 
 tion of middle ear, 1171 
 in ophthalmia neonatorum, 
 
 1186 
 Disease, appearance of the skin 
 
 in, 5 
 Buhl's, 92 
 
 clinical investigation of, 1 
 cough in, 6 
 cry in, 6 
 decubitus in, 4 
 expression of the face in, 3 
 faecal evacuations in, 8 
 features of, 3 
 mode of drinking in, 6 
 temperature in, 12 
 urine in, 8 
 Winckel's, 92 
 Disinfection after purpura 
 
 haemorrhagica, 384 
 against seat-worms, 532 
 during pertussis, 190 
 in acute milk infection, 479 
 in cholera, 248 
 in influenza, 219 
 in malignant measles, 130 
 in scarlet fever, 149 
 in variola, 170 
 of intubation-tubes, 897 
 of skin in variola, 169 
 
 134 
 
 in hys- 
 
 suppura- 
 
INDEX. 
 
 1215 
 
 Disinfection of typhoid dejec- 
 tions. -207 
 Dislocation of hip. congenital, 
 1082 
 diagnosis of. 1082 
 etiology of, 10S2 
 prognosis of, 10S3 
 symptoms of, 1082 
 treatment of, 1083 
 at birth, treatment of, 85 
 in utero, causes of, 84 
 Displacement of viscera in 
 
 pleurisy, 942 
 Disseminated sclerosis in he- 
 reditary syphilis, 647 
 Dissociation symptom of syrin- 
 gomyelia, 812 
 Distichiasis. treatment of, 1182 
 Diuretic pill, compound, 985 
 Diuretics in chronic tubal 
 
 nephritis, 1023 
 Diuretin in scarlatinal nephri- 
 tis, 148 
 Dolichocephalic idiocy, 671 
 Douche in atrophic rhinitis, 836 
 Dover's powder in phthisis, 302 
 
 in pleurisy, 946 
 Drainage, permanent, in asci- 
 tes, 574 
 Dried-blood test for typhoid 
 
 fever, 205 
 Drinking, mode of, in disease, 6 
 in disease of throat, 6 
 in pneumonia, 6 
 in severe bronchitis, 6 
 in soreness of mouth, 6 
 Drinking-water in etiology of 
 amoebic dysentery, 490 
 of dysentery, 486 
 Drinks in diabetic diet, 1003 
 Drop-foot in acute poliomyeli- 
 tis, 793 
 Dropsy. See QZdema. 
 
 in acute tubal nephritis, 1012 
 in chronic tubal nephritis, 
 
 1019 
 of the brain, 624. See Hydro- 
 cephalus. 
 Drowsiness in jaundice, 543 
 
 in measles, 120 
 Drugs in etiology of acute 
 
 tubal nephritis, 1011 
 Drum-head. See Drum-mem- 
 brane. 
 Drum-membrane, distention of, 
 1167 
 in childhood, misapprehen- 
 sions concerning, 1167 
 incision of, 1168 
 retraction of, in chronic tym- 
 panic catarrh, 1175 
 Dry cases of tracheotomy, 882 
 catarrh, 833 
 
 cups in epidemic cerebro- 
 spinal meningitis, 213 
 pleurisy, 935 
 Dryness of tissues in diabetes 
 
 mellitus, 1000 
 Ductus arteriosus, persistence 
 of, 971 
 diagnosis of, 972 
 Duke's method of artificial 
 
 respiration, 79 
 Dulness, area of, in pericardial 
 effusion, 975 
 movable, in pleural effusion, 
 value of, in children, 943 
 
 Dulness of liver, superior border 
 
 of, 16 
 Duodenum, condition of, in ty- 
 phoid fever, 196 
 Dysesthesia in Landry's paral- 
 ysis, 799 
 Dysentery, 485 
 amoebic, 490 
 
 diagnosis of, 491 
 lesions of liver in, 490 
 morbid anatomy of, 490 
 prognosis of, 491 
 symptoms of, 491 
 catarrhal, 485 
 absence of specific germ in, 
 
 486 
 diagnosis of, 489 
 etiology of, 485 
 improper feeding in, eti- 
 ology of, 486 
 microscopic appearances iu, 
 
 487 
 prognosis of, 489 
 symptoms of, 488 
 diphtheritic, 491 
 microscopical appearances 
 in, 491 
 disinfection in, 492 
 hygiene of, 492 
 in scarlet fever, 140 
 morbid anatomy of, 486 
 prophylaxis of, 492 
 treatment of, 492 
 varieties of, 485 
 Dyslexia, 659 
 Dyspepsia, acute. See Gastric 
 
 catarrh, acute. 
 Dysphagia in Landry's paraly- 
 sis, 799 
 Dysphrasia, 659 
 Dyspnoea, expiratory, 10 
 causes of, 10 
 in aortic stenosis, 982 
 in asthma, 958 
 in bronchitis, 929 
 in broncho-pneumonia, 906 
 in chronic heart-disease, 981 
 in fibroid phthisis, 965 
 in leukaemia, 374 
 in lymphatic anaemia, 371 
 in marked laryngeal stenosis, 
 
 10 
 in mitral stenosis, 982 
 in pericarditis, 975 
 in pleurisy, 941 
 in progressive pernicious 
 
 anaemia, 365 
 in pulmonary tuberculosis, 
 
 296 
 in secondary anaemia, 361 
 in spasmodic laryngitis, 840 
 inspiratory, causes of, 10 
 in substantive emphysema, 
 953 
 Dystochia from hydronephro- 
 sis, 1029 
 
 Ear, anatomy of, 1167 
 diseases of, 1158 
 
 importance of, 1158 
 embryology of, 1158 
 external, affections of, 1159 
 internal, affections of, 1175 
 middle, acute simple inflain- 
 mation of, 1166 
 affections of, 1166 
 chronic catarrh of, 1174 
 
 Ear, middle, chronic suppura- 
 tion of, 1170 
 treatment of eczema of, 
 
 1109 
 treatment of, method of hold- 
 ing child in, 1159 
 Earache, a symptom, 1166 
 Eberth's bacillus, 195 
 Ecchymosis in cholera, 239 
 of conjunctiva, 1191 
 of eyelids, 1184 
 treatment of, 1184 
 Echinococcus cyst of brain, 
 
 636 
 Echolalia, 661 
 Eclampsia, 741 
 diagnosis of, 745 
 etiology of, 742 
 in chronic constipation, 498 
 in lithaemia, 98 
 in prognosis of scarlatina, 
 
 144 
 in rachitis, 341 
 pathology of, 743 
 prognosis of, 744 
 seat of origin of, 741 
 symptoms of, 744 
 treatment of, 745 
 Ectopia cordis, 973 
 Ectropion, 1183 
 Eczema, 1100 
 after vaccination, 175 
 associated with asthma, 957 
 diagnosis of, 1103 
 
 from papular urticaria, 1103 
 from pediculosis capillitii, 
 
 1104 
 from scabies, 1103 
 from syphilodermata, 1103 
 etiology of, 1102 
 in lithsemia, 99 
 intertrigo, 1102 
 
 treatment of, 1110 
 marginal, of lids, 1179 
 of ears, treatment of, 1109 
 of face, treatment of, 1109 
 of lids, treatment of, 1110 
 of scalp, treatment of, 1109 
 prognosis of, 1109 
 resemblance of, to mucous 
 
 catarrhs, 1101 
 rubrum or madidans, 1101 
 seborrhceal, 1091 
 squamosum, 1101 
 treatment of, 1104 
 of regional forms of, 1109 
 Eczematous inflammations of 
 
 auricle, 1160 
 Education in moral imbecilitv, 
 
 679 
 Educational treatment of 
 
 idiocy, 678 
 Effusion, pleural, diagnosis of, 
 943 
 diagnostic use of hypo- 
 dermic needle in, 943 
 Eggs in diabetic diet. 1003 
 
 in lithsemic diet. 99 
 Ehrlich's reaction in acute tu- 
 berculosis, 281 
 test, in children. 200 
 EichofPs thymol soap. 1103 
 Elbow-joint disease. 1080 
 diagnosis of. 1080 
 prognosis of, 10S0 
 symptoms of. 1080 
 treatment of. 1081 
 
1216 
 
 INDEX. 
 
 Elaterium in chronic tubal 
 
 nephritis, 1023 
 Electric cataphoresis in tinea 
 
 tonsurans, 1154 
 Electrical excitability in tet- 
 any, 765 
 Electricity in acute poliomy- 
 elitis, 794 
 in incontinence of urine, 
 
 997 
 in infantile cerebral palsies, 
 
 657 
 in naevus vascularis, 1138 
 Electrization of stomach in 
 
 mucous disease, 461 
 Electro-cautery in hypertro- 
 phic rhinitis, 833 
 Electrolysis in treatment of 
 lupus vulgaris, 1142 
 of molluscum epitheliale, 
 
 1130 
 of naevus pigmentosus, 1132 
 of verruca, 1131 
 Elongation of uvula, 471 
 Emaciation in hydrocephalus, 
 627 
 in tuberculous meningitis, 
 
 611, 618 
 in typhoid fever, 198 
 rapid, in diabetes mellitus, 
 1000 
 Embolism in acute endocar- 
 ditis, 978 
 in infantile cerebral palsies, 
 
 656 
 of brain in rheumatism, 353 
 Embryocardia, 988 
 Embryonine, 1002 
 Emetics in broncho-pneumo- 
 nia, 911 
 in eclampsia, 745 
 Emotions in etiology of hys- 
 teria, 729 
 Emphysema, compensatory, 950 
 etiology of, 950 
 pathology of, 951 
 symptoms of, 951 
 treatment of, 953 
 in pertussis, 188 
 interstitial, 950 
 of eyelids, 1184 
 pulmonary, 950 
 subpleural, complicating 
 
 broncho-pneumonia, 918 
 substantive, 951 
 etiology of, 951 
 pathology of, 951 
 physical signs of, 953 
 prognosis of, 953 
 symptoms of, 953 
 treatment of, 953 
 surgical, after tracheotomy, 
 
 886 
 vesicular or alveolar, 950 
 Emprosthotonos in cerebro- 
 spinal meningitis, 210 
 Empyema, 935 
 in etiology of pericarditis, 
 
 975 
 in pertussis, 187 
 in scarlatinal nephritis, 142 
 necessitatis, 946 
 of antrum in etiology of 
 
 nasal myxomata, 841 
 perforation of, 945 
 Enamel-germ. 410 
 Endemic cretinism, 684 
 
 Endocardial murmurs in rheu- 
 matism, 352 
 Endocarditis, acute, 977 
 etiology of, 977 
 physical signs of, 978 
 prognosis of, 979 
 symptoms of, 978 
 treatment of, 980 
 with old valvular lesions, 
 979 
 during scleroderma, 1133 
 in diphtheria, 256 
 in rheumatism, 352 
 in scarlatinal nephritis, 143 
 in typhoid fever, 201 
 in variola, 167 
 relation of, to chorea, 978 
 ulcerative, 353 
 Enemata against seat-worms, 
 532 
 in chronic intestinal indi- 
 gestion, 471 
 in constipation, 499 
 in prolapse of rectum, 591 
 nutritive, in peritonitis, 263 
 Enlargement of liver, diagnosis 
 
 of, 540 
 Enterectomy in intussuscep- 
 tion, 523 
 Enteric fever. See Typhoid 
 
 fever. 
 Enteroclysis in cholera, 289 
 Entero-colitis. See, also, Milk 
 infection subacute. 
 anatomical changes of, 480 
 chronic, 467. See Indigestion, 
 
 chronic intestinal. 
 in measles, 124 
 in variola, 167 
 sea-air in treatment of, 62 
 Enterorraphy, circular, in con- 
 genital malformations of 
 intestines, 576 
 in intussusception, 523 
 Enterotomy in intussusception, 
 
 522 
 Entropion, 1182 
 
 treatment of, 1183 
 Enucleation in sympathetic 
 
 irritation. 11S3 
 Eosinophile cells, value of, 
 
 in diagnosis, 376 
 Epilation in tinea favosa, 1150 
 
 in tinea tonsurans, 1153 
 Epilepsie larvee, 750 
 Epilepsy, 747 
 as a cause of incontinence of 
 
 urine, 998 
 diagnosis of, 751 
 from gross brain disease, 
 
 751 
 from hysteria, 751 
 from uraemia, 751 
 etiology of, 748 
 in hereditary syphilis, 645 
 in hydrocephalus. 626 
 in infantile cerebral palsies, 
 
 653 
 morbid anatomy of, 748 
 motor symptoms of, 749 
 pathology of, 748 
 prognosis of, 752 
 symptoms of, 749 
 psychic, 750 
 sensory, 749 
 treatment of, 752 
 varieties of, 751 
 
 Epileptic headache, 722 
 
 insanity, treatment of, 710 
 Epileptogenetic centres, 742 
 Epileptoid period of hysteria,. 
 
 730 
 Epiphora in diseases of lachry- 
 mal sac, 1199 
 Epiphyseal swelling in syphilis, 
 diagnosis of, from rickets, 
 107 
 Epiphyseo-diaphyseal separa- 
 tion in hereditary sphy- 
 ilis, 107 
 Epistaxis in chronic heart dis- 
 ease, 981 
 in haemophilia, 377 
 in measles, 124 
 in typhoid fever, 197, 198 
 Epithelioid cells, 278 
 Epstein's apparatus for bowel- 
 washing, 460 
 Ergot in cerebro-spinal men- 
 ingitis, 608 
 in diabetes insipidus, 1006 
 in diabetes mellitus, 1004 
 in epidemic cerebro-spinal 
 
 meningitis, 213 
 in incontinence of urine, 
 
 998 
 in Landry's paralysis, 800 
 Ergotine in gastro-intestinal 
 haemorrhage, 87 
 in haemorrhage of typhoid 
 
 fever, 207 
 in scarlatinal nephritis, 148 
 Erotomania, 703 
 Eruption of cerebro-spinal men- 
 ingitis, 211 
 of chicken-pox, 156 
 of erysipelas, 226 
 of rubella, 153 
 of scarlet fever, 137 
 of typhoid fever, 199 
 of variola, 165 
 stage of desiccation of, 
 
 165 
 stage of maturation of, 
 
 165 
 upon mucous membranes, 
 165 
 Eruptions, exanthematous, on 
 eyelids, 1179 
 in cholera, 242 
 in diphtheria, 259 
 in measles, 120 
 in rheumatism, 352 
 in rubella, 153 
 Erysipelas, 221 
 after tracheotomy, 885 
 after vaccination, 175 
 complications and sequelae 
 
 of, 226 
 contagiousness of, 223-228 
 definition of, 221 
 diagnosis of, 227 
 from acne rosacea, 227 
 from angeio-neurotic oede- 
 ma, 227 
 from erythema, 227 
 from malignant oedema, 
 
 227 
 from urticaria, 227 
 etiology of, 221 
 history of, 221 
 in chicken-pox, 159 
 of auricle, 1160 
 of new-born, 90, 225 
 
INDEX. 
 
 1217 
 
 Erysipelas, pathological anat- 
 omy of, 223 
 prognosis of, 227 
 pulmonary lesions in, 224 
 symptoms of, 225 
 Therapeutic use of, 229 
 treatment of, 22S 
 with peritonitis, 564 
 Ervthema annulare, 1098 
 bullosum, 109S 
 caloricum. 1096 
 gyratuni, 109S 
 idiopathic, 1095 
 infantile, 1097 
 
 diagnosis of, from measles, 
 1095 
 from rotheln, 1098 
 from scarlatina, 1098 
 treatment of, 1098 
 in rheumatism, 354 
 intertrigo, 1096 
 diagnosis of, 1096 
 treatment of, 1096 
 in vaccination, 175 
 iris, 1098 
 
 marginatum, 1098 
 multiforme, 1098 
 diagnosis of, 1099 
 etiology of, 1099 
 prognosis of, 1099 
 treatment of, 1099 
 nodosum, 1099 
 of buttocks in subacute milk 
 
 infection, 481 
 of legs in typhoid fever, 
 
 199 
 pernio, 1096 
 
 treatment of, 1097 
 relapsing scarlatiniform, 1100 
 diagnosis of, 1100 
 
 from scarlatina, 1100 
 treatment of, 1100 
 simplex, 1095 
 symptomatic, 1097 
 traumaticum, 1096 
 tuberculatum, 1098 
 venenatum, 1096 
 vesiculosum, 1098 
 Ervthematous syphiloderm, 
 
 1143 
 Eserine in ophthalmia neona- 
 torum, 1187 
 in phlyctenular keratocon- 
 junctivitis, 1193 
 Essential shrinking of con- 
 junctiva, 1192 
 Estlander's operation, 948 
 Etat mamelonne, 447 
 Ethmoiditis, necrosing, in eti- 
 ology of nasal niyxomata, 
 841 
 Ethyl iodide in asthma, 961 
 Eucalyptol in tuberculosis, 302 
 Eucalyptus in malaria, 318 
 Eustachian tube, formation of, 
 
 1158 
 Evacuation of bowels during 
 urination in vesical cal- 
 culus, 1042 
 Exalgin in chorea, 762 
 Examination of the mouth and 
 
 fauces, 17 
 Exanthemata in etiology of 
 acute tubal nephritis, 
 1011 
 of bronchitis, 924 
 of chronic peritonitis, 568 
 
 77 
 
 Exanthemata in etiology of 
 middle-ear inflammation, 
 1166 
 Exanthematous eruption on 
 
 eyelids, 1179 
 Excision in treatment of ad- 
 herent prepuce, 1058 
 Exercise, 35 
 hours for, 357 
 in chronic gastric catarrh, 
 
 451 
 in chronic heart disease, 
 
 984 
 in convalescence from acute 
 
 nephritis, 1018 
 in etiology of paroxysmal 
 
 hematuria, 994 
 in functional affections of 
 
 heart, 990 
 in lithsemia, 100 
 in pseudo-hypertrophic mus- 
 cular paralysis, 773 
 in pulmonary emphysema, 
 953 
 Expectoration in asthma, 958 
 in bronchitis, 928 
 in broncho-pneumonia, 907 
 in croupous pneumonia, 915 
 in fibroid phthisis, 965 
 in gangrene of lung, 922 
 in measles, 120 
 Expiratorv dyspnoea, causes of, 
 10 ' 
 respiration, character of, 10 
 
 significance of, 10 
 theory of compensatory em- 
 physema, 950 
 of substantive emphysema, 
 952 
 Exploratory incision in chronic 
 
 peritonitis, 570 
 Exploring needle in appendi- 
 citis, 514 
 Exposure in etiology of acute 
 gastric catarrh, 442 
 of rheumatism, 351 
 External ear, affections of, 
 
 1159 
 Extra-cellular pigmented bod- 
 ies in malaria, 306 
 Exudate in infectious pseudo- 
 membranous tonsillitis, 
 418 
 Exudates, pleural, chemical 
 composition of, 937 
 interchange of fluids in, 
 
 937 
 without microbic elements, 
 939 
 Eye, diseases of, 1178 
 
 refraction of, in childhood, 
 1201 
 Eyelid, furuncle of, treatment 
 
 of, 1178 
 Eyelids, abscess of, 1178 
 diseases of, 1178 
 ecchymosis of, 1184 
 emphysema of, 1184 
 injuries of, 1184 
 syphilis of, 1180 
 tumors and hypertrophies of, 
 1180 
 Eyes, treatment of, in measles, 
 
 128 
 Eye-strain in migraine. 721 
 Eye-symptoms of hydroceph- 
 alus. 626 
 
 Face, expression of, in health 
 and disease, 3 
 treatment of eczema of, 1109 
 Facial hemiatrophy, progres- 
 sive, 775 
 symptoms of, 776 
 treatment of, 776 
 nerve, obstetric paralysis of, 
 
 83 
 paralysis of, 774 
 diagnosis of, 775 
 etiology of, 774 
 in otitis media, 1117 
 in tuberculous meningitis, 
 
 617 
 symptoms of, 774 
 treatment of, 775 
 phenomenon in tetany, 766 
 Facies in asthma, 958 
 in bronchitis, 929 
 in hereditary ataxia, 818 
 in suppurative hepatitis, 554 
 in typhoid fever, 197 
 Fsecal accumulation, diagnosis 
 of, 14 
 evacuations in catarrhal ul- 
 ceration of the intestines, 
 8 
 in diarrhoea of sucklings, 8 
 in disease, 8 
 in dysentery, 8 
 in entero-colitis, 8 
 in follicular enteritis, 8 
 in health, 8 
 in helminthiasis, 8 
 in indigestion, 8 
 in intestinal catarrh, 8 
 in tubercular disease, 8 
 in tuberculous ulceration 
 
 of the intestines, 8 
 in typhoid fever, 8 
 Fasces in jaundice, 543 
 incontinence of, in tubercu- 
 lous meningitis, 618 
 Failure of heart, sudden, in 
 diphtheria, 256 
 sources of, in sounding for 
 stone, 1044 
 Fall fever. See Typhoid fever. 
 Fallopian tube, tuberculosis of, 
 
 299 
 Faradism in simple jaundice of 
 
 infants, 545 
 Farinaceous food, when per- 
 missible, 22 
 Fascia, cervical, deep, 872 
 
 superficial, 872 
 Fascicular keratitis, 1193 
 Fasciotomy in club-foot, 1084 
 Fat, deficiency of, in food of 
 rachitics, 323 
 in human milk, 44 
 in milk, 46 
 relative size of globules- of, 
 46 
 percentage of, in modified 
 milk, 55 
 Fatty calculus, 1038 
 degeneration, acute, of new- 
 born. 92 
 Fauces, appearance of, in 
 health. 17 
 ascarides in, 527 
 examination of. 17 
 Favus, 1148, See Tin?a fa- 
 vosa. 
 Features of disease, 3 
 
1218 
 
 INDEX. 
 
 Febrile and post-febrile insan- 
 ity, 706 
 Feeble-mindedness in infantile 
 
 cerebral palsies, 654 
 Feeding, 18 
 after tracheotomy, 884 
 artificial, 21 
 
 asses' milk in, 25 
 attenuants in, 23 
 bicarbonate of sodium in, 
 
 23 
 goat's milk in 25 
 lime-water in, 25 
 method of preparation in, 
 
 23 
 mode of administration of, 
 
 30 
 modified milk in, 55 
 peptonization in, 25 
 position of child in, 31 
 preservation of milk for, 31 
 quantity of food for, 22 
 rules for, 21 
 selection of food for, 21 
 
 of milk for, 31 
 " strippings " in, 25 
 substitutes for milk in, 28 
 sugar of milk in, 23 
 table for, 24 
 vomiting in, 25 
 by wet-nurse, 20 
 from maternal breast, 18 
 
 duration of, 18 
 improper, in etiology of acute 
 intestinal indigestion, 
 465 
 in acute milk infection, 478 
 in insanity, 708 
 in tuberculosis, 301 
 mixed. 19 
 Feet, enlargement of, in acro- 
 megaly, 691 
 Fehleisen, streptococcus of, 223 
 Fehling's solution, composition 
 of, 1000 
 qualitative test by, 1000 
 quantitative test by, 1001 
 Femur, changes in, in rachitis, 
 337 
 fracture of, at birth, 85 
 Fenestrated spring forceps for 
 
 circumcision, 1059 
 Fermentation, butyric, 45 
 reaction of, 45 
 intestinal, in litheemia, 97 
 lactic, 45 
 
 bacteria in, 44 
 test for sugar, 1001 
 Ferrum dialysatum in chronic 
 
 tubal nephritis, 1023 
 Fetor in atrophic rhinitis, 834 
 Fever. See Temperature. 
 in rheumatism, 352 
 in scurvy, 392 
 scarlet. See Scarlet fever. 
 typhoid. See Typhoid fever. 
 Fever-blister. See Herpes sim- 
 plex. 
 " Feverish " breath, 7 
 Fibrinous calculus, 1038 
 exudates in scarlatina, 139 
 diagnosis of, from diph- 
 theria. 139 
 pleurisy, 936 
 Fibroid limitation of tubercle, 
 278 
 phthisis. See Phthisis, fibroid. 
 
 Fibrous deposits in chronic 
 tympanic catarrh, 1175 
 nodules in rheumatism, 354, 
 978 
 Fibula, changes in, in rachitis, 
 
 337 
 Fievre dothienenterie, 194 
 infectieuse tuberculeuse sur 
 aigue, 280 
 Filaria sanguinis hominis a 
 cause of chyluria, 995 
 a cause of hsematuria, 993 
 Fish in diabetic diet, 1003 
 Fissure of anus, 586 
 Fistula, fsecal, 576 
 
 after appendicitis, 515 
 in ano, 585 
 
 treatment of, 586 
 of lachrymal sac, 1200 
 Fistulae, perineal, in congenital 
 malformation of rectum, 
 581 
 Flagellate bodies in tertian 
 
 malaria, 306 
 " Flat-chest," 432 
 "Flat-nose," 842 
 Flatulency in chronic intesti- 
 nal indigestion, 468 
 Flesh, loss of, in tuberculous 
 
 meningitis, 611 
 Flour-ball, 51 
 
 preparation of, 24 
 Fluid in hydronephrosis, 1030 
 Fluorescine in diagnosis of cor- 
 neal abrasion, 1197 
 Focal epilepsy, 747 
 symptoms in brain abscess, 
 632 
 Foetal head, compression of, 83 
 
 rachitis, 322 
 Foetus, rachitic, description of, 
 
 330 
 Follicular amygdalitis, diph- 
 theritic nature of, 251 
 trachoma, 1190 
 ulceration of bowel, 481 
 Fontanelle, anterior, ossifica- 
 tion of, 13 
 bruit of, in rachitis, 339 
 bulging of. 13 
 depressed, in chronic gastric 
 
 catarrh, 448 
 in simple atrophy, 505 
 late closure of, in rickets, 331 
 puncture of, in hydroceph- 
 alus, 628 
 Food, average quantity of, for 
 infants, 346 
 daily average of, for children, 
 
 346 
 daily quantity of, 22- 
 in etiology of rachitis, 323 
 insufficiency of, 503 
 in treatment of constipation, 
 499 
 Food and drink admissible in 
 
 diabetes mellitus, 1003 
 Foods, artificial, chemistry of, 
 47 
 comparison of, 52 
 predigested, 29 
 to be avoided in diabetic diet, 
 1003 
 Foramen ovale, patency of, 968 
 
 cause of, 969 
 Forceps, obstetric, injuries 
 from, 83 
 
 Forceps, obstetric, limitations 
 of, 83 
 precautions in using, 83 
 Foreign bodies in auditory 
 canal, 1163 
 treatment of, 1164 
 in caecum or appendix, 509 
 in cornea, 1197 
 in larynx, trachea, and 
 bronchi, 865 
 diagnosis of, 866 
 from acute larvngitis, 
 
 866 
 from laryngeal obstruc- 
 tion by lymphatic en- 
 largement, 867 
 from oedema of glottis, 
 867 
 prognosis of, 867 
 symptoms of, 865 
 treatment of, 867 
 in rectum, 595 
 body, impaction of, in tym- 
 panum, 1165 
 Forest's method of artificial 
 
 respiration, 79 
 Fractures at birth, prognosis 
 and treatment of, 85 
 in utero, 85 
 Frank pneumonia and typhoid 
 fever, differential diag- 
 nosis of, 204 
 Freckles. See Lentigo. 
 Fremitus, hydatid, in renal 
 cysts, 1028 
 vocal, in broncho-pneumonia, 
 908 
 French measles. See Rubella. 
 Fresh air in rachitis, 343 
 
 in tuberculosis, 300 
 Friction in massage, 57 
 Friction-sound in pleurisy, 942 
 
 in pericarditis, 975 
 Friedreich's disease, 815. See, 
 
 also, Ataxia, hereditary. 
 Friedrichshall water in jaun- 
 dice, 547 
 Fromentine in diabetes, 1002 
 Fruehjahr's catarrh, 1189 
 Fruits in diabetic diet, 1003 
 
 in lithaemic diet, 99, 100 
 Fuchsin, Ziehl's solution of, 271 
 Fundus oculi, haemorrhages in, 
 
 in leukaemia, 374 
 Fungus of favus, microscopy 
 of, 1149 
 of tinea tricophytina, 1152 
 Furuncle of auditorv canal, 1161 
 treatment of,' 1125-1161 
 of eyelids, 1178 
 Furunculosis, 1124 
 in chicken-pox, 159 
 in typhoid fever, 199 
 post-eczematous, 1101 
 Furunculus, 1123 
 diagnosis of, 1124 
 from carbuncle, 1124 
 from syphiloderm, 1124 
 etiology of, 1124 
 prognosis of, 1124 
 treatment of, 1124 
 
 Gait in hereditary ataxia, 818 
 
 in idiocy, 674 
 
 in Pott's disease, 1066 
 Gallic acid in diabetes insip- 
 idus, 1006 
 
INDEX. 
 
 1219 
 
 Gallic acid in haemorrhage of 
 
 typhoid fever. '207 
 Galton whistle in diagnosis of 
 
 aural disease, 1176 
 Galvanism in alopecia areata, 
 1137 
 in constipation. 502 
 in diabetes insipidus, 1006 
 in Raynaud's disease, 824 
 Galvano-cautery in lupus, 1142 
 in stomatitis mycosa, 407 
 in ulcer of cornea, 1195 
 -puncture in enlarged tonsils, 
 423 
 Gangrene, diabetic, rarity of, in 
 children. 1000 
 in parotitis, 180 
 in vaccinia. 175 
 of lung. 919 
 etiology of. 919 
 following broncho - pneu- 
 monia, 906-908 
 in tuberculosis, 920 
 pathology, 921 
 symptoms of. 921 
 treatment of, 923 
 with chronic bronchitis, 
 
 920 
 with septic processes of ear, 
 
 920 
 with ulcerations in mouth, 
 920 
 symmetrical, 822. See, also, 
 Raynaud's disease. 
 Gangrenous varicella, 160 
 Gastric catarrh, acute, 441 
 diagnosis of. 444 
 
 from meningitis, 444 
 from pneumonia, 444 
 from scarlet fever, 444 
 from typhoid fever, 444 
 etiology of, 441 
 pathology of, 442 
 prognosis of. 445 
 symptoms of, 443 
 treatment of, 445 
 chronic, 446 
 course of, 449 
 diagnosis of, 449 
 
 from typhoid fever, 450 
 etiology of 446 
 in infancy, 448 
 pathology of, 446 
 prognosis of, 450 
 simulating pernicious anae- 
 mia, 449 
 symptoms of, 447 
 treatment of, 450 
 fever. See Typhoid fever. 
 juice, action of, on milk, 21 
 ulcer, 452 
 
 etiology of, 452 
 prognosis of, 453 
 symptoms of, 452 
 treatment of, 453 
 Gastritis, atrophic, 450 
 
 chronic glandular. See Gas- 
 tric catarrh, chronic. 
 mucous, 450 
 simple, 449 
 Gastro-adenitis, 441 See, also, 
 
 Gastric catarrh, acute. 
 Gastro-intestinal catarrh. See 
 Milk infection, subacute. 
 chronic. See Mucous dis- 
 ease. 
 tuberculosis following, 282 
 
 Gastro-intestinal disorder in eti- 
 ology of eclampsia, 542 
 of laryngismus, 859 
 of urticaria, 1120 
 haemorrhage, 86 
 Gastro-malacia, 453 
 Gavage in dysentery, 492 
 Gelatin, preparation of, 23 
 Gelsemium in chronic bleph- 
 arospasm, 1181 
 General development, 12 
 in health, 12 
 
 of the new-born child, 12 
 management of children, 18 
 Genital organs, involvement 
 
 of, in parotitis, 180 
 Genu valgum, treatment of, 
 
 108S 
 Geratubungen, 55 
 German measles. See Rubella. 
 Germicidal drugs in acute milk 
 
 infection, 479 
 Giant-cells in tubercle, 278 
 Giddiness in brain abscess, 632 
 in cerebro-spinal meningitis, 
 209 
 Girdle sensation in acute mye- 
 litis, 784 
 in tumors of spinal cord, 
 802 
 Glands, anterior mediastinal, 
 tuberculosis of, 284 
 axillary, swelling of, in vac- 
 cinia, 174 
 bronchial, enlargement of, in 
 etiology of bronchitis, 
 925 
 enlargement of, in measles, 
 
 122 
 tuberculosis of, 284 
 cardiac, tuberculosis of, 284 
 disorders of, 1091 
 enlargement of, in lymphatic 
 
 anaemia, 371 
 in rubella, 154 
 
 inguinal, enlargement of, in 
 milk infection, 481 
 swelling of, in vaccinia, 
 174 
 in measles, 120 
 intercostal, tuberculosis of, 
 
 284 
 lymphatic, enlargement of, 
 13 
 in leukaemia, 375 
 mesenteric, tuberculosis of, 
 
 286 
 posterior mediastinal, tuber- 
 culosis of, 284 
 sternal, tuberculosis of 284 
 tracheal, tuberculosis of, 284 
 tracheo-bronchial, tubercu- 
 losis of, 284 
 Glandular enlargements after 
 vaccination, 175 
 in diphtheria, 256 
 with eczema, 1101 
 Glioma of orbit, 1201 
 Gliomata of brain and menin- 
 ges, 635 
 Globus hystericus, 730 
 Gluten-flour in diabetes, 1002 
 Glycerin in diuretic formula?, 
 
 1017 
 Goat's milk in artificial feed- 
 ing, 25 
 Goitre with cretinism, 682 
 
 Gold and sodium chloride in 
 chronic interstitial neph- 
 ritis, 1026 
 Gonococcus, diagnostic value 
 of, 1053 
 of Neisser, 1185 
 value of, in diagnosis of vul- 
 vovaginitis, 1056 
 Gonorrhcea, ante-partum treat- 
 ment of, 88 
 in male children, 1053 
 treatment of, 1054 
 of mouth, in new-born, 88 
 treatment of, 89 
 Gonorrheal infection of new- 
 born, 88 
 ophthalmia, 88 
 Gout, American, 94 
 concealed, 94 
 
 in etiology of psoriasis, 1112 
 
 of vesical calculus, 1039 
 
 Gouty kidney. See Nephritis, 
 
 chronic interstitial, 1025 
 Grand movements, period of, in 
 
 hysteria, 731 
 Granulations of wound after 
 
 tracheotomy, 886 
 Grattage in trachoma, 1191 
 Gravel in bladder, symptoms 
 of, 1008 
 in diabetes insipidus, 1006 
 Green stools in acute intestinal 
 indigestion, 466 
 in chronic intestinal indi- 
 gestion, 468 
 Grippe and typhoid fever, dif- 
 ferential diagnosis of, 
 204 
 Grisolle sign in variola, 167 
 Growing pains, 758 
 Grunting expiration in bron- 
 chitis, 928 
 prognostic importance of, 
 930 
 Gum-lancing, danger of, 413 
 Gumma, 1144 
 of brain, 636 
 of iris, 1198 
 Gummata in hereditary syph- 
 ilis, 646 
 Gummatous iritis, 1198 
 Gums, bleeding of, in scorbutus, 
 391 
 condition of, in tvphoid 
 fever, 199 
 Gymnastics in hysteria, 740 
 in scoliosis, 1064 
 
 Habit chorea, 1181 
 
 due to eye -strain, 1202 
 Habits of life in etiology of 
 
 chlorosis, 362 
 Haeniaternesis in tuberculosis 
 
 of the bowels. 288 
 Haematogenous jaundice. 543 
 
 in new-born. 92 
 Haematoma of sterno-eleido- 
 
 mastoid muscle. 72 
 Haematomata of auricle. 1160 
 Hematuria. 991 
 
 diagnosis ot\ from calculi, 
 ^ 992 
 from cystitis or pyelitis, 
 
 992 
 from hvperanuia of kidney, 
 
 from icteric urine. 991 
 
1220 
 
 INDEX. 
 
 Hseraaturia, diagnosis of, from 
 passive hyperaeniia, 992 
 from tuberculosis of blad- 
 der, 992 
 in acute tubal nephritis, 
 
 1011 
 in malarial fever, 314 
 in scarlatinal nephritis, 
 
 treatment of, 148 
 in scorbutus, 391 
 in tumors of kidney, 1036 
 in vesical calculus, 1042 
 paroxysmal, 994 
 Hsemic murmur in secondary 
 
 anaemia, 361 
 Haemoglobin, excess of, at birth, 
 76 
 percentage of, in chlorosis, 
 
 363 
 proportion of, in infancy, 
 359 
 Haernoglobinuria, acute, of 
 new-born, 92 
 in erysipelas, 227 
 in Eaynaud's disease, 822 
 Haemophilia, 377 
 etiology of, 377 
 hereditary transmission of, 
 
 377 
 morbid anatomy of, 377 
 prognosis of, 378 
 in females, 378 
 treatment of, 378 
 Haemoptysis in chronic pulmo- 
 nary tuberculosis, 295 
 in fibroid phthisis, 965 
 in gangrene of lung, 922 
 in tuberculosis, 277 
 Haemorrhage after tonsillot- 
 omy, 426 
 cerebral, following asphyxia, 
 74 
 following labor, 74 
 forms of, 74 
 during tracheotomy, 881 
 fatal, after gum -lancing, 413 
 
 after tonsillotomy, 426 
 from kidney, 992 
 from mucous surfaces, blood- 
 count in, 82 
 from vagina, 82 
 gastro-intestinal, 86 
 
 pathology of, 87 
 in abscission of the tonsils, 
 
 426 
 in infantile cerebral palsies, 
 
 656 
 in new-born, 73 
 causes of, 74 
 diagnosis of, 74 
 etiology of, 73 
 parenchymatous, 75 
 prophylaxis of, 75 
 intestinal, in scorbutus, 391 
 
 in typhoid fever, 199 
 meningeal, in infantile cere- 
 bral palsies, 655 
 multiple, following umbilical 
 
 infection, 73 
 secondary, after tracheotomy, 
 
 885 
 subperiosteal, in scorbutus, 
 
 480 
 umbilical, 85 
 treatment of, 86 
 Haemorrhages from mucous sur- 
 faces, 82 
 
 Haemorrhages in cirrhosis of 
 liver, 558 
 treatment of, 560 
 in jaundice, 544 
 
 from obliteration of bile- 
 ducts, 546 
 in leukaemia, 374 
 in pertussis, 118 
 in whooping-cough, 116 
 of the skin, 1125 
 punctiform, in pernicious 
 anaemia, 366 
 Haemorrhagic infarcts in ty- 
 phoid fever, 196 
 pleurisy in morbus Werlhofii, 
 936 
 in scurvy, 936 
 Haemorrhoids, 592 
 
 in cirrhosis of liver, 558 
 Hair, falling out of, in typhoid 
 
 fever, 198 
 Halitosis, causes of, 7 
 Hall's method of artificial res- 
 piration, 79 
 Hands, enlargement of, in 
 
 acromegaly, 691 
 Harrison's groove, 326, 335 
 Head, foetal, compression of, 83 
 retraction of, in cerebral 
 meningitis, 599 
 Headache, 718 
 
 diagnosis and prognosis of, 
 
 724 
 etiological varieties of, 723 
 in acute gastric catarrh, 443 
 in acute tubal nephritis, 1011 
 in brain abscess, 632 
 in brain tumors, 636 
 in cerebral meningitis, 599 
 in cerebro-spinal meningitis, 
 
 209 
 in chicken-pox, 151 
 in chronic gastric catarrh, 
 
 447 
 in erysipelas, 225 
 in leukaemia, 374 
 in measles, 119 
 in tuberculous meningitis, 
 
 611, 612 
 in typhoid fever, 197 
 in variola, 164 
 mechanism of, 718 
 persistent, in hereditary 
 
 syphilis, 645 
 treatment of, 725 
 vertical, in chlorosis, 363 
 with tumors of spinal cord, 
 804 
 Headaches due to organic dis- 
 ease, 721 
 from eye-strain, 1202 
 Head-banging, 713 
 Head-louse, 1156 
 Head-nodding and head-jerk- 
 ing, 713 
 Hearing, mechanical aids to, 
 
 1049 
 Heart, congenital affections of, 
 968 
 symptoms of, 973 
 treatment of, 973 
 disease in etiology of chronic 
 gastric catarrh, 991 
 chronic, 981 
 
 clinical history of, 981 
 etiology of, 981 
 prognosis of, 983 
 
 Heart disease, chronic, symp- 
 toms of, 981 
 treatment of, 984 
 functional affections of, 986 
 course of, 989 
 diagnosis of, 989 
 etiology of, 986 
 prognosis of, 989 
 symptoms of, 987 
 treatment of, 989 
 in diphtheria, 254 
 in typhoid fever, 200 
 irregularity of, during sleep, 
 
 987 
 lesions of, in typhoid fever, 
 
 197 
 obstructive lesions of, in 
 etiology of bronchitis, 
 925 
 organic diseases of, 974 
 peculiarities of, in childhood, 
 
 974 
 rapid, 988 
 
 relative weight of, 974 
 slow, 988 
 syphilis of, 106 
 Heart-action, irregularity of, 
 
 in children, 987 
 Heart-consciousness, 988 
 Heat in interstitial keratitis, 
 1197 
 in ophthalmia neonatorum, 
 1187 
 Hebetude in adenoid vegeta- 
 tions, 431 
 Hebrew race, haemophilia in, 
 
 377 
 Height, increase of, in typhoid 
 
 fever, 198 
 Hemianaesthesia in hysteria, 
 733 
 in tumors of crura cerebri, 
 641 
 Hemianopsia in acromegaly, 
 691 
 in brain tumors, 640 
 in hysteria, 733 
 in infantile cerebral palsies, 
 
 651 
 in migraine, 719 
 Hemicrania. See Migraine. 
 Hemiplegia from obstetric 
 injury, 83 
 in hereditary syphilis, 646 
 in typhoid fever, 200 
 Henoch's disease, 384 
 Hepatitis, suppurative, 535 
 diagnosis of. 554 
 prognosis of, 555 
 treatment of, 555 
 with dysentery, 555 
 Hepatogenous jaundice, 543 
 Hereditary ataxic paraplegia, 
 815. See, also, Ataxia, 
 hereditary. 
 syphilis. See Syphilis, hered- 
 itary. 
 Heredity in etiology of cleft 
 palate, 434 
 of diabetes mellitus, 999 
 of eczema, 1102 
 of hysteria, 728 
 of laryngismus stridulus, 
 
 859 
 of leukaemia, 373 
 of lithaemia, 94 
 of myotonia, 688 
 
IXDEX. 
 
 1221 
 
 Heredity in etiology of pemphi- 
 gus. 1115 
 of pseudo-hypertrophic 
 
 paralysis, 771 
 of psoriasis, 1112 
 of rachitis, 323 
 of Raynaud's disease, 823 
 of rheumatism, 351 
 of substantive emphy- 
 sema. 951 
 of tuberculous meningitis, 
 
 610 
 of vesical calculus, 1039 
 Hernia, cecal, 536 
 
 umbilical. 86 
 Herpes facialis. See Herpes 
 simplex. 
 febrilis. See Herpes simplex. 
 iris, 1099 
 
 labialis in croupous pneu- 
 monia, 915 
 of auricle, 1160 
 simplex, 1116 
 zoster, 1116, 1117 
 Herpetic eruptions in tvphoid 
 
 fever, 199 
 High operation in tracheot- 
 omy, 878 
 High-arched palate, 430 
 Hip. congenital dislocation of, 
 
 1082 
 Hip-joint disease, 1072 
 
 abscess in treatment of, 
 
 1076 
 ankylosis from, 1081 
 atrophy in, 1072 
 Buck's extension in, 1074 
 deformity in, 1072, 1073 
 diagnosis of, 1072 
 etiology of, 1072 
 operative treatment of, 1076 
 pain in, 1072 
 pathology of, 1072 
 premonitorv symptoms of. 
 
 13 
 prognosis of, 1074 
 sea-air in, 64 
 symptoms of, 1072 
 Taylor's hip-splint in, 1074, 
 
 * 1075 
 treatment of, 1074 
 Hives, See Urticaria. 
 Hoarseness in chicken-pox, 157 
 
 in laryngeal disease, 6 
 " Holding-breath " spells, 340 
 Holt's rule for changes in 
 formula of modified 
 milk, 55 
 Home modifications of cow's 
 
 milk, 56 
 Hordeolum, treatment of, 1178 
 Horse-pox, vaccination with 
 
 virus of, 173 
 Hot bath in acute tubal neph- 
 ritis, 1015 
 douche in acute middle-ear 
 inflammation, 1168 
 in chronic suppurating 
 
 middle ear, 1171 
 in furuncle of auditory 
 
 canal, 1161 
 in suppurating middle ear, 
 1170 
 Hot-air bath in acute tubal ne- 
 phritis, 1014 
 in scarlatinal nephritis, 
 147 
 
 Huguier's operation, 580 
 Humanized milk. 26, 48 
 
 analysis of, 49 
 Humerus, changes in, in ra- 
 chitis. 336 
 fracture of, at birth, 85 
 " Hunger for oxygen," 76 
 Hunvadi water in jaundice, 
 
 * 547 
 Hutchinson's teeth, 114 
 Hydatid cysts of kidney, 1028 
 diagnosis of, 1029 
 pathologv and symptoms 
 
 of, 1028 
 prognosis of, 1029 
 treatment of, 1029 
 fluid from liver, 542 
 fremitus, 556 
 of liver, 555 
 tumor of omentum, 570 
 Hydremia in etiology of 
 
 ascites, 571 
 Hydragogue cathartics in 
 chronic tubal nephritis, 
 1023 
 Hvdrencephalic cry, descrip- 
 tion of, 6, 612 
 Hydrocephalic idiocy, 671 
 Hydrocephalus, 624 
 duration of, 628 
 etiology of, 625 
 externus, 624 
 in hereditary syphilis, 646 
 intern us, 624 
 morbid anatomy of, 628 
 symptoms of, 626 
 treatment of, 628 
 varieties of, 624 
 with spina bifida, 627 
 Hydrochloric acid, deficiency 
 of, in acute gastric 
 catarrh, 443 
 in cholera, 244 
 with pepsin, in chronic 
 gastric catarrh, 451 
 Hydrogen peroxide in acute 
 follicular tonsillitis, 419 
 in angina of variola, 169 
 in atrophic rhinitis, 836 
 in chronic suppurating 
 
 middle ear, 1171 
 in diphtheria, 264 
 in eczema of auricle, 1161 
 in gonorrhoea of mouth, 89 
 in scarlet fever, 146 
 in whooping-cough, 192 
 Hydronephrosis, 1029 
 diagnosis of, from ascites, 
 1030 
 from ovarian cyst, 1030 
 from pyonephrosis and peri- 
 nephric abscess, 1030 
 from renal cysts. 1030 
 etiologv and pathology of, 
 
 1*029 
 
 prognosis of, 1031 
 
 symptoms of, 1030 
 
 treatment of, 1031 
 
 Hydrophobophobia, 704 
 
 Hyoscine in chorea, 763 
 
 in epidemic cerebrospinal 
 meningitis, 213 
 Hyperesthesia, in acute myel- 
 itis, 784 
 in cerebro-spinal meningitis, 
 
 211 
 in hysteria. 732 
 
 Hyperesthesia in Raynaud's 
 disease, 821 
 in simple cerebro-spinal men- 
 ingitis, 606 
 in tumors of spinal cord, 802 
 in typhoid fever, 200 
 Hyperalgesia in hysteria, 732 
 Hyperidrosis, 1093 
 etiology of, 1093 
 prognosis of, 1094 
 treatment of, 1094 
 Hyper metropia in infancy and 
 
 childhood, 1202 
 Hyperpyrexia in croupous 
 pneumonia, 917 
 in measles, 129 
 in rheumatism of children, 
 
 352 
 in scarlet fever, 137 
 Hypertrophies of skin, 1128 
 Hypertrophy of fingers, 602 
 of right heart in fibroid 
 
 phthisis, 966 
 of tonsils. See Tonsils, hyper- 
 trophy of. 
 Hypodermic administration of 
 mercury in syphilo- 
 derma, 1146 
 puncture in diagnosis of 
 pleural effusion, 944 
 safety of, in pleurisy, 944 
 Hypoderrnoclysis in cholera, 
 
 246 
 Hypophosphites in tuberculo- 
 sis, 301 
 Hypopyon keratitis, 1195 
 Hysteria, 727 
 diagnosis of, 739 
 from epilepsy, 739 
 from organic paralysis, 740 
 etiology of, 728 
 interparoxysmal symptoms 
 
 of, 732 
 paroxysmal symptoms of, 729 
 statistics of, in children, 728 
 symptoms of, 729 
 treatment of, 740 
 Hysterical headache, 724 
 Hystero-epilepsy, 730 
 
 Ichthyol in chicken-pox, 161 
 Ichthyosis, 1128 
 
 diagnosis of, 1129 
 
 etiology of, 1129 
 
 hystrix, 1128 
 
 prognosis of, 1129 
 
 simplex, 1128 
 
 treatment of, 1129 
 Icterus neonatorum, 87 
 
 physiological, of new-born, 
 87 
 Idiocy, 648, 667 
 
 accidental, 671 
 
 classification of, 670 
 pathological, 676 
 
 congenital, 670 
 
 developmental, 670 
 
 diagnosis of. 676 
 
 etiology of. 673 
 
 from hydrocephalus. 626 
 
 from obstetric injury. 83 
 
 legal definitions of, 668 
 
 pathology of, 675 
 
 prognosis o(. ti?7 
 
 symptoms of. t>74 
 
 treatment of. 677 
 Idiotic myxoedermateuse, 684 
 
1222 
 
 INDEX. 
 
 Idiots savants, 670 
 Iguipuncture in enlarged ton- 
 sils, 423 
 Ileal intussusception, 517 
 Ileo-csecal intussusception, 517 
 
 valve in typhoid fever, 196 
 Ileo-colic intussusception, 517 
 Ileo-colitis. See Dysentery. 
 Ileum, changes in, in typhoid 
 
 fever, 196 
 Ill-temper in tuberculous men- 
 ingitis, 611, 616 
 Imbecility, 667, 668 
 Immunity, artificial, in cholera, 
 234 
 in tuberculosis, 277 
 personal, from cholera, 234 
 Imperative acts or movements, 
 703 
 movements, etiology of, 716 
 diagnosis of, 716 
 in defective children, 712 
 prognosis of, 716 
 treatment of, 717 
 Impetigo contagiosa, 1117 
 after vaccination, 175 
 diagnosis of, 1119 
 etiology of, 1118 
 prognosis of, 1119 
 relation of, to vaccinia, 
 
 1119 
 treatment of, 1119 
 Improper feeding in etiology of 
 acute gastric catarrh, 
 441 
 Incision and drainage in peri- 
 tonitis, 567 
 in furuncle of auditory canal, 
 
 1161 
 in perinephritic abscess, 1034 
 in pleural effusion, 947 
 
 disadvantage of, 947 
 in treatment of hydatid of 
 liver, 557 
 of hydatids of kidney, 
 1029 
 of drum-membrane, 1168 
 in suppurating middle ear, 
 1170 
 Incisions in operations for ap- 
 pendicitis, 514 
 Incontinence of urine, 996 
 in lithsemia, 96 
 in tuberculous meningitis, 
 
 618 
 spontaneous cure of, at 
 
 puberty, 996 
 treatment of, 997 
 Incubator, Auvard's, 80 
 Indigestion, acute intestinal, 
 465 
 etiology of, 465 
 prognosis of, 466 
 synonyms of, 465 
 treatment of, 466 
 chronic intestinal, 467 
 diagnosis of, 469 
 etiology of, 467 
 prognosis of, 468 
 synonyms of, 467 
 treatment of, 470 
 of infants, dietetic treatment 
 of, 29 
 Indigo calculus, 1038 
 Indolent corneal ulcers, 1194 
 Infancy, duration of, 1 
 Infantile cerebral palsies, 649 
 
 Infantile osteomalacia and cre- 
 tinism, 682 
 paralysis, sea-air in, 65 
 remittent fever, 194 
 Infants, chronic constipation 
 in, 497 
 nursing, wasting in, 504 
 vaccination of, 176 
 Infants' food, value of, 22 
 Infarcts, hemorrhagic, in ty- 
 phoid fever, 196 
 Infection by tubercle bacilli in 
 milk, 286 
 in utero, 73 
 
 by tubercle bacilli, 90 
 
 by typhoid bacilli, 90 
 
 modes of, in cholera, 234 
 
 in measles, 117 
 of tracheotomy wound, 885 
 of typhoid fever by water, 
 
 195 
 septic, of new-born, 89 
 through umbilicus, 89 
 prophylaxis of, 89 
 treatment of, 89 
 tubercular, of new-born, 90 
 
 dog's serum in, 91 
 typhoid, of new-born, 90 
 Infections attacking the new- 
 born, 88 
 of blood in new-born, 92 
 Infectious diseases in etiology 
 of pleurisy, 938 
 with parotitis, 179 
 Inflammation in intussuscep- 
 tion, 521 
 sympathetic, of eye, 1199 
 Inflammations of skin, 1095 
 Inflammatory phenomena in, 
 
 vaccination, 175 
 Influenza, epidemic, 214 
 bacteriology of, 214 
 circulatory symptoms in, 216 
 clinical history of, 216 
 complications and sequelae of, 
 
 217 
 convalescence from, 219 
 definition of, 214 
 diagnosis of, 218 
 from bronchitis, 218 
 from meningitis, 218 
 from pneumonia, 218 
 from simple catarrh, 218 
 from typhoid fever, 218 
 disinfection in, 218 
 etiology of, 214 
 gastro-intestinal symptoms 
 
 in, 217 
 incubation of, 215 
 in etiology of bronchitis, 
 
 924 
 in infants, 215 
 loss of weight in, 216 
 nervous symptoms in, 217 
 pathology of, 215 
 prognosis and mortality of, 
 
 218 
 respiratory symptoms in, 
 
 216 
 treatment of, 219 
 with parotitis, 180 
 Infusoria in gangrene of lung, 
 
 921 
 Injections in gonorrhoea, 1054 
 in intussusception, 521 
 intravascular, in cholera, 
 247 
 
 Injuries, obstetric, medico-legal 
 aspect of, 83 
 treatment of, 84 
 Innutrition in etiology of bron- 
 chitis, 925 
 Insanity, 697 
 cataleptic, 701 
 choreic, 700 
 
 circular or alternating, 700 
 diagnosis of, 707 
 differences of, in child and 
 
 adult, 697 
 epileptic, 701 
 general etiology of, 707 
 hysterical, 700 
 in children, 697 
 in infants, 697 
 moral, 702 
 
 treatment of, 710 
 primary delusional, 702 
 prognosis of, 708 
 treatment of, 708 
 varieties of, in children, 698 
 Insistent idea, 703 
 Inspection of chest, 15 
 Inspiration of amniotic liquid, 
 
 76 
 Inspiration-pneumonia, 76, 91 
 Inspiratory dyspnoea, 10 
 causes of, 10 
 theory of compensatory em- 
 physema, 950 
 of substantive emphysema, 
 952 
 Instillations into auditory 
 
 canal, 1169 
 Instinctive perversions, 702 
 Insufflation, mouth-to-mouth, 
 
 79 
 Internal ear, affections of, 1175 
 rarity of, in children, 1175 
 Interruption of stream in vesi- 
 cal calculus, 1042 
 Interstitial emphysema, 950 
 keratitis. See Keratitis, in- 
 terstitial. 
 pneumonia. See Phthisis, 
 fibroid. 
 Intertrigo in simple atrophy, 
 
 505 
 Intestinal antiseptics in dysen- 
 tery, 492 
 in mucous disease, 459 
 in typhoid fever, 206 
 catarrh, chronic. See Indi- 
 gestion, chronic intestinal. 
 lavage in acute milk infec- 
 tion, 477 
 lesion in typhoid fever, 196 
 parasites. See Parasites, in- 
 testinal. 
 Intestine, large, abscess of, 583 
 Intestines, chronic diffuse tu- 
 berculosis of, 282 
 congenital malformations of, 
 
 575 
 tuberculosis of, 286 
 Intravascular injections in 
 
 cholera, 247 
 Intubation of larynx, 891 
 
 accidents during and after, 
 
 895 
 after-treatment of, 896 
 feeding after, 896 
 indications for, 891 
 in spasmodic laryngitis, 
 856 
 
INDEX. 
 
 1223 
 
 Intubation of larynx in steno- 
 sis of larynx, 898 
 instruments for. 892 
 position of patient for, 894 
 preparations for, 893 
 prognosis in, 891 
 technique of, 894 
 unfavorable cases for, 898 
 Intubation-tubes, disinfection 
 of, 897 
 removal of. S97 
 Intussusception, 517 
 chronic, 520 
 diagnosis of, 520 
 from appendicitis, 520 
 from colic, 520 
 from dysentery, 520 
 from enteritis, 520 
 from faecal impaction, 520 
 from internal strangula- 
 tion, 520 
 from suppurative peritoni- 
 tis, 520 
 etiology of, 518 
 irreducible, 518 
 locality of, 517 
 morbid anatomy of, 518 
 prognosis of, 520 
 symptoms of, 519 
 treatment of, 521 
 Intussusceptions, double, 517 
 
 triple, 517 
 Intussusceptum, 517 
 Intussuscipiens. 517 
 Invagination of bowel. See 
 
 Intussusception. 
 "Inward spasms" in simple 
 
 atrophy, 506 
 Iodide of iron in bronchial 
 catarrh of rachitis, 347 
 of potassium in hydroceph- 
 alus, 628 
 in syphilis, 116 
 in tuberculous meningitis, 
 623 
 Iodides in amyloid kidney, 
 1025 
 in rheumatic pleurisy, 357 
 Iodine in acquired labyrinthine 
 deafness, 1176 
 in chronic peritonitis, 569 
 in lupus vulgaris, 1140 
 Iodine-test in amyloid kidney, 
 
 1024 
 Iodoform in scrofuloderma, 1143 
 in tuberculosis, 301 
 ointment in chicken-pox, 161 
 Ipecacuanha in bronchitis, 932 
 in broncho-pneumonia, 910 
 in congestion of liver, 551 
 in constipation, 500 
 in jaundice, 548 
 in spasmodic laryngitis, 851 
 Iris and ciliary body, diseases 
 of, 1197 
 and ciliarv region, injuries 
 of, 1198 
 Iritis, 1198 
 
 in hereditary syphilis, 112 
 treatment of, 1198 
 Iron in anaemia after malarial 
 fever, 318 
 in chicken-pox, 161 
 in chlorosis, 364 
 in chronic heart disease, 957 
 in convalescence of mucous 
 disease, 462 
 
 Iron in convalescence of rheu- 
 matism, 357 
 in lymphatic anaemia, 372 
 in phthisis, 302 
 in purpura hemorrhagica, 
 
 383 
 in secondary anaemia, 361 
 in splenic anaemia, 370 
 in syphilis, 116 
 in variola, 170 
 
 iodide, syrup of, in chronic 
 peritonitis, 569 
 in lymphatism, 433 
 Irregular remittent fevers, 312. 
 See Remittent fevers, irreg- 
 ular. 
 Irrigation in diphtheritic dys- 
 entery, 495 
 in naso - pharyngeal diph- 
 theria, 263 
 intestinal, in dysentery, 493 
 in subacute milk infection, 
 
 483 
 method of, 494 
 of bowel in mucous disease, 
 
 460 
 of pleural cavity after resec- 
 tion, 948 
 of stomach in mucous dis- 
 ease, 460 
 Irritability in tuberculous men- 
 ingitis, 611 
 Irritation, sympathetic, of eye, 
 
 1199 
 Ischio-rectal abscess, 588 
 Ischuria, hysterical, 735 
 Italians, frequency of rachitis 
 
 among, 320 
 Itch. See Scabies. 
 Itching about anus with seat- 
 worms, 530 
 in eczema, 1101 
 in jaundice, 543 
 treatment of, 548 
 Itch-mite, 1158 
 
 Jaborandi in acute tubal 
 nephritis, 1014 
 in erysipelas, 228 
 in scarlatinal nephritis, 147 
 Jackson ian epilepsy, 747 
 Jacobi on origin of calculi, 95 
 Jalap in scarlatinal dropsy, 148 
 Jambul in diabetes mellitus, 
 
 1005 
 Japanese, non-occurrence of 
 
 rachitis among, 324 
 Jaundice, 543 
 diagnosis of, 544 
 from Addison's disease, 
 
 544 
 from chlorosis, 544 
 from malaria, 544 
 from pernicious anaemia, 
 544 
 due to congenital obliteration 
 
 of bile-ducts, 545 
 epidemic, 545 
 etiology of, 543 
 following acute gastric ca- 
 tarrh, 444 
 from inflammation of umbil- 
 ical vein, 545 
 haematogenic, in new-born, 
 
 92 
 in childhood, 547 
 in cirrhosis of liver, 558 
 
 Jaundice in croupous pneumo- 
 nia, 917 
 in hydatid of liver, 556 
 in new-born, 544 
 in Eaynaud's disease, 823 
 in Winckel's disease, 546 
 simple, in infants, 543, 544 
 Jejunal intussusception, 517 
 Jellies in diabetic diet, 1003 
 Joint affection in rheumatism, 
 352 
 disease, chronic, 1071 
 
 old, deformities from, 1081 
 tuberculous, 1072 
 swelling in haemophilia, 377 
 Juvenile dementia from hered- 
 itary syphilis, 706 
 myxoedema, 684 
 
 Kaposi's disease, 1137 
 Katatonia, 701 
 Keratitis, interstitial, 1096 
 in late hereditary syphilis, 
 
 115 
 symptoms of, 1096 
 treatment of, 1097 
 punctata, 1098 
 purulent, 1094 
 Kerato- conjunctivitis, phlyc- 
 tenular, 1092 
 etiology of, 1092 
 symptoms of, 1093 
 treatment of, 1093 
 Kidney, amyloid disease of. 
 See Amyloid disease of 
 kidney. 
 complications of, in chicken- 
 pox, 159 
 congenital cystic degenera- 
 tion of, 1027 
 hydatid cysts of, 1028 
 in diphtheria, 254 
 in malarial fever, 309 
 in rachitis, 327 
 in scarlet fever, 135 
 in typhoid fever, 197 
 large fatty, 1021 
 large white, 1021 
 lesions of, in cholera, 239 
 
 in diabetes mellitus, 999 
 tumors of. See Tumors of 
 kidney. 
 Kidneys, chronic diffuse tuber- 
 culosis of, 282 
 syphilis of, 106 
 tuberculosis of, 298 
 "Kink" of whooping-cough, 
 
 186 
 Klebs-Loffier bacillus, relations 
 of, to diphtheria, 251, 266 
 Kleptomania, 703 
 Knapp's roller-forceps, 1191 
 Knee-jerk in hereditarv ataxia, 
 817 
 in Pott's disease, 1066 
 Knee-joint disease, 1076 
 ankylosis from, 1081 
 diagnosis of, 1077 
 etiology of. 107t> 
 operative treatment of, 
 
 1079 
 pathology of, 107? 
 prognosis of, 1078 
 symptoms ot\ 1077 
 Thomas's splint in. 1078, 
 
 1079 
 treatment of, 1078 
 
1224 
 
 INDEX. 
 
 Knock -knee, brace for, 1089 
 treatment of, 1088 
 
 Koplik's eruption in measles, 
 120 
 
 Koster's theory of congenital 
 cystic degeneration of 
 kidney, 1027 
 
 Kousso against taeniae, 537 
 
 KrulPs method in jaundice, 
 548 
 
 Kussmaul's apparatus for irri- 
 gating stomach, 560 
 
 Kyphosis, 334 
 
 in syringomyelia, 813 
 
 Labor, precipitate, injuries 
 
 from, 84 
 Labyrinth, formation of, 1158 
 Labyrinthine lesion in total 
 
 deafness, 1176 
 Lachrymal abscess, 1200 
 apparatus, disease of, 1199 
 gland, abscess of, 1199 
 
 inflammation of, 1199 
 sac and duct, diseases of, 1199 
 sac, fistula of, 1200 
 Lactalbumin, 46 
 Lactation, commencement of, 
 
 18 
 Lactic acid, decomposition of, 
 45 
 in cholera, 244 
 in etiology of rheumatism, 
 
 351 
 'presence of, in acute gas- 
 tric catarrh, 443 
 Lactic-acid theory of rachitis, 
 
 324 
 Lactophenin in typhoid fever, 
 
 206 
 Lactose, digestion of, 44 
 in human milk, 44 
 properties of, 44 
 Lacunae of bone, 328 
 Lagophthalmos, 1182 
 Lamellar cataract. See Cata- 
 ract, congenital. 
 Landry's paralysis, 798 
 Laparotomy for perforation in 
 typhoid fever, 207 
 in intussusception, 522 
 Lardaceous disease, 1024. See, 
 also, Amyloid disease of 
 kidney. 
 Laryngeal obstruction, 258 
 symptoms of, 268 
 in diphtheria, 258 
 Laryngismus stridulus, 857 
 complications of, 862 
 course and duration of, 861 
 diagnosis of, 862 
 
 from bilateral paralysis 
 of glottis-dilators. 862 
 from spasmodic laryn- 
 gitis, 862 
 etiology of, 858 
 in hereditary syphilis, 645 
 in rachitis, 340 
 paroxysm of, described, 
 
 861 
 pathology of, 860 
 j)rognosis of, 862 
 relation of, to tetany, 857 
 symptoms of, 860 
 synonyms of, 857 
 treatment of, 862 
 Laryngitis, catarrhal, 844 
 
 Laryngitis, catarrhal, etiology 
 of, 845 
 in broncho-pneumonia, 845 
 in pulmonary phthisis, 845 
 in typhoid fever, 845 
 pathology of, 845 
 eatarrhalis simplex, 846 
 complications of, 847 
 diagnosis of, 847 
 prognosis of, 847 
 treatment of, 847 
 diphtheritic, tracheotomy in, 
 
 873 
 in measles, 124 
 spasmodic, 848 
 diagnosis of, 850 
 
 from laryngismus strid- 
 ulus, 850 
 from true croup, 850 
 severe, 852 
 course of, 853 
 symptoms of, 852 
 treatment of, 854 
 prophylactic, 856 
 symptoms of, 848 
 treatment of, 850 
 suffocative, in chicken-pox, 
 159 
 Laryngotomy in treatment of 
 foreign bodies in larynx 
 and trachea, 868 
 Laryngo-tracheotomy in treat- 
 ment of foreign bodies 
 in larynx and trachea, 
 868 
 Larynx, ascarides in, 527 
 Lassar's paste, 1107 
 
 modification of, 1096 
 Lateral lithotomy, 1049 
 Lausedat's drops, 245 
 Lavage of stomach in cholera, 
 248 
 in chronic gastric catarrh, 
 451 
 Laxatives in lithaemia, 101 
 in pleurisy, 946 
 in subacute milk infection, 
 483 
 Lead, acetate of, in cholera, 246 
 Leeches in peritonitis, 566 
 in typhlitis, 513 
 in uraemic convulsions, 1016 
 Lentigo, etiology of, 1128 
 
 treatment of, 1128 
 Leptomeningitis, acute spinal, 
 779 
 diagnosis of, 780 
 
 from hemorrhage, 780 
 from myelitis, 780 
 from tetanus, 780 
 from tetany, 780 
 etiology of, 779 
 pathology of, 779 
 treatment of, 781 
 chronic cerebral, 600 
 
 spinal, 781 
 simple. See 3Ieningitis, simple. 
 subacute cerebral, 600 
 Letzerich's bacillus, 382 
 Leucocytosis in hereditary 
 
 syphilis, 110 
 Leucoderma, 1135 
 diagnosis of, 1135 
 from morphoea, 1132 
 from nerve-leprosy, 1136 
 from partial albinism, 1135 
 etiologv of, 1135 
 
 Leucoderma, prognosis of, 1136 
 
 treatment of, 1136 
 Leucoma, 1195 
 Leukaemia, 373 
 diagnosis of, 375 
 
 from pseudo-leukaemia, 375 
 from scrofulosis, 375 
 from splenic anaemia, 375 
 etiology of, 373 
 morbid anatomy of, 375 
 prognosis of, 376 
 treatment of, 376 
 Leyden's crystals in asthma, 
 
 957 
 Lichen planus, 1110 
 diagnosis of, 1111 
 prognosis of, 1111 
 treatment of, 1111 
 scrofulosorum, 1142 
 tropicus, 1094. See Miliaria. 
 urticatus, relation of, to ec- 
 zema, 1120 
 Lids, eczema of, 1110 
 
 phtheiriasis of, 1180 
 Liebig's foods, analysis of, 51 
 preparation of, 41 
 with milk, analysis of, 52 
 Ligaments, changes in, in 
 
 rachitis, 326 
 Lime, saccharated solution of, 
 
 formula for, 23 
 Linimentum exsiccans, 1107 
 Lipoma of peritoneum, 570 
 Lippitudo, 1179 
 Lips, condition of, in tvphoid 
 
 fever, 197, 199 
 Liquor potassee in acid lithi- 
 
 asis, 1009 
 Lithaemia, 94 
 alloxuric bodies as a cause of, 
 
 94 
 convulsions in, 97, 98 
 diet in, 99 
 eclampsia in, 98 
 eczema in, 99 
 etiology of, 94 
 exercise in, 100 
 gastric pain in, 96 
 gastro-enteric symptoms in, 
 96 
 in functional heart affec- 
 tions, 990 
 inactivity as a cause of, 94 
 incontinence of urine in, 96 
 influence of heredity in, 94 
 intestinal fermentation in, 
 
 97 
 mother's milk in, 99 
 migraine in, 98 
 nausea in, 96, 97 
 nervous symptoms in, 97 
 painful urination in, 95 
 pelvic disease in, 100 
 precocity in, 97, 98 
 reflex factors in, 100 
 sick headache in, 98 
 symptoms of, 95 
 temperature in, 97 
 treatment of, 99 
 uric acid as a cause of, 95 
 urine in, 96, 99 
 vomiting in, 96, 97 
 of blood in, 97 
 Lithaemic eczema, 99 
 Lithia in treatment of vesical 
 
 calculus, 1045 
 Lithia-water in lithaemia, 101 
 
INDEX. 
 
 1225 
 
 Lithiasis. 1006. 1007 
 diagnosis of, 1009 
 etiology of. 100S 
 prognosis. 1009 
 treatment of, 1009 
 Lithie acid in the blood, 94 
 Lithium benzoate in lithaernia, 
 101, 102 
 carbonate in diabetes mel- 
 
 litus. 1004 
 citrate in lithaeniia, 102 
 Litholapaxy. 1046 
 advantages of. 1050 
 conclusions regarding, 1051 
 in females. 1052 
 Lithotomy. 1046 
 lateral, 1049 
 
 emasculation after, 1049 
 median, 1049 
 suprapubic. 104S 
 
 in females. 1052 
 vaginal. 1052 
 Lithuria. 94 
 Littre's operation, 580 
 Liver, amyloid disease of, 551 
 diagnosis of. 552 
 symptoms of, 552 
 treatment of, 552 
 apparent enlargement of, 541 
 chronic diffuse tuberculosis 
 
 of, 282 
 cirrhosis of, 558 
 diagnosis of, 559 
 etiology of, 288 
 treatment of, 559 
 congestion of, 549 
 diseases of, 538 
 
 compared with adults, 538 
 diagnosis of, 541 
 general etiology of, 538 
 general symptomatology 
 
 of, 539 
 physical examination in, 
 540 
 enlarged, diagnosis of, from 
 
 tumor of kidney, 542 
 fatty, 551 
 
 treatment of, 551 
 hydatid of, 555 
 diagnosis of, 557 
 
 from pleural effusion, 557 
 prognosis of, 557 
 treatment of, 557 
 in infancy and childhood, 
 
 540 
 in pernicious anaemia, 367 
 
 malaria, 309 
 in rachitis, 326 
 in typhoid fever, 203 
 lesions of, in cholera, 239 
 in diphtheria, 254 
 in typhoid fever, 196 
 operative exploration of, 542 
 palpation of, 541 
 passive congestion of, 540 
 percussion of, 541 
 pus from, 542 
 
 syphilitic inflammation of, 
 106, 552 
 diagnosis of, 553 
 treatment of, 553 
 tuberculosis of, 288 
 Liver-dulness, superior border 
 
 of, 16 
 Local applications in erysipe- 
 las, 229 
 asphyxia, 821 
 
 Local asphyxia and symmetri- 
 cal gangrene. See Ray- 
 naud's disease. 
 syncope, 821 
 
 treatment of pertussis, 192 
 Localizing symptoms of brain 
 
 tumors, 637 
 Locomotor ataxia in hereditary 
 syphilis, 647 
 with syringomyelia, 813 
 Lordosis in double congenital 
 dislocation of hip, 1082 
 in Pott's disease, 1066 
 in pseudo-hypertrophic paral- 
 ysis, 769 
 in syringomyelia, 813 
 Lotions in eczema, 1106 
 Low operation in tracheotomy, 
 
 876 
 Lumbar nephrotomy for pyo- 
 nephrosis, 1032 
 pain in acute tubal nephritis, 
 
 1011 
 puncture for hydrocephalus, 
 628 
 Lung, abscess of, 923 
 fibroid induration of. See 
 
 Phthisis, fibroid. 
 gangrene of, 919 
 Lungs, cirrhosis of. See Phthi- 
 sis, fibroid. 
 congestion of, in typhoid 
 
 fever, 197 
 hypostatic congestion of, in 
 subacute milk infection, 
 481 
 lesions of, in diphtheria, 254 
 
 in pernicious malaria, 309 
 syphilis of, 105 
 tuberculosis of, 292 
 Lupus hypertrophicus, 1140 
 serpiginosus, 1140 
 verrucosus, 1140 
 vulgaris, 1139 
 diagnosis of, 1140 
 etiology of, 1140 
 prognosis of, 1140 
 treatment of, 1140 
 Luschka's tonsil, 428 
 Lustgarten, bacillus of, in 
 
 syphilis, 103 
 Lymphadenitis, retropharyn- 
 geal. See Retropharyn- 
 geal abscess. 
 tracheotomy for, 427 
 Lymphadenoma of kidney, 
 
 1035 
 Lymphatic anaemia. See 
 Anaemia, lymphatic. 
 glands, enlargement of, 13 
 Lymphatism in chronic follic- 
 ular pharyngitis, 418 
 in hypertrophy of tonsils, 
 418 
 Lymphocytes, 278 
 Lysis in typhoid fever, 202 
 
 Mackenzie's astringent mixt- 
 ure, 426 
 
 Macrocephalic idiocy, 671 
 
 Macula of cornea, 1195 
 
 Magnesium carbonate in consti- 
 pation, 499 
 citrate in constipation, 499 
 
 Malaria and typhoid fever, dif- 
 ferential diagnosis of, 
 204 
 
 Malaria in etiology of anaemia, 
 360 
 of leukaemia, 373 
 of urticaria, 1120 
 Malarial cachexia, 313 
 
 morbid anatomy of, 309 
 fever, 303 
 
 aestivo-autumnal type of, 
 312 
 parasites of, 307 
 conditions favorable to, 
 
 303 
 course and prognosis of, 
 
 317 
 diagnosis of, 315 
 
 from tuberculosis, 315 
 etiology and pathology of, 
 
 303 
 examination of blood in, 
 
 366 
 geographical distribution 
 
 of, 303 
 morbid anatomy of, 306 
 pernicious, 314 
 prophylaxis of, 317 
 quartan, parasite of, 366 
 quotidian or double tertian, 
 
 311 
 relation of types of, to 
 
 types of organism, 304 
 specific micro-organism of, 
 
 304 
 symptoms of, 309 
 synonyms of, 303 
 tertian intermittent type 
 of, 310 
 parasite of, 304 
 peculiarities of, in voung 
 
 children, 311 
 temperature in, 310 
 time of paroxysm of, 
 312 
 treatment of, 317 
 visceral affections asso- 
 ciated with, 314 
 with typhoid, 315 
 haematuria, 992 
 haemoglobinuria, theories of, 
 
 992 
 infection in Eavnaud's dis- 
 ease, 823 
 Male fern against taeniae, 537 
 Malformations, congenital, 84 
 diagnosis of, 85 
 simulating fracture, 84 
 of intestines, congenital, 575 
 causes of, 576 
 diagnosis of, 576 
 prognosis of, 576 
 treatment of, 576 
 of rectum and anus, congen- 
 ital. 577 
 pathology of, 57? 
 Malignant growths in caecum, 
 516 
 measles, 128 
 Maltose, 45 
 Malt-sugar. 46 
 Management of children, 18 
 at sea-shore. 67 
 bathing in. 32 
 clothing in. 34 
 exercise in. 35 
 feeding in. 18 
 sleep in. 34 
 Mania. 699 
 after influenza, 218 
 
1226 
 
 INDEX. 
 
 Mania, homicidal, 703 
 
 moral, 703 
 Marasmus. See Atrophy, sim- 
 ple. 
 Marginal abscess, 587 
 
 keratitis, 1193 
 Marie's disease, 600. See Acro- 
 megaly. 
 Markoe's wry-neck face, 1063 
 Marrow of bone, 328 
 
 of long bones in lymphatic 
 anaemia, 372 
 Massage in constipation, 518 
 in incontinence of urine, 969 
 in pseudo-hypertrophic mus- 
 cular paralysis, 773 
 in scoliosis, 1064 
 in simple jaundice of in- 
 fants, 561 
 of cornea, 1140 
 Mastitis in new-born, 91 
 Mastoid tenderness in suppu- 
 ration of the middle ear, 
 1169 
 Masturbation from seat-worms, 
 
 530 
 Masturbational insanity, 706 
 
 treatment of, 710 
 Maternal influence in hered- 
 itary syphilis, 104 
 Maxillae, changes in, in rachi- 
 tis, 334 
 McBurney's point in typhlitis, 
 
 510 
 Measles, 117-130 
 black, 123 
 
 complications of, 123 
 decline of, 122 
 definition of, 117 
 diagnosis of, 124 
 from acute catarrh, 124 
 from eczema, 125 
 from rubella, 125 
 from scarlatina, 125 
 from syphilitic roseola, 125 
 from variola. 125 
 eruption of, 120 
 etiology of, 117 
 experimental inoculation of, 
 
 117 
 hybrid. See Rubella. 
 incubation of, 118 
 in etiology of bronchitis, 924 
 of chronic tubal nephritis, 
 1019 
 malignant, 123, 128 
 modified forms of, 123 
 morbid anatomy of, 118 
 mortality of, 126 
 prognosis of, 125, 126, 
 quarantine in, 130 
 relapses and second attacks 
 
 of, 126 
 sequelae of, 124 
 symptoms of, 119 
 treatment of, 126 
 with pertussis, 208 
 with whooping-cough, 124 
 without catarrh, 123 
 without interruption, 123 
 Meats in diabetic diet, 1003 
 
 in lithsemic diet, 99 
 Mechanism of paroxysms of 
 spasmodic laryngitis, 849 
 Meckel's diverticulum, 575 
 in intussusception, 517 
 Meconium, vomiting of, 576 
 
 Median lithotomy, 1049 
 Melsena in tuberculosis of the 
 bowels, 288 
 neonatorum, 92 
 
 ulcer of duodenum in, 92 
 Melancholia, 699 
 agitated, 699 
 in typhoid fever, 200 
 treatment of, 709 
 Meniere symptoms in internal 
 
 ear disease, 1176 
 Meninges, involvement of, in 
 chronic suppuration of 
 middle ear, 1173 
 Meningitis, basilar. See Men- 
 ingitis, tubercular. 
 following operation, 598 
 cerebral, simple, 596 
 diagnosis of, 601 
 from cerebral pneu- 
 monia, 601 
 from middle-ear dis- 
 ease, 601 
 from pyaemia, 602 
 from tubercular men- 
 ingitis, 601 
 from typhoid fever, 602 
 etiology of, 596 
 morbid anatomy of, 597 
 prognosis of, 602 
 symptoms of, 598 
 treatment of, 602 
 cerebro-spinal, simple, 605 
 diagnosis of, 607 
 from tetanus, 608 
 from tubercular, 608 
 from typhoid fever, 
 608 
 distinguished from cere- 
 bro-spinal fever, 605 
 etiology of, 605 
 prognosis of, 608 
 symptoms of, 605 
 treatment of, 608 
 of Pott's disease, 1065 
 pneumonic lesions in, 598 
 spinal, 777 
 syphilitic, diagnosis of, from 
 
 tubercular, 646 
 tuberculous, 610 
 
 and typhoid fever differen- 
 tial diagnosis of, 204 
 diagnosis of, 619 
 
 from pain tumor, 619 
 from gastro-intestinal 
 
 disorder, 619 
 from hysteria, 619 
 from infantile convul- 
 sions, 619 
 from pneumonia, 620 
 from typhoid fever, 619 
 duration of, 619 
 etiology of, 610 
 in Pott's disease, 1067 
 morbid anatomy of, 620 
 prognosis, 618 
 symptoms, 611 
 with parotitis, 179 
 Mental changes in brain 
 tumor, 677 
 in tuberculous meningitis, 
 615 
 symptoms of hvdrocephalus, 
 626 
 Menthol in tuberculosis, 302 
 Mercurial ointment in peri- 
 tonitis, 566 
 
 Mercurial stomatitis, resem- 
 blance of, to stomatitis 
 ulcerosa, 402 
 Mercurials in diphtheria, 262 
 Mercuric chloride in chronic 
 interstitial nephritis, 
 1026 
 in ophthalmia neonato- 
 rum, 1187 
 Mercuric-chloride baths in 
 syphiloderma, 1146 
 solution in corneal ulcer, 
 1195 
 Mercury in acquired laby- 
 rinthine deafness, 1176 
 in acute myelitis, 787 
 in acute spinal leptomenin- 
 gitis, 781 
 in cerebral meningitis, 603 
 in chronic peritonitis, 569 
 in hereditary syphilis, 115 
 in hydrocephalus, 628 
 in interstitial keratitis, 1200 
 in syphiloderma, 1146 
 Mesenteric glands, chronic dif- 
 fuse tuberculosis of, 282 
 lesions of, in typhoid fever, 
 
 196 
 swelling of, in tvphoid 
 
 fever, 196 
 tuberculosis of, 286 
 Mesenteron, 577 
 Methylene blue, Gabbet- 
 Ernst's solution of, 271 
 in malaria, 318 
 Microcephalic idiocy, 673 
 Micrococci in meconium, 472 
 Micrococcus of Fehleisen, 90 
 Micro-organisms in etiology 
 of eczema, 1103 
 in measles, 118 
 in spinal fluid in acute lepto- 
 meningitis, 779 
 in whooping-cough, 184 
 Micturition, frequent, in dia- 
 betes mellitus, 999 
 in gravel, 1008 
 in hydronephrosis, 1030 
 in vesical calculus, 1170 
 painful, causes of, 9 
 Middle ear, acute simple in- 
 flammation of, 1166 
 diagnosis of, 1168 
 acute suppurative inflam- 
 mation of, 1169 
 symptoms of, 1169 
 affections of, 1166 
 chronic catarrh of, 1174 
 chronic suppuration of, 
 
 1170 
 stages of inflammation of, 
 1168 
 Migraine, 719 
 diagnosis of, 720 
 etiology of, 720 
 in lithsemia, 98 
 pathology of, 720 
 treatment of, 720 
 Miliaria, 1094 
 crystallina, 1094 
 diagnosis of, 1095 
 
 from eczema papulosum,, 
 
 1095 
 from varicella, 1095 
 from vesicular eczema. 
 1094 
 etiology of, 1095 
 
IXDEX. 
 
 1227 
 
 Miliaria in rachitis, 339 
 papulosa, 1094 
 Treatment of. 1095 
 vesiculosa, 1094 
 Miliary tuberculosis, acute, 279 
 Milium, 1093, 1183 
 etiology of. 1093 
 prognosis of. 1093 
 treatment of, 1093 
 Milk, albuminoids in. 46 
 and cream modifications of, 
 
 for infant feeding, 53 
 as a culture medium, 472 
 as a source of typhoid infec- 
 tion. 195 
 breast-, 19 
 casein in, 46 
 chemistry of, 37 
 commercial bottled, 38 
 compared with other foods, 
 
 37 
 composition of, 37 
 condensed, 49 
 dilution of. for food, 47 
 
 with lime- water, 47 
 fat in, 46 
 
 home modification of, 56 
 human, albuminoids in, 41, 
 44 
 color of. 41 
 
 comparison with cow's, 41 
 constancy of composition 
 
 of, 41 ' 
 reaction of, 41 
 specific gravity of, 41 
 table of analyses of, 42, 43, 
 taste of, 41 
 humanized, 48 
 
 in acute tubal nephritis, 1018 
 in Pott's disease, 1068 
 in typhoid fever, 205 
 infection, 471 
 acute, 475-479 
 diagnosis of, 477 
 from cholera, 477 
 from sunstroke, 477 
 etiology of, 475 
 from condensed milk, 
 
 475 
 prognosis of, 477 
 season of, 475 
 synonyms of, 475 
 treatment of, 477 
 advantages of the term, 
 
 465 
 subacute, 479 
 
 complications of, 481 
 diagnosis of, 482 
 from chronic intestinal 
 indigestion, 482 
 . from intussusception, 
 482 
 dietetic treatment of, 
 
 482 
 etiology of, 479 
 prognosis of, 482 
 prophylaxis of, 482 
 synonyms of, 479 
 treatment of, 482 
 inorganic matter in, 46 
 
 analysis of, 47 
 legal standard of, in various 
 
 States, 40 
 modified. See Modified milk. 
 peptonized, characters of, 25 
 prohibited in acute milk in- 
 fection, 477 
 
 Milk, prohibited in subacute 
 milk infection, 482 
 prophylactic precautions in 
 
 marketing, 473 
 sound dairy, analysis of, 40 
 
 characteristics of, 40 
 sterilization of, 26, 39, 47 
 transportation of, 31 
 Milkers, accidental inoculation 
 
 of, with vaccinia, 172 
 Milk-laboratories, 53 
 
 Walker-Gordon, 55 
 Milk-mixtures, percentage, 53 
 Milk-secretion, diminished, 
 
 treatment of, 20 
 Milk-sugar, 46 
 percentage of, in modified 
 milk, 55 
 Milk-teeth, appearance of, 17 
 Mineral waters in lithaemia, 
 
 102 
 Mitral obstructive murmur, 
 982 
 regurgitant murmur, 981 
 regurgitation, 981 
 prognosis of, 983 
 stenosis, 982 
 prognosis of, 984 
 Mixed feeding, 19 
 
 or fusible phosphate calculus, 
 
 1038 
 treatment in syphilis, 116 
 Modified milk, 53 
 feeding with, 55 
 home preparation of, 56 
 percentage of constituents 
 for feeding healthy in- 
 fant, 55 
 preparation of, 54 
 theoretical basis for feeding 
 with, 55 
 Molluscum contagiosum of eye- 
 lids, 1183 
 epitheliale, 1129 
 diagnosis of, 1130 
 etiology of, 1129 
 treatment of, 1130 
 Monas scarlatinosum, 132 
 Mongolian idiots, 671 
 Monomania, suicidal, 703 
 Monophobia, 704 
 Monsel's solution in haemo- 
 philia, 378 
 Morbid fears, 704 
 impulses, 702 
 
 movements in infantile cere- 
 bral palsies, 652 
 propensities, 703 
 Morbus cseruleus, 5 
 maculosus. See Purpura 
 hemorrhagica. 
 Morphine in asthma, 960 
 in diphtheria, 262 
 in phthisis, 302 
 Morphoea, 1134 
 
 diagnosis of, from keloid, 
 1134 
 from leprosy, 1134 
 from leucoderma, 1134 
 etiology of, 1134 
 prognosis of, 1135 
 treatment of, 1135 
 Mortality of first year, 68 
 Motor symptoms of syringo- 
 myelia, 812 
 Mouth, changes in, in disease, 
 17 
 
 Mouth, cleansing of, at birth, 
 78 
 diseases of, 396 
 
 general etiology of, 396 
 examination of, 17 
 exanthematous eruptions in, 
 
 18 
 inflammation of, changes in, 
 
 18 
 mucous membrane of, in 
 
 health, 17 
 of the infant, 396 
 primary syphilitic lesions of, 
 
 408 
 secondary syphilitic lesions 
 of, 408 
 Mouth-breathing in adenoid 
 vegetations, 429 
 in hypertrophic rhinitis, 831 
 with enlarged tonsils, 423 
 Mouth-suction of tracheotomy 
 
 wound, 880 
 Muco-pus in urine in vesical 
 
 calculus, 1043 
 Mucous disease, 454 
 appetite in, 456 
 breath in, 456 
 diagnosis of, 457 
 
 from ascaris lumbricoi- 
 
 des, 457 
 from dysentery, 457 
 from pulmonary tuber- 
 culosis, 457 
 diet in, 458 
 etiology of, 454 
 microscopy of stools in, 
 
 457 
 morbid anatomy of, 457 
 mucus in stools of, 456 
 nervous symptoms of, 456 
 nervous theory of, 455 
 pain in, 456 
 prognosis of, 458 
 skin in, 456 
 symptoms of, 455 
 synonyms of, 454 
 temperature in, 456 
 tongue in, 455 
 treatment of, 478 
 urine in, 456 
 membranes, changes in, in 
 rachitis, 326 
 lesions of erysipelas in, 
 224 
 patches, treatment of, 1147 
 surfaces, hemorrhages from, 
 82 
 Mucus, hypersecretion of, in 
 chronic gastric catarrh, 
 446 
 Mulberry calculus. See Oxa- 
 
 late-of-lime calculus. 
 Mulls, plaster and salve, of 
 
 Unna, in eczema, 1103 
 Mumps. See Parotitis. 
 Murmur in acute endocarditis, 
 979 
 in aortic regurgitation. 0S3 
 in aortic stenosis. 982 
 in mitral regurgitation, 981 
 in mitral stenosis. 982 
 in stenosis of pulmonary 
 
 artery, 971 
 in tricuspid regurgitation, 
 983 
 Murmurs, luemie. in chlorosis, 
 363 
 
1228 
 
 INDEX. 
 
 Murmurs, hsemic, in leukaemia, ! 
 374 ^ | 
 
 in pernicious anaemia, 366 
 in anomalies of auriculo- 
 
 ventricular orifices, 970 
 transient, in rapid or irregu- 
 lar hearts, 987 
 Muscles, lesions of, in typhoid 
 
 fever, 197 
 Muscular atrophy in hereditary 
 ataxia, 818 
 with tumors of spinal cord, 
 803 
 power in hereditary ataxia, 
 
 818 
 rheumatism. See Rheuma- 
 tism, muscular. 
 Musk in diphtheria, 261 
 Mussey's modification of 
 
 Whitehead gag, 436 
 Mustard-bath in malignant 
 
 measles, 129 
 Mydriatics in treatment of 
 concomitant convergent 
 strabismus, 1203 
 Myelitis, 782 
 acute, 782 
 
 diagnosis of, 786 
 etiology of, 782 
 pathology of, 783 
 treatment of, 785 
 chronic, 787 
 
 with simple cerebro-spinal 
 meningitis, 606 
 Myocarditis in tvphoid fever, 
 
 200 
 Myopathic atrophy, infantile 
 type of, 771 
 juvenile type of, 771 
 Myopia, infrequencv of, in 
 
 childhood, 1202 
 Myo-sarcoma of kidney, 1035 
 Myositis, syphilitic, 111 
 Myotatic excitability in hered- 
 itary ataxia, 817 
 Myotonia, 687 
 diagnosis of, 689 
 etiology of, 688 
 pathology of 688 
 treatment of, 689 
 Myotonic reaction, 688 
 Myotonus with tumors of spi- 
 nal cord, 803 
 Mysophobia, 704 
 Myxcedema, juvenile, 684 
 Mvxcedematous idiocy, 684 
 Myxomata, nasal, 837 
 etiology of, 838 
 morbid anatomy of, 841 
 treatment of, 841 
 Myxo-sarcoma of kidney, 1035 
 
 N^dvi of eyelids, 1180 
 Nsevus pigmentosus, 1131 
 etiology of, 1131 
 prognosis of, 1131 
 treatment of, 1131 
 pilosus, 1131 
 spilus, 1131 
 vascularis, 1137 
 diagnosis of, 1138 
 etiology of, 1138 
 prognosis of, 1138 
 treatment of, 1138 
 verrucosus. 1131 
 Nails, condition of, in typhoid 
 fever, 199 
 
 Naphthaline in cholera, 244 
 in jaundice, 549 
 in mucous disease, 460 
 Naphthol in ichthyosis, 1129 
 Narrowing of rectum, congen- 
 ital, 578 
 Nasal catarrh, chronic, after 
 scarlatina, 142 
 in etiology of chronic ca- 
 tarrh of middle ear, 1174 
 douche in etiology of middle- 
 ear inflammation, 1166 
 myxomata, 837 
 stenosis, 830 
 Naso-pharyngeal adenoid hy- 
 pertrophy, 428 
 etiology of, 429 
 histology of, 428 
 treatment of 432 
 Naso-pharyngitis, 415 
 Naso-pharynx, local treatment 
 
 of, in variola, 169 
 Nausea, 9 
 and vomiting in brain- 
 tumors, 637 
 in chronic gastric catarrh, 
 
 447 
 in lithsemia, 96, 97 
 in rubella, 154 
 in typhoid fever, 197, 198 
 in vaccinia, 174 
 Nebula of cornea, 1195 
 Neck, anterior region of, anat- 
 omy of, 872 
 arteries of, concerned in 
 tracheotomy, 872 
 Necrosis of temporal bone in 
 chronic inflammation of 
 middle ear, 1173 
 osseous in typhoid fever, 
 197 
 Negroes, frequency of rachitis 
 among, 320 
 rarity of trachoma among, 
 1190 
 Nelaton's operation, 522 
 Neoplasms as a cause of hsema- 
 
 turia, 992 
 Nephrectomy for hydronephro- 
 sis, 1031 
 for pyonephrosis, 1032 
 in children, 1037 
 in tumors of kidney, 1036 
 Nephritic colic, 1170 
 Nephritis, acute tubal, 1011 
 diagnosis of, 1012 
 
 from chronic nephritis, 
 
 1012 
 from cyanotic indura- 
 tion, 1012 
 etiology of, 1011 
 morbid anatomy of, 1012 
 prognosis of, 1013 
 synonyms of, 1011 
 treatment of, 1013 
 chronic interstitial, 1025 
 etiology of, 1025 
 morbid, anatomy of, 1026 
 prognosis of, 1026 
 rarity of, in childhood, 
 
 1025 
 synonyms of, 1025 
 treatment of, 1026 
 chronic tubal, 1018 
 diagnosis of 1020 
 
 from amyloid kidney, 
 1020 
 
 Nephritis, chronic tubal, diag- 
 nosis from chronic 
 interstitial nephri- 
 tis, 1020 
 from cyanotic indura- 
 tion, 1020 
 etiology of, 1018 
 morbid anatomy of, 1020 
 in first stage, 1020 
 in second stage, 1021 
 in third stage, 1021 
 prognosis of, 1021 
 in first stage, 1021 
 in second stage, 1022 
 in third stage, 1022 
 synonyms of, 1018 
 treatment of, 1022 
 
 of convalescence from 
 1022 
 complicating croupous pneu- 
 monia, 917 
 in chicken-pox, 159 
 in cirrhosis of liver, 559 
 in late hereditary syphilis, 
 
 115 
 in parotitis, 180 
 in subacute milk infection, 
 
 481 
 in suppurative hepatitis, 554 
 scarlatinal. See Scarlatinal 
 
 nephritis. 
 with parotitis, 179 
 Nephrotomy for hydroneph- 
 rosis, 1031 
 Nerve, superior laryngeal, irri- 
 tation of, in pertussis. 1S5 
 Nerves, peripheral, affections 
 of, in hereditary syph- 
 ilis, 647 
 disorders of, in tetany, 765 
 Nervous diseases in causation 
 of chronic constipation, 
 497 
 symptoms in bronchitis, 929 
 in lithseniia, 97 
 in typhoid fever, 200 
 system, influence of, in child- 
 hood, 1 
 obstetric injuries to, 82 
 Nervousness in lithsemia, 97 
 Nettle-rash, See Urticaria. 
 Neuritic headache, 724 
 Neuritis multiple, after paro- 
 titis, 180 
 complicating epidemic cer- 
 ebro-spinal meningitis, 
 211 
 peripheral, after diph- 
 theria, 259 
 New growths of skin, 1137 
 New-born, haemorrhage in, 73 
 Night-dress for summer, 34 
 
 for winter, 34 
 Night-terrors due to eye-strain, 
 
 1202 
 Nipples, India-rubber, 30 
 Nitre in hydatids of kidney, 
 
 1029 
 Nitre-paper in asthma, 961 
 Nitro-glycerin in asthma, 961 
 in atelectasis, 903 
 in diphtheria, 262 
 in scarlet fever, 148 
 Nitro-muriatic acid in lith- 
 aeruia, 102 
 in oxalate-of-lime lithiasis, 
 1010 
 
INDEX. 
 
 1229 
 
 Nocturnal epilepsy. 751 
 Noma, 405. See. also, Stomatitis 
 
 gangrenosa. 
 Nomenclature of affections of 
 
 middle ear, 1166 
 Nose, diseases of. 626 
 Nose-picking with taenia?, 535 
 Nursing, importance of regu- 
 larity in, IS 
 intervals between, IS 
 proper position in, IS 
 woman, diet of, 41 
 Nursing-bottle, care of, 30 
 graduated, 30 
 improper form of, 503 
 Nutrolaetis, 311 
 Nuts in diabetic diet, 1003 
 Xux vomica in chronic gastric 
 catarrh, 151 
 in chronic intestinal indi- 
 gestion, 151 
 in functional heart affec- 
 tions, 9S9 
 in incontinence of urine, 
 
 997 
 in night-sweats, 302 
 in simple atrophy, 507 
 Nymphomania, 703 
 Nystagmus, 715 
 in albinos, 1135 
 in hereditary ataxia, 818 
 in infantile cerebral palsies, 
 652 
 
 Obsteteic foeceps, injuries 
 from, 83 
 prognosis of, 81 
 limitations of, 83 
 precautions in using, 83 
 injuries, medico-legal aspect 
 of, 83 
 treatment of, 81 
 paralysis, 82 
 Obstruction, laryngeal symp- 
 toms of, 870 
 Obturator for cleft palate, 135 
 Occlusion of anus, complete, 
 
 578 
 Oculo-motor symptoms in 
 
 syringomyelia, 813 
 Odor in favus, 1119 
 
 in stomatitis gangrenosa, 106 
 of breath in gangrene of 
 lung, 922 
 OZdema, 13 
 
 cardiac variety of, 13 
 
 fugitive, 1181 
 
 hepatic variety of, 363 
 
 in chicken-pox, 159 
 
 in chlorosis, 363 
 
 in chronic heart disease, 981 
 
 in progressive pernicious 
 
 anaemia, 365 
 in scarlatinal nephritis, 141 
 in secondary anaemia, 361 
 in tumors of kidney, 1036 
 localized, in scarlatinal neph- 
 ritis, 142 
 in suppurative hepatitis, 
 553 
 of eyelids, 1183 
 in renal and cardiac dis- 
 ease, 1181 
 of face in rubella, 154 
 of glottis in pertussis, 188 
 of lungs in acute tubal neph- 
 ritis, 1012 
 
 Oedema of lungs in chronic tu- 
 bal nephritis, 1020 
 of neck after tracheotomy, 
 
 885 
 renal variety of, 13 
 OSsophagismus, 735 
 Oesophagus, perforation of, 285 
 Offensive breath, causes of, 7 
 Oidium albicans, 400 . 
 Ointments, application of, 1107 
 
 in eczema, 1106 
 Old deformities of joints, 1081 
 Oleum phosphoratuni in ra- 
 chitis, 349 
 Omentum, tumors of. See 
 
 Peritoneum, tumors of. 
 Onychia, syphilitic, 112 
 Oogonia of Ferran, 233 
 Operative treatment of con- 
 comitant convergent 
 strabismus, 1203 
 Ophthalmia in measles, 124 
 neonatorum, 88, 1185 
 prognosis of, 1186 
 prophylaxis of, 88, 1188 
 results of, 1186 
 symptoms of, 1186 
 treatment of, 1186 
 phlyctenular. See Kerato- 
 conj unctivitis, phlyctenular. 
 Opisthotonos, cervical, in cere- 
 bral meningitis, 600 
 in cerebro-spinal meningitis, 
 
 210 
 in tuberculous meningitis,617 
 with tumors of spinal cord, 
 803 
 Opium in acute endocarditis, 
 980 
 in acute intestinal indiges- 
 tion, 467 
 in bronchitis, 931 
 in cerebral meningitis, 604 
 in cerebro-spinal meningitis, 
 
 608 
 in cholera, 246 
 
 in chronic heart disease, 985 
 in croupous pneumonia, 918 
 in diabetes insipidus, 1006 
 in diabetes mellitus, 1004 
 in epidemic cerebro-spinal 
 
 meningiti, 213 
 in intussusception, 521 
 in pericarditis, 976 
 in peritonitis, 567 
 in pertussis, 191 
 in purpura haemorrhagiea, 
 
 383 
 in rheumatism, 357 
 in therapeutics of childhood, 
 
 35 
 in tuberculous meningitis / 622 
 in typhlitis, 513 
 Optic atrophy in hereditary 
 ataxia, 818 
 in hydrocephalus, 626 
 disk, appearance of, with 
 
 tumors of cord, 804 
 neuritis after erysipelas, 227 
 in brain abscess, 632 
 in brain tumors, 637 
 in cerebral meningitis, 599 
 in simple cerebro-spinal 
 
 meningitis, 606 
 in tuberculous meningitis, 
 611, 618 
 Orange-juice in scorbutus, 395 
 
 Orbit, bleeding in, 1201 
 caries of, 1200 
 cellulitis of, 1200 
 cysts of, 1201 
 diseases of, 1200 
 morbid growths of, 1201 
 periostitis of, 1200 
 I Orthopaedics, 1062 
 Osseous system, alterations of, 
 in rachitis, 328 
 in health, 327 
 Ossicles of ear, caries of, 1172 
 stiffening of the ligaments 
 of, 1175 
 Osteitis in chicken-pox, 159 
 Osteo - chondritis, svphilitic, 
 
 106 
 Osteoplasty, 435 
 Otic vesicle, 1158 
 Otitis in influenza, 217 
 in measles, 124 
 in scarlatinal nephritis, 143 
 in typhoid fever, 199 
 in variola, 167 
 media in chicken-pox, 159 
 in typhoid fever, 199 
 Ova of pediculus capitis, 1156 
 Ovaries, tuberculosis of, 299 
 Over-feeding in etiology of 
 acute intestinal indiges- 
 tion, 465 
 of eczema, 1102 
 Ovoid bodies in aestivo-autum- 
 
 nal fever, 308 
 Oxalate-of-lime calculus, 1038 
 
 sediments in urine, 1006 
 Ox-gall in constipation, 500 
 Oxyuris vermicularis, 529 
 diagnosis of, 531 
 habitat of, 529 
 method of infection by, 
 
 529 
 ova of, 529 
 treatment of, 531 
 Ozaena, 833 
 Ozone in sea-air, 60 
 
 Pachymeningitis externa, 
 777 
 interna, 778 
 Pagenstecher's ointment, 1196 
 Pain in acute myelitis, 781 
 in acute poliomyelitis, 791 
 in chronic gastric catarrh, 
 
 119 
 in chronic heart disease, 981 
 in chronic peritonitis, 568 
 in croupous pneumonia, 915 
 in diseases of liver, 532 
 
 diagnosis of, from pleu- 
 risy, 510 
 from pleurodynia. 510 
 in hip-joint disease, 1072 
 in intussusception, 519 
 in knee-joint disease. 1077 
 in mitral stenosis. 982 
 in pericarditis, 975 
 in peritonitis, 565 
 in Pott's disease. 1066. 1067 
 in Eaynaud's disease. 821 
 in simple cerebro-spinal men- 
 ingitis. 606 
 in suppurative hepatitis. 553 
 in tumors of kidney. 1035 
 
 of spinal cord. 802 
 in typhlitis. 510 
 in vesical calculus. 1042 
 
1230 
 
 INDEX. 
 
 Painful micturition, 9 
 
 in lithaeinia, 95 
 Paints in eczema, 1109 
 Palate, soft, appearance of, 17 
 Pallor in chronic tubal neph- 
 ritis, 1020 
 Palpation of chest, 16 
 Palpitation in chlorosis, 363 
 in chronic heart disease, 981 
 in mitral stenosis, 982 
 in pericarditis, 975 
 of heart, 989 
 Palsies, cerebral, acquired, 651 
 infantile cerebral, 649 
 
 diagnosis of, differential, 
 
 656 
 etiology of, 650 
 morbid anatomy of, 654 
 prognosis of, 656 
 statistics of, 650 
 symptoms of, 651 
 treatment of, 656 
 occurring during parturition, 
 
 651 
 of pre-natal origin, 620 
 Palsy in tuberculous meningi- 
 tis, 611, 617 
 of brachial plexus in heredi- 
 tary syphilis, 647 
 Pancreas, syphilis of, 106 
 Pancreatic disease, relation of, 
 to diabetes mellitus, 971 
 juice in new-born, 463 
 Pancreatin in jaundice, 548 
 
 in simple atrophy, 507 
 Pannus, 1190 
 
 phlyctenular, 1193 
 Panophthalmitis from ophthal- 
 mia neonatorum, 1186 
 Pantophobia, 704 
 Papilla of tooth, 410 
 Papillary trachoma, 1190 
 Papular syphiloderm, 1144 
 Papules in stomatitis syphilit- 
 ica, 409 
 Paracentesis abdominis in 
 ascites, 574 
 in ascites of cirrhosis of liver, 
 
 561 
 in chronic peritonitis, 569 
 of cornea, 1195 
 of drum-membrane, 1169 
 pericardii, 977 
 Paradoxical pulse, 988 
 Paraesthesia in Landry's paral- 
 ysis, 799 
 in Eaynaud's disease, 821 
 in tumors of spinal cord, 802 
 Paralexia, 659 
 Paralysis, diphtheritic, 259 
 treatment of, 266 
 facial, 774 
 hysterical, 734 
 in acute gastric catarrh, 444 
 in acute spinal leptomenin- 
 gitis, 780 
 in cerebral meningitis, 599 
 in cerebro-spinal meningitis^ 
 
 210 
 infantile, 789 
 in hydrocephalus, 626 
 in measles, 124 
 in Pott's disease, 1066 
 recognition of, 1068 
 treatment of, 1071 
 in tuberculous meningitis, 
 617 
 
 Paralysis, Landry's. 798 
 diagnosis of, 799 
 
 from myelitis, 799 
 etiology of, 798 
 pathology of, 798 
 prognosis of, 799 
 symptoms of, 798 
 treatment of, 799 
 local, in simple cerebro-spinal 
 
 meningitis, 607 
 obstetric, 82 
 rachitic, 342 
 
 with tumors of spinal cord, 
 803 
 Paralytic deformities, 1086 
 Paramimia, 659 
 Paranephric cyst, 1028 
 Paranoia, 702 
 Paraphimosis, 1060 
 Paraplegia in acute spinal lep- 
 tomeningitis, 780 
 in hereditary syphilis, 647 
 Parasites, intestinal, 524 
 Parasitic affections of skin, 
 
 1148 
 Parenchymatous keratitis. See 
 Keratitis, interstitial. 
 nephritis, acute. See Neph- 
 ritis, acute tubal. 
 chronic. See Nephritis, 
 chronic tubal. 
 Paresis with tumors of spinal 
 
 cord, 803 
 Paretic dementia, 705 
 Parker's soda solution, 882 
 Parotid gland, enlargement and 
 suppuration of, in ty- 
 phoid fever, 199 
 Parotitis, 177 
 bacillus of, 178 
 bacterium in, 178 
 complications of, 180 
 conditions of infection in, 
 
 189 
 definition of, 187 
 epidemics of, 187 
 etiology of, 188 
 incubation of, 189 
 infectious, etiology of, 188 
 in influenza, 217 
 in typhoid fever, 199 
 involvement of other glands 
 
 in, ISO 
 micrococci in, 188 
 pathological anatomy of, 187 
 period of greatest contagious- 
 ness of, 181 
 quarantine in, 181 
 traumatic, 187 
 
 etiology of, 188 
 treatment of, 180 
 Paroxysmal haematuria, 994 
 Parrot's disease, 648 
 
 nodes, 108 
 Passionate movements, period 
 
 of, in hysteria, 731 
 Pastes in eczema, 1107 
 Pasteurization, 28, 48 
 Patency of foramen ovale, 968 
 Patent foods in etiology of 
 
 scorbutus, 389 
 Paternal influence in hered- 
 itary syphilis, 103 
 Pathophobia, 704 
 Pavor nocturnus with pin- 
 worms. 530 
 Pediculosis, 1156 
 
 Pediculosis, etiology of, 1157 
 
 treatment of, 1157 
 Pediculus capitis, 1156 
 
 pubis on eyebrows, 1180 
 Pelletierine against taeniae, 536 
 Pelvic bones, changes in, in 
 rachitis, 336 
 disease in lithaeinia, 100 
 Pelvimetry, 74 
 Pemphigus, 1114 
 diagnosis of, 1115 
 etiology of, 1115 
 foliaceus, 1115 
 of conjunctiva, 1092 
 prognosis of, 1115 
 treatment of, 1115 
 vulgaris, 1114 
 Pepsin in diphtheria, 264 
 Pepsol in typhoid fever, 206 
 Peptogenic milk-powder, 26, 48 
 
 method of using, 48 
 Peptones, formation of, 45 
 Peptonization in artificial feed- 
 ing, 25 
 partial, advantages of, 26 
 Peptonized milk, characters of, 
 
 25 
 Percentage milk-mixtures, 53 
 Percussion of chest, 16 
 method of, in child, 16 
 resonance in health, 16 
 Perforation of bowel in ca- 
 tarrhal dysentery, 486 
 in typhoid fever, 196, 199 
 of caecum or appendix, diag- 
 nosis of, 512 
 Pericarditis, 974 
 
 complicating croupous pneu- 
 monia, 917 
 during scleroderma, 1133 
 etiology of, 975 
 in rheumatism, 353 
 in scarlatinal nephritis, 
 in typhoid fever, 201 
 in variola, 167 
 physical signs in, 975 
 prognosis of, 976 
 treatment of, 977 
 tuberculous, 298 
 without liquid effusion, 
 Perinephritic abscess, 1032 
 diagnosis of, 1033 
 etiologv and pathologv of, 
 
 1032 
 prognosis of, 1033 
 symptoms of, 1033 
 treatment of, 1034 
 Periostitis in late hereditary 
 syphilis, 114 
 in typhoid fever, 197 
 nodular, in rheumatism, 352 
 of orbit, 1200 
 syphilitic, 107 
 Periproctitis, 588 
 Peritoneum, tumors of, 570 
 prognosis of, 571 
 treatment of, 571 
 Peritonitis, acute, 563 
 diagnosis of, 566 
 etiology of, 563 
 morbid anatomy of, 564 
 prognosis of, 566 
 treatment of, 566 
 ulceration of, pus from, 
 565 
 chronic, 568 
 
 diagnosis of, 569 
 
 142 
 
 353 
 
INDEX. 
 
 1231 
 
 Peritonitis, chronic, diagnosis 
 of, from tubercular pe- 
 ritonitis. 568 
 etiology of, 568 
 prognosis of, 569 
 treatment of, 569 
 chronic adhesive tuberculous, 
 290 
 diagnosis of, 291 
 prognosis of, 291 
 treatment of, 291 
 in intussusception, 518 
 in new-born. 90, 563 
 in typhoid fever, 196, 199 
 in utero, 563 
 tuberculous, 2SS 
 ascitic form of, 2S9 
 morbid anatomy of, 283 
 ulcerative form of, 290 
 Peritonsillar abscess, 421 
 diagnosis of, 421 
 etiology of, 421 
 evacuation of, 422 
 prognosis of, 421 
 treatment of, 421 
 Perityphlitis, 509 
 Permanent teeth, 17 
 
 order of appearance of, 411 
 Pernicious malarial fever, 314 
 Peroxide of hydrogen in chick- 
 en-pox, 161 
 Persistence of ductus arteriosus, 
 
 971 
 Perspiration in rachitis, 325, 
 338 
 profuse, in etiology of consti- 
 pation, 497 
 Pertussis, 190. See Whooping- 
 cough. 
 in etiology of bronchitis, 924 
 of mucous disease, 454 
 Petechia? in cholera, 242 
 in invasion of variola, 164 
 significance of, 164 
 Petechial fever. See Cerebro- 
 spinal meningitis, epidemic. 
 Petit mal, 751 
 Peyer's patches in cholera, 236 
 
 in typhoid fever, 196 
 Pharyngitis, acute, 415 
 diagnosis of, 415 
 etiology of, 415 
 pathology and symptoms 
 
 of, 415 
 prognosis of, 416 
 treatment of, 416 
 chronic, 417 
 
 treatment of, 417 
 folliculous, acute, 415 
 chronic, 418 
 treatment of, 418 
 in scarlet fever, 137 
 lateralis, 418 
 Pharynx, appearance of, in 
 
 health, 17 
 Phenacetin, caution in the use 
 of, 36 
 in acute folliculous tonsillitis, 
 
 420 
 in bronchitis, 932 
 in diabetes mellitus, 1004 
 in eczema, 1105 
 in endocarditis, 1108 
 in epidemic cerebro-spinal 
 
 meningitis, 213 
 in measles, 130 
 in migraine, 720 
 
 Phenacetin in parotitis, 180 
 in pleurisy, 946 
 in pyrexia of broncho-pneu- 
 monia, 912 
 in scarlet fever, 145 
 in whooping-cough, 192 
 Phimosis, 1057 
 as a cause of enuresis, 998 
 secondary, 1059 
 Phlebitis, umbilical, 89 
 Phlegmon of orbit, 1200 
 Phlegmonous ulceration in vac- 
 cinia, 175 
 Phlyctenular kerato-conj unc- 
 tivitis, 1192 
 pannus, 1193 
 ulcers, 1193 
 Phlyctenule, 1192 
 Phobias, 704 
 Phosphate of sodium in lith- 
 
 rernia, 101 
 Phosphatic sediments in urine, 
 
 1006 
 Phosphorus in laryngismus 
 stridulus, 864 
 in rachitis, 347 
 Photophobia in cerebral men- 
 ingitis, 599 
 in cerebro-spinal meningitis, 
 
 210 
 in simple conjunctivitis, 
 
 1185 
 in spring catarrh, 1189 
 | Photopsia in migraine, 719 
 i Phtheiriasis of lids, 1180 
 
 treatment of, 1180 
 | Phthisis, fibroid, 963 
 diagnosis of, 966 
 
 from chronic pleurisy, 
 
 966 
 from pulmonary tubercu- 
 losis, 966 
 etiology of, 963 
 morbid anatomy of, 964 
 prognosis of, 966 
 symptoms and course of, 
 
 965 
 treatment of, 966 
 pulmonalis. See Tuberculosis, 
 pulmonary. 
 in etiology of amyloid 
 kidney, 1024 
 Physical examination, order 
 
 of examination in, 9 
 Physiognomy of adenoid vege- 
 tations, 430 
 Pick's linimentum exsiccans, 
 1108 
 paste. 1096 
 " Pigeon - breast " deformity, 
 
 432 
 Pilocarpine in acquired laby- 
 rinthine deafness, 1176 
 in acute tubal nephritis, 
 
 1014 
 in asthma, 961 
 in chronic tubal nephritis, 
 
 1022 
 in erysipelas, 228 
 in jaundice, 548 
 in scarlatinal nephritis, 147 
 in spasmodic laryngitis, 851 
 Pin -worm. See O.rynris ver- 
 micular is. 
 Piperadzin in lithiasis, 1010 
 Pityriasis rosea. 1122 
 diagnosis of, 1122 
 
 Pityriasis rosea, diagnosis of, 
 from circinate syphi- 
 lide, 1122 
 from ringworm, 1122 
 from seborrhoea, 1122 
 etiology of, 1122 
 prognosis of, 1122 
 treatment of, 1122 
 Placenta, syphilis of, 105 
 
 tuberculosis of, 273 
 Plagiocephalic idiocy, 671 
 Plasmodium malaria?, 304 
 Plaster-of-Paris bandage in 
 club-foot, 1084 
 jacket in Pott's disease, 1069 
 splint for hip-joint disease, 
 1075 
 for knee-joint disease, 1078 
 Plasters in eczema, 1107 
 Plethora, definition of, 359 
 Pleura, thickening of, in 
 fibroid phthisis, 964 
 tuberculosis of, 298 
 Pleurisy, 935 
 complicating croupous pneu- 
 monia, 917 
 complications of, 945 
 diagnosis of, 943 
 etiology of, 937 
 following broncho-pneumo- 
 nia, 908 
 frequency of, 935 
 gangrenous, 921 
 in erysipelas, 224, 227 
 in rheumatism, 353 
 in variola, 167 
 pathology of, 935 
 physical signs of, 941 
 prognosis of, 945 
 symptoms of, 940 
 treatment of, 946 
 tubercular, pathology of, 936 
 with effusions, 935 
 Pleuritis necessitatis, 936 
 Pleurosthotonos in cerebro- 
 spinal meningitis, 210 
 Plox scindens, 133 
 Pneumatic speculum in chronic 
 
 tympanic catarrh, 1175 
 Pneumococcus in exudate of 
 simple meningitis, 597 
 of Frankel in broncho-pneu- 
 monia, 904 
 in croupous pneumonia, 
 913 
 Pneumonia, catarrhal. See 
 Broncho-pneumonia. 
 in measles, 123 
 chronic. See Phthisis, fibroid. 
 following bronchopneu- 
 monia, 907 
 complicated by parotitis, 178 
 with pleurisy, incomplete 
 crisis in, 944 
 croupous. 913 
 
 complications and sequels 
 
 of, 917 
 diagnosis of, 917 
 
 from broncho-pneumo- 
 nia, 917 
 from pleurisy with effu- 
 sion. 917 
 etiology of. 913 
 in pertussis. 188 
 morbid anatomy of 914 
 physical signs of. 916 
 prognosis of. 918 
 
1232 
 
 INDEX. 
 
 Pneumonia, croupous, symp- 
 toms of, 914 
 treatment of, 918 
 varieties of, 916 
 embolic, in rheumatism, 353 
 fibrinous. See Pneumonia, 
 
 croupous. 
 following asphyxia, 80 
 in diabetics, 1000 
 in etiology of fibroid phthi- 
 sis, 963 
 of pericarditis, 975 
 infective interstitial, in ery- 
 sipelas, 224 
 in rheumatism, 353 
 in septic infection, 89 
 inspiration, 76, 91 
 lobar. See Pneumonia croup- 
 ous. 
 lobular. See Broncho-pneu- 
 monia. 
 migrans, 916 
 mode of drinking in, 6 
 septic, in scarlet fever, 142 
 staphylococci in, 74 
 with parotitis, 179 
 Pneumothorax complicating 
 broncho-pneumonia, 908 
 Pockmarks in chicken-pox, 157 
 Pointing of perinephritic ab- 
 scess, 1033 
 Poliomvelitis, acute anterior, 
 789 
 diagnosis of, 793 
 
 from cerebral palsy, 
 
 793 
 from diphtheritic pal- 
 sy, 793 
 etiology of, 789 
 morbid anatomy of, 789 
 pathology of, 790 
 prognosis of, 793 
 symptoms of, 790 
 treatment of, 794 
 subacute and chronic ante- 
 rior, 795 
 diagnosis of, 796 
 
 from neuritis, 796 
 treatment of, 797 
 Politzer bag in middle-ear in- 
 flammation, 1168 
 inflation in chronic tympanic 
 catarrh, 1175 
 in suppurating middle ear, 
 1169 
 Poluboskos in diabetes, 1002 
 Polyadenitis, diagnosis of, from 
 Hodgkin's disease, 283 
 from syphilis, 283 
 tuberculous, 283 
 
 after infectious disease, 283 
 Polymyoclonus, post-hemiple- 
 
 gic, 652 
 Polyp masses in chronic sup- 
 purating middle ear, 1171 
 umbilical, 86 
 Polypus of rectum, 592 
 Polyuria in diabetes insipidus, 
 1005 
 in etiology of constipation, 
 497 
 Pomegranate against taeniae, 
 
 536 
 Porencephaly, 649 
 Post-natal atelectasis, 899. See 
 
 Atelectasis, post-natal. 
 Posture in infancy, 12 
 
 Posture in perinephritic ab- 
 scess, 1033 
 Postures in rising in pseudo- 
 hypertrophic paralysis, 
 770 
 Potassium acetate in ascites, 
 573 
 
 in rheumatism, 357 
 bromide in chorea, 763 
 
 in diabetes insipidus, 1006 
 
 in eclampsia, 746 
 
 in epidemic cerebro-spinal 
 meningitis, 213 
 
 in erysipelas, 229 
 
 in infancy, 36 
 
 in pertussis, 191 
 
 in scarlet fever, 146 
 
 in variola, 169 
 carbonate in treatment of 
 
 stone, 1045 
 chlorate as a cause of haema- 
 turia, 992 
 
 in acute pharyngitis, 416 
 
 in diphtheria, 262 
 
 in diseases of the mouth, 
 397 
 
 in mercurial stomatitis, 409 
 
 in stomatitis ulcerosa, 404 
 citrate in measles, 128 
 iodide in acute myelitis, 787 
 
 in asthma, 961 
 
 in brain tumors, 644 
 
 in broncho-adenitis, 931 
 
 in cerebral meningitis, 603 
 
 in cerebro-spinal menin- 
 gitis, 213 
 
 in chronic interstitial ne- 
 phritis, 1026 
 
 in cirrhosis of liver, 559 
 
 in epilepsy, 752 
 
 in fibroid phthisis, 967 
 
 in interstitial keratitis, 
 1197 
 
 in pulmonarv emphysema, 
 954 
 
 in syphiloderma, 1146 
 salts in acute tubal nephritis, 
 1017 
 Pott's disease, 1064 
 
 abscess in, 1067 
 treatment of, 1071 
 
 ambulatorv treatment of, 
 1068 
 
 amvloid changes in, 1067 
 
 cervical, 1066 
 
 complications of, 1066 
 
 deformity in, 1066, 1068 
 
 diagnosis of, 1067 
 
 dorsal, 1066 
 
 etiology of, 1064 
 
 gait in, 1066 
 
 lumbar, 1066 
 
 pain in, 1066, 1067 
 
 paralysis in, 1066 
 treatment of, 1071 
 
 pathology of, 1065 
 
 prognosis of, 1068 
 
 psoas spasm in, 1067 
 
 pulmonarv tuberculosis in, 
 1067 
 
 symptoms of, 1065 
 
 treatment of, 1068 
 
 tuberculous meningitis in, 
 1067 
 Poultices forbidden in conjunc- 
 tivitis, 1185 
 in bronchitis, 933 
 
 I Poultices in pericarditis, 976 
 in peritonitis, 566 
 in peritonsillar abscess, 422 
 i Pouting perforation of drum- 
 membrane, significance 
 of, in suppurating mid- 
 dle ear, 1170 
 Powder-burns of eyelid, 1184 
 Powders in eczema, 1106 
 Preecordial distress, 988 
 
 pain, 988 
 Predigested food in acute in- 
 testinal indigestion, 465 
 in mucous diseases, 458 
 Predigestion, chemistry of, 47 
 Predisposition in etiology of 
 
 diphtheria, 252 
 Prepuce, adherent, 1057 
 treatment of, 1058 
 traction upon, in gravel, 
 1008 
 Preputial adhesions, spontane- 
 ous separation of, 1057 
 Presystolic mitral murmur, 
 comparative frequency 
 of, 982 
 murmur in mitral stenosis, 
 982 
 Priapism in acute myelitis, 784 
 
 in adherent prepuce, 1057 
 Prickly heat, 1094. See Mili- 
 aria 
 Primarv pleurisv, etiology of, 
 
 937, 940 
 Prince's staphylorraphy- 
 
 needle, 436 
 Proctitis, 587 
 
 acute catarrhal, 588 
 chronic catarrhal, 588 
 j Proctodaeum, 577 
 I Procursive epilepsy, 751 
 Profound sleep in etiology of 
 incontinence of urine, 
 996 
 Prolapsus ani in chronic intes- 
 tinal indigestion, 469 
 of rectum, 590 
 in pertussis, 188 
 Proliferation, zone of, in ra- 
 chitic bone, 329 
 Prophvlaxis of septic infection, 
 
 89 
 Prostate gland in children, 
 
 1045 
 Prostration in cholera, 237 
 
 in variola, 164 
 Proteid food, excess of, as a 
 cause of lithaemia, 94 
 poisons from toxicogenic 
 germs, 474 
 Proteids, percentage of, in 
 
 modified milk, 55 
 Prurigo, 1123 
 Pruritus ani, 584 
 
 genital, in diabetes mellitus, 
 
 1000 
 in vaccinia, 174 
 Pseudo-croup, 848 
 Pseudo-diphtheria, 418. See 
 Tonsillitis, infectious 
 
 pseudo-membranous. 
 in variola, 167 
 Pseudo-hypertrophic muscular 
 paralysis, 768 
 diagnosis of, 773 
 from congenital spas- 
 tic paraplegia, 773 
 
INDEX. 
 
 1233 
 
 Pseudohypertrophic muscular 
 paralysis, diagnosis of, 
 from progressive 
 chronic neuritis, 773 
 etiology of. 771 
 morbid anatomy of, 772 
 treatment of, 773 
 Pseudo-membrane of diphthe- 
 ria, 254 
 of pharynx in variola, 165 
 Pseudo-membranes, strepto- 
 cocci in, 251 
 varieties of, 260 
 Psoas abscess in Pott's disease, 
 1067 
 spasm in Pott's disease, 1067 
 Psoriasis, 1111 
 circinata, 1112 
 diagnosis of, 1112 
 
 from scaling svphilides, 
 
 1113 
 from scaly eczema, 1112 
 from seborrhoea, 1112 
 diffusa, 1112 
 etiology of, 1112 
 guttata, 1112 
 gyrata. 1112 
 nummularis, 1112 
 prognosis of, 1113 
 punctata, 1112 
 treatment of, 1113 
 varieties of, 1112 
 "Psychical equivalent" of 
 
 hysteria, 736 
 Ptomaines in scarlatinal neph- 
 ritis, 140 
 in septic infection, 89 
 Ptosis, 1182 
 Ptvalin, scarcity of, in infants, 
 
 45 
 Pubic louse in eyebrows or 
 
 lashes, 1156 
 Puerile respiration, 16 
 Pulmonarv arterv, stenosis of, 
 970 
 emphysema, 950 
 orifice and artery, atresia of, 
 
 971 
 resonance, alterations of, 17 
 at bases, 17 
 
 in infrascapular regions, 17 
 in interscapular space, 17 
 in scapular region, 17 
 tuberculosis. See Tubercu- 
 losis, pulmonary. 
 in Pott's disease, 1067 
 Pulsating pleurisy, 945 
 Pulse, 10 
 
 diminished frequency of, 11 
 in jaundice, 11 
 in nephritis, 11 
 importance of, in diagnosis, 
 
 11 
 in acute milk infection, 476 
 in acute spinal leptomenin- 
 gitis, 780 
 in acute tubal nephritis, 1011 
 in asthma, 958 
 in bronchitis, 928 
 in broncho-pneumonia, 906 
 in catarrhal dysentery, 488 
 in cerebral meningitis, 599 
 in cerebro-spinal meningitis, 
 
 211 
 in childhood, character of, 11 
 in chlorosis, 363 
 in cholera, 238 
 
 78 
 
 Pulse in chronic tubal nephri- 
 tis, 1019 
 increased frequency of, 11 
 in croupous pneumonia, 915 
 in diphtheria, 256 
 in erysipelas, 225 
 in gangrene of lung, 922 
 in influenza, 216 
 in invasion of variola, 164 
 in jaundice, 543 
 in leukaemia, 374 
 in measles, 120, 121 
 in pericarditis, 947 
 in peritonitis, 565 
 in pernicious anaemia, 366 
 in pleurisy, 940, 941 
 in post-natal atelectasis, 900 
 in rachitis, 339 
 in rubella, 154 
 in scarlet fever, 136 
 in simple cerebro - spinal 
 
 meningitis, 607 
 in stomatitis gaugraenosa, 406 
 in subacute purpura haemor- 
 
 rhagica, 381 
 in tuberculous meningitis, 
 
 611,612 
 in typhoid fever, 198, 200 
 palpation of, in infants, 11 
 relation of, to fever, 11 
 Pulsus paradoxus, 987 
 Pumpkin-seed against taeniae, 
 
 537 
 Puncture, lumbar, for hydro- 
 cephalus, 628 
 Pupil, alterations of, with tu- 
 mors of spinal cord, 804 
 in cerebro-spinal meningitis, 
 
 210 
 in simple cerebro-spinal men- 
 ingitis, 606 
 in uraemia, 1011 
 Pupillary symptoms in heredi- 
 tary ataxia, 818 
 in syringomyelia, 813 
 Pupils in cerebral meningitis, 
 599 
 in coma of pernicious malaria, 
 
 314 
 in tuberculous meningitis, 
 617 
 Purgatives in cerebral meningi- 
 tis, 603 
 in cerebro-spinal meningitis, 
 
 608 
 in typhlitis and appendicitis, 
 513 
 Purpura, 1125 
 after influenza, 218 
 diagnosis of, 1127 
 from flea-bite, 1127 
 from scurvy, 1127 
 etiology of, 1127 
 haemorrhagica, 379, 1126 
 acute, 384 
 cases complicating preg- 
 nancy, 386 
 cases with marked sepsis, 
 
 285 
 cases with visceral hem- 
 orrhages, 386 
 essential, 379 
 ordinary cases of, 380 
 secondary, 387 
 
 after fright, etc., 388 
 in non-syphilitic infants, 
 388 
 
 Purpura haemorrhagica, sec- 
 ondary,^ syphilitic in- 
 fants, 388 
 with anaemia, etc., 388 
 with cases of severe jaun- 
 dice, 388 
 with infectious diseases, 
 
 388 
 with malignant endocar- 
 ditis, 388 
 with multiple sarcomata, 
 388 
 subacute, 380 
 constitutional symptoms 
 
 of, 380 
 haemorrhagic symptoms 
 
 of, 380 
 pathology of, 381 
 prognosis of, 382 
 treatment of, 382 
 neonatorum, 1126 
 prognosis of, 1127 
 rheumatica, 387, 1126 
 simplex, 387 
 treatment of, 1127 
 Purulent corneal ulcer, 1194 
 iritis, 1198 
 pleurisy, 935 
 Pustular syphiloderm, 1144 
 Pustule of haemorrhagic variola, 
 163 
 of variola. 163 
 Putty stools, 468 
 Pyonephrosis, 1031 
 diagnosis of, 1032 
 etiology and pathology of, 
 
 1031 
 prognosis of, 1032 
 treatment of, 1032 
 tubercular, 298 
 Pyopneumothorax, 945 
 Pyrexia, types of, 12 
 Pyrogallic acid in lupus vulga- 
 ris, 1141 
 Pyromania, 703 
 Pyrophobia, 704 
 Pyuria, 995 
 in stone in bladder, 1009 
 
 Quarantine in measles, 130 
 
 in rubella, 155 
 Quartan malarial fever, charac- 
 teristics of, 312 
 parasite of, 306 
 differences of, from 
 tertian, 306 
 Questioning the attendants, 
 
 definite order in, 2 
 Quincke's lumbar puncture in 
 diagnosis of tubercu- 
 lous meningitis, 620 
 in hydrocephalus. 629 
 Quinine and urea, muriate of, 
 in malaria, 317 
 in acute endocarditis, 9S0 
 in acute middle-ear inflam- 
 mation, 1169 
 in amcebic dysentery. 495 
 in asthma, 962 
 in broncho-pneumonia, 911 
 in croupous pneumonia. 918 
 in eczema, 1105 
 in malarial fever, 317 
 in malignant measles. 128 
 in measles. 128 
 in pertussis. 191 
 in Raynaud's disease. 825 
 
1234 
 
 INDEX. 
 
 Quinine in rheumatism, 357 
 in scarlet fever, 146 
 in tuberculosis, 302 
 in variola, 169, 170 
 locally in pertussis, 192 
 Quinsy. See Peritonsillar ab- 
 scess. 
 Quotidian intermittent fever, 
 diagnosis of, 315 
 temperature in, 311 
 
 Eace in etiology of vesical cal- 
 culus, 1040 
 Kachitic bone, analyses of, 330 
 child, characters of, 331 
 deformities, 1087 
 
 of pelvis, 336 
 foetus, 330 
 
 head, description of, 332 
 paralysis, 342 
 pseudo-cretinism, 682 
 rosary, diagnostic value of,322 
 Eachitis, 319 See, also, Rickets. 
 age of occurrence of, 322 
 among the well-to-do, 320 
 anatomical characters in 
 stage of deformity of, 
 
 330 
 in stage of proliferation 
 
 of, 328 
 in stage of reconstruction 
 of, 338 
 changes in osseous system in, 
 327 
 in soft tissue in 325 
 of cranial bones in, 331 
 definition of, 319 
 diagnosis of, 320 
 dietetic causes of, 325 
 due to proprietary foods, 323 
 etiologv of, 323 
 foetal, 322 
 frequency of, 319 
 among Italians and ne- 
 groes, 320 
 general symptoms of, 338 
 hygienic treatment of, 342 
 pathology of, 325 
 treatment of, 342 
 Eadius, changes in, in rachitis, 
 
 336 
 Eales in asthma, 959 
 in bronchitis, 930 
 in broncho-pneumonia, 908 
 in pleurisy, 942 
 in pneumonia, 916 
 in pulmonary tuberculosis, 
 296 
 Eapid heart, 988 
 
 with tumors of spinal cord, 
 804 
 Eash. See, also, Eruption. 
 
 in malignant measles, 123 
 Eashes. See, also, Eruptions. 
 in chronic gastric catarrh, 
 
 448 
 initial, in variola, 164 
 Easpberry excrescence, 174 
 Eaynaud's disease, 820 
 
 course, duration, results of, 
 
 824 
 diagnosis of, 824 
 etiology of, 822 
 pathology of, 823 
 relation of intermittent 
 
 hsemoglobinuria to, 823 
 treatment of, 824 
 
 Eeaction of degeneration in 
 
 acute poliomyelitis, 791 
 Eeactions, electrical, in acute 
 poliomyelitis, 791 
 in pseudo - hypertrophic 
 paralysis, 771 
 Eectum, absence of, 583 
 
 congenital narrowing of, 578 
 diseases of, 584 
 foreign bodies in, 595 
 imperforate, 578 
 
 perineal operation for, 479 
 malignant diseases of, 594 
 nsevus of, 593 
 polypus of, 592 
 
 treatment of, 593 
 prolapsus of, 590 
 diagnosis of, 591 
 treatment of, 591 
 varieties of, 590 
 with seat-worms, 530 
 stricture of, 589 
 syphilis of, 589 
 ulceration of, 589 
 wounds of, 594 
 Eecurrence after nephrectomy 
 for tumors of kidney, 
 1037 
 after operations for stone, 
 
 1047 
 in endocarditis, 978 
 of paroxysms of spasmodic 
 laryngitis, 849 
 Eecurrent attacks in purpura 
 hsemorrhagica, 381 
 headache, 721 
 " Eed softening," 630 
 Eeduplication of second sound 
 at apex in endocarditis, 
 979 
 Eeflex headache, 723 
 insanities, 706 
 
 irritation of anus in chronic 
 gastric catarrh, 449 
 of nostrils in chrornic gas- 
 tric catarrh, 449 
 pains in vesical calculus, 1043 
 symptoms from cerumen im- 
 paction, 1162 
 Eeflexes in acute myelitis, 784 
 in acute poliomyelitis, 791 
 in athetosis, 695 
 in hereditary ataxia, 817 
 in infantile cerebral palsies, 
 
 652 
 with tumors of spinal cord, 
 803 
 Eefraction of eve in childhood, 
 
 1201 
 Eegurgitation, aortic, 983 
 mitral, 981 
 tricuspid, 983 
 Eeinfection in rubella, 154 
 Eelapses in rubella, 154 
 
 in subacute milk infection, 
 
 482 
 in typhoid fever, 198 
 Eemittent fevers, irregular, 312 
 Eenal cirrhosis. See Nephritis, 
 chronic interstitial. 
 cysts, 1027 
 
 insufficiency in chronic heart 
 
 disease, treatment of, 985 
 
 sclerosis. See Nephritis, 
 
 chronic interstitial. 
 
 Eesection of rib in empyema, 
 
 947 
 
 Eesonance of chest, different 
 degrees of, 16 
 percussion, in health, 16 
 pulmonary, alterations of, 
 17 
 at bases, 17 
 in infrascapular regions, 
 
 17 
 in interscapular space, 17 
 in scapular region, 17 
 Eesorcin in erysipelas, 229 
 in mucous disease, 459 
 in pertussis, 192 
 Eespiration, 10 
 accelerated, causes of, 10 
 arrest of, during trache- 
 otomy, 881 
 artificial, Duke's method, 79 
 Forest's method, 79 
 Hall's method, 79 
 Eeynolds's method, 79 
 Schultze's method, 78 
 Sylvester's method, 79 
 changes in, in tuberculous 
 
 meningitis, 618 
 Cheyne-Stokes, 10 
 diminished frequency of, 10 
 expiratory, 10 
 in ascites, 15 
 in asthma, 958 
 in bronchitis, 928 
 in cerebral meningitis, 599 
 increase in rapidity of, 10 
 in enteritis, 15 
 in infancy, 16 
 in malignant measles, 123 
 in measles, 122 
 in peritonitis, 15, 565 
 in pleurisy and pneumonia, 
 
 15 
 in post-natal atelectasis, 901 
 in rachitis, 15 
 
 in severe spasmodic laryn- 
 gitis, 852 
 in tubercular meningitis, 604 
 in variola, 164 
 irregularity of, 10 
 in children, 987 
 mode of estimating, 10 
 puerile, 16 
 
 rapid, in hysteria, 735 
 rates of, during sleep, 10 
 
 in children, 10 
 type of, in children, 10 
 Eest in chronic tubal nephritis, 
 1022 
 in hip-joint disease, 1074 
 in knee-joint disease, 1078 
 in Pott's disease, 1068 
 Eesults of corneal ulceration, 
 
 treatment of, 1196 
 Eetention of clots in hgerna- 
 
 turia, 991 
 Eetraction of chest-wall in 
 
 atelectasis, 901 
 Eetractors in tracheotomy, 
 
 caution in use of, 878 
 Eetro-pharyngeal abscess, 427 
 treatment of, 428 
 lymphadenitis, 427 
 tracheotomy in, 440 
 Eeynolds's method of artificial 
 
 respiration, 79 
 Ehabdis genitalis a cause of 
 
 hematuria, 993 
 Ehabdo-sarcoma of kidney, 
 1035 
 
IXJDEX. 
 
 1235 
 
 Rhagades in hereditary syph- 
 ilis. 160 
 svphilitic. characteristics of. 
 408 
 Rheumatic diathesis in etiology 
 of acute gastric catarrh, 
 443 
 Rheumatism, 351 
 acute, 351 
 course and duration of, 355 
 cutaneous eruptions in, 354 
 definition of. 351 
 diagnosis of. 354 
 from cerebro-spinal fever, 
 
 355 
 from pyseruia, 355 
 from rickets, 355 
 from scarlatinal rheu- 
 matism, 354 
 from scurvy, 355 
 from syphilis, 355 
 etiology of. 351 
 prognosis of, 355 
 treatment of. 356 
 after influenza, 217 
 chrouic, 358 
 
 diagnosis of, from rheu- 
 matoid arthritis, 35S 
 treatment of, 353 
 in etiologv of acute endocar- 
 ditis. '977 
 of pericarditis, 975 
 of psoriasis, 1112 
 of vesical calculus, 1039 
 local treatment of, 357 
 morbid anatomy of, 352 
 muscular, 357 
 diagnosis of, 358 
 
 from neuralgia, 358 
 prognosis of, 358 
 treatment of, 358 
 of the legs in scurvy, 391 
 with peritonitis, 564 
 Rhinitis, acute, 826 
 treatment of, 827 
 atrophic, 833 
 diagnosis of, 835 
 from hereditary syphilis, 
 835 
 treatment of, 836 
 hypertrophic, 829 
 diagnosis of, 831 
 pathology of, 829 
 treatment of, 832 
 purulent, 828 
 
 treatment of, 829 
 simple chronic, 828 
 diagnosis of, 828 
 Ribs, changes in, in rachitis, 
 
 334 
 Rickets. See Rachitis. 
 acute, 342 
 in the etiology of eclampsia, 
 
 742 
 in the etiology of laryngis- 
 mus stridulus, 858 
 of splenic anaemia, 368 
 predisposing to scorbutus, 
 389 
 Rigidity and contractures in 
 infantile cerebral palsies, 
 652 
 in acute spinal leptomenin- 
 gitis, 779 
 in simple cerebro-spinal men- 
 ingitis, 606 
 Rigors. See Chills. 
 
 Ringworm. See Tinea tricho- 
 
 phytina. 
 Romanowsky's method of stain- 
 ing in malaria, 316 
 Rosanilin hydrochlorate in 
 
 tinea tonsurans, 1153 
 Rose spots in typhoid fever, 
 
 199 
 Roseola, epidemic. See Rubella. 
 
 infantilis, 1097 
 Rotch, Thomas M., method of 
 
 modified milk, 53 
 Rotheln. See Rubella. 
 Round-worm. See Ascaris lum- 
 
 bricoides. 
 Rubella, 152 
 complications and sequelae of, 
 
 154 
 definition of, 152 
 diagnosis of, 154 
 from measles, 154 
 from scarlet fever, 155 
 distinction of, from measles, 
 
 154 
 incubation of, 152 
 in etiology of bronchitis, 924 
 morbilliforrne, 153 
 prognosis of. 154 
 quarantine in, 155 
 scarlatiniforme, 153 
 symptoms of, 153 
 synonyms of, 152 
 treatment of, 155 
 Rubeola. See Measles. 
 
 Saccharin in diabetic diet, 
 
 1003 
 Saccharomyces albicans, 401 
 
 biology of, 401 
 Saemisch's section, 1195 
 Salads in lithsemic diet, 100 
 Salicin in rheumatism, 357 
 
 in scarlatinal arthritis, 146 
 Salic vlate of bismuth in typhoid 
 * fever, 206 
 of sodium in lithsemia, 101 
 Salicylates in lithaemia, 101 
 in rheumatic tonsillitis, 357 
 value of, in rheumatism, 356 
 in treatment of warts, 1131 
 in tuberculosis, 302 
 Salicylic-creasote plaster-mull 
 
 in lupus, 1141 
 Salines in dysentery, 493 
 
 in peritonitis, 567 
 Salivation in stomatitis ulce- 
 rosa, 404 
 Salol in cholera, 244 
 
 in chronic gastric catarrh, 
 
 451 
 in gonorrhoea, 1054 
 in jaundice, 549 
 in lithsemia, 101 
 in mucous disease, 459 
 in parotitis, 180 
 in vulvo-vaginitis, 1056 
 Salophen in chorea, 762 
 Santonin against ascarides, 528 
 
 against seat-worms, 531 
 Sarcoma of eyelids, 1181 
 of kidnev, 1035 
 of orbit, 1201 
 of peritoneum, 570 
 Sarcomata of brain and menin- 
 ges, 635 
 Satyriasis, 703 
 Scabies, 1154 
 
 Scabies, diagnosis of, from ecze- 
 ma, 1155 
 etiology of, 1155 
 prognosis of, 1155 
 treatment of, 1155 
 Scalp, eczema of, treatment of, 
 
 1109 
 Scaphocephalic idiocy, 671 
 Scarification in treating ery- 
 sipelas, 229 
 Scarlatina. See Scarlet fever. 
 fulminans, 137 
 intermittens, 139 
 miliaria, 139 
 pupulosa, 138 
 
 pemphigoides seu bullosa, 139 
 petechialis seu hsemorrhagica, 
 
 139 
 simplex, 137 
 sine angina, 137 
 with pertussis, 188 
 Scarlatinal nephritis, 140 
 
 diagnosis of, from septic, 
 
 142 
 heart-failure in, 148 
 prognosis of, 144 
 treatment of, 146 
 Scarlatiniform erythema fol- 
 lowing chicken-pox, 159 
 Scarlet fever, 146. See, also, 
 Scarlatina. 
 association of, with vari- 
 cella, 131 
 bacteriology of, 133 
 complications of, 139 
 contagion after disinfection 
 iu, 133 
 by fomites, 133 
 by milk, 133 
 contagiousness of, 131 
 contagium of, 132 
 danger in light cases of, 144 
 day of minimum tempera- 
 ture in, 137 
 definition of, 130 
 diagnosis of, 143 
 from erythema scarlatini- 
 forme, 143 
 from measles, 144 
 from rubella, 144 
 disinfection of bedding 
 after, 151 
 of room after, 151 
 endocarditis with, 978 
 etiology of, 131 
 examination of urine in, 
 
 147 
 history of, 131 
 incubation of, 136 
 in etiology of chronic tu- 
 bal nephritis, 1018 
 of pericarditis, 975 
 microbic origin of, 132 
 mode of transmission of, 
 
 133 
 mortality c*f, 145 
 pathology of, 135 
 prognosis of, 144 
 prophylaxis of, 149 
 
 failure of drugs in, 149 
 quarantine in, 149 
 sequelae of. 142 
 symptoms of. 136 
 treatment of, 136 
 value of isolation in, 149 
 varieties of, 139 
 Schools, physical culture in, 54 
 
1236 
 
 INDEX. 
 
 Schultze's method of artificial 
 
 respiration, 78 
 
 Sclerema neonatorum, 1132 
 
 diagnosis of, 1132 
 
 from oedema, 1132 
 etiology of, 1132 
 prognosis of, 1132 
 treatment, 1132 
 Scleroderma, 1133 
 diagnosis of, 1133 
 from Kaposi's disease, 1134 
 from sclerema neonato- 
 rum, 1133 
 etiology of, 1133 
 prognosis of, 1134 
 treatment of, 1134 
 Sclerosis, lateral, with syringo- 
 myelia, 813 
 of Ammon's horn in epi- 
 lepsy, 748 
 of tubercle, 278 
 Scoliosis, 334, 1063 
 causes of, 54 
 diagnosis of, 1063 
 due to Pott's disease, 1064 
 etiology of, 1063 
 in syringomyelia, 813 
 mechanical support in, 1064 
 prognosis of, 1064 
 treatment of, 54 
 Scorbutus, 389 
 diagnosis of, 395 
 etiology of, 389 
 pathology of, 390 
 prognosis of, 395 
 relation to rickets, 392 
 symptoms of, 391 
 treatment of, 395 
 Scrofula, relation of, to tuber- 
 culosis, 277 
 Scrofuloderma, 1143 
 diagnosis of, 1143 
 etiology of, 1142 
 treatment of, 1143 
 Scrofulous diathesis, 276 
 
 in etiology of acute gastric 
 catarrh, 442 
 iritis, 1198 
 kidney, 298 
 Scurvy, 389. See Scorbutus. 
 
 as a cause of hsematuria, 994 
 Scutulum of favus, 1148 
 Sea-air, 60 
 in asthma, 63 
 in chorea, 64 
 in convalescence, 62 
 from measles, 128 
 in diseases of the eye, 65 
 in entero-colitis, 62 
 in nasal catarrh, 63 
 in pharyngeal catarrh, 63 
 in phthisis, 63 
 in Pott's disease, 64 
 in rheumatism, 64 
 in rickets, 64 
 in whooping-cough, 65 
 odor of, 60 
 ozone in, 60 
 sodium chloride in, 90 
 Sea-bathing, 65 
 effects of, 66 
 frequency of, 66 
 hour for, 66 
 rules for, 66 
 season for, 66 
 value of, 65 
 Sea-coast, clothing at, 67 
 
 Sea-coast, death-rate at, 61 
 exercise at, 67 
 food at, 67 
 rainfall at, 62 
 temperature at, 61 
 wind at, 62 
 Season in etiology of chorea, 
 756 
 of erysipelas, 221 
 of malaria, 304 
 of measles, 118 
 of variola, 163 
 of whooping-cough, 182 
 Seat-worm. See Oxyuris ver- 
 
 micularis. 
 Sea-water, composition of, 65 
 Sebaceous cyst of eyelid, 1183 
 Seborrhoea, 1091 
 diagnosis of, 1091 
 from eczema, 1091 
 from psoriasis, 1091 
 etiology of, 1091 
 of lid-border. See Blephari- 
 tis. 
 prognosis of, 1092 
 treatment of, 1092 
 Second attacks of whooping- 
 cough, 182 
 Sedentary habits in etiology of 
 constipation, 497 
 life in etiology of constipa- 
 tion, 497 
 Sediment in urine of acute tu- 
 bal nephritis, 1012 
 Segmentation of malarial or- 
 ganisms, 306 
 relation of, to paroxysm, 
 306 
 Sensory symptoms of syringo- 
 myelia, 812 
 Septal deflection in adenoid 
 
 hypertrophy, 431 
 Septic diseases in etiology of 
 acute tubal nephritis, 
 1011 
 infection of new-born, 89 
 prophylaxis of, 89 
 treatment of, 89 
 Septicaemia in etiology of bron- 
 chitis, 925 
 in scarlet fever, 142 
 Septieo-pyfemia of new-born. 
 
 pleurisy in, 938 
 Serous cystic tumors of perito- 
 neum, 570 
 exudate in peritonitis, 565 
 irido-cyclitis, 1198 
 iritis, 1198 
 Serpiginous corneal ulcer, 1194 
 Serum-test for typhoid fever, 
 
 205 
 Serum treatment of croupous 
 
 pneumonia, 918 
 Sex in etiologv of chlorosis, 
 362 
 of chorea, 756 
 of chronic peritonitis, 568 
 of cirrhosis of the liver, 
 
 558 
 of diabetes mellitus, 999 
 of intussusception, 518 
 of laryngismus stridulus, 
 
 858 
 of rheumatism, 351 
 of simple meningitis, 596 
 of tuberculous meningitis, 
 610 
 
 Sex in etiology of typhlitis, 510 
 of vesical calculus, 1040 
 of whooping-cough, 183 
 in prognosis of pertussis, 189 
 Sexual organs in idiocy, 675 
 power in hereditary ataxia, 
 817 
 Shell-fish in diabetic diet, 1003 
 Shingles. See Herpes zoster. 
 Shoe for club-foot, 1085 
 Shoes for children, 34 
 Shoulder-joint disease, 1081 
 prognosis of, 1018 
 symptoms of, 1081 
 treatment of, 1081 
 Signe de Dance, 519 
 Silver nitrate in jaundice, 548 
 in ophthalmia neonatorum, 
 
 1187 
 in stomatitis aphthosa, 400 
 catarrhal is, 398 
 syphilitica, 409 
 Simple atrophy. See Atrophy, 
 simple. 
 corneal ulcer, 1194 
 Sinapisms in Landry's paral- 
 ysis, 799 
 Siphonage in empyema, 948 
 of chest, details of operation, 
 949 
 Size, average, of new-born 
 
 child, 12 
 Skeleton, effect of rachitis 
 
 upon, 337 
 Skin, appearance of, iu dis- 
 ease, 5 
 in health, 5 
 atrophies of, 1135 
 condition of, in health, 13 
 in intestinal tuberculosis 
 
 13 
 in marasmus, 13 
 in mucous disease, 13 
 in protracted diarrhoea, 13 
 diseases of, 1090 
 haemorrhages of, 1125 
 hypertrophies of, 1128 
 in acute poliomyelitis, 792 
 in post-natal atelectasis, 900 
 in scarlet fever, 136 
 in simple atrophy, 505 
 in typhoid fever. 197 
 new growths of, 1137 
 parasitic affections of, 1198 
 symptoms in tvphoid fever,. 
 199 
 Skoda's resonance, 296 
 Skull, depressions in, 83 
 Sleep, 34 
 amount required, 34 
 in chronic gastric catarrh,. 
 
 449 
 in typhoid fever, 198 
 regularity in, 34 
 temperature of room for, 35 
 " Sleeping cool," 4 
 " Sleeping high," 4 
 Sloughing corneal ulcer, 1194 
 Slow fever. See Typhoid fever. 
 heart, 988 
 
 pulse in acute gastric catarrh, 
 444 
 in diphtheria, 256 
 Small-pox. See Variola. 
 Soap plaster, Hardaway's modi- 
 fication of Pick's, 1108 
 Pick's, in eczema, 1108 
 
INDEX. 
 
 1237 
 
 Soda solution. Parker's, 8S2 
 Sodium bicarbonate in chronic 
 gastric catarrh, 451 
 in rheumatism. 357 
 in stomatitis mycosa, 402 
 bromide in chronic heart 
 disease, 9S5 
 in uraeniic convulsions, 
 1016 
 ethvlate for nsevus vascu- 
 laris. 1139 
 hvpophosphite in furunculus, 
 
 1124 
 phosphate in cirrhosis of liver, 
 560 
 in congestion of liver, 551 
 in constipation. 499 
 in jaundice. 548 
 in litha?rnia. 101 
 salicylate in acute folliculous 
 tonsillitis, 420 
 iu chorea, 762 
 in diabetes mellitus, 1004 
 in lithseruia, 1101 
 in peritonsillar abscess, 421 
 in rheumatism. 356 
 Softening of tubercle, 278 
 Solitarv follicles in tvphoid 
 
 fever, 196 
 Solution, Gabbet-Ernst's, 271 
 
 of fuchsin. Ziehl's, 271 
 Somatose in typhoid fever diet, 
 
 206 
 Somnambulism, 732 
 Somnial epilepsy, 751 
 Sore throat. See Angina. 
 in chicken-pox, 157 
 in typhoid fever, 199 
 Soups in diabetic diet, 1003 
 Soya flour in diabetes, 1002 
 Sparteine in atelectasis, 903 
 
 in peritonitis, 567 
 Spasm in laryngismus stridu- 
 lus, 861 
 inward, 744 
 Spasmodic laryngitis, severe 
 
 form, 852 
 Spasmus glottidis. See Laryn- 
 gismus stridulus. 
 Specific fevers in etiology of 
 acute gastric catarrh, 442 
 Spectacles in treatment of 
 concomitant convergent 
 strabismus, 1203 
 Speech, affections of, due to 
 peripheral paralysis, 664 
 bad habits of, 665 
 defects and anomalies of, 658 
 from adenoid growths, 665 
 treatment of, 665 
 in cretinism, 681 
 in hereditary ataxia, 818 
 in idiocy, 675 
 Sphincter ani, paralysis of, 
 with tumors of spinal 
 cord, 804 
 Spigelia against ascarides, 529 
 
 against seat-worms, 531 
 Spina bifida in hydrocephalus, 
 
 627 
 Spinal cord, tumors of, 801 
 tenderness in acute lepto- 
 meningitis, 779 
 Spine, lateral curvature of, 
 1063. See Sclerosis. 
 tuberculosis of, 1064. See 
 Pott's disease. 
 
 Spirillum cholerese Asiaticse, 
 232 
 bacteriology of, 232 
 modes of multiplication 
 
 of, 232 
 multiplication of, in cul- 
 ture-media, 233 
 poison elaborated by, 235 
 Spleen, chronic diffuse tubercu- 
 losis of, 282 
 enlargement of, diagnosis of, 
 14 
 in malarial cachexia, 314 
 in rachitis, 326 
 in diphtheria, 254 
 in leukseinia, 374 
 in pernicious malaria, 309 
 in splenic anaemia, 368 
 in typhoid fever, 196, 197, 200 
 superior border of, 17 
 syphilis of, 105 
 Splenectomy in leukaemia, 376 
 Splints for knee-joint disease, 
 
 1078 
 Sporadic cerebro-spinal menin- 
 gitis. See Meningitis, 
 simple cerebrospinal. 
 cretinism, 684 
 Spraying in diphtheria, 264 
 Sprays in hypertrophic rhinitis, 
 
 832 
 Squamous blepharitis. See 
 
 Blepharitis. 
 Squills in broncho-pneumonia, 
 883 
 in severe spasmodic laryngi- 
 tis, 854 
 Squint. See Strabismus. 
 Stacke operation in chronic 
 suppurating middle ear, 
 1172 
 Stammering, 664 
 Staphylococci in croupous pneu- 
 monia, 914 
 Staphylococcus albus in acute 
 folliculous tonsillitis, 418 
 in broncho-pneumonia, 904 
 in peritonitis, 564 
 pyogenes aureus in acute fol- 
 liculous tonsillitis, 418 
 Staphyloma of cornea, 1195 
 
 treatment of, 1196 
 Staphylorraphy, 435 
 
 conditions for success in, 436 
 Starch, digestion of, 45 
 diastase in, 45 
 fermentation of, 22 
 Starvation, partial, in treat- 
 ment of taenia, 536 
 Statistics in appendicitis, 516 
 of operations for stone, 1047 
 of tracheotomy, 873 
 Status eclampticus, 744 
 
 epilepticus, 751 
 Stenosis, aortic, 973 
 mitral, 973 
 of aorta, 963 
 of con us arteriosus, 962 
 of pulmonary artery, 961 
 causes of, 962 
 symptoms of, 962 
 Sterilization, 47 
 apparatus for, 26 
 at low temperature, 48 
 method of, 27 
 of milk, 26 
 advantages of, 48 
 
 Sterilization of milk, disadvan- 
 tages of, 48 
 Sterilized milk, character of, 27 
 Stigmata degenerationis, 654 
 in cirrhosis of liver, 558 
 of epilepsy, 751 
 of hysteria, 732 
 Stimulants. See Alcohol. 
 in acute milk infection, 478 
 in cerebral meningitis, 604 
 in croupous pneumonia, 918 
 in dysentery, 493 
 in erysipelas, 229 
 in post-natal atelectasis, 903 
 "Stomach cough" in chronic 
 
 gastric catarrh, 149 
 Stomach-washing in acute milk 
 
 infection, 477 
 Stomatitis aphthosa, 399 
 etiology of, 399 
 prognosis of, 400 
 treatment of, 400 
 catarrhal is, 397 
 erythematous form of, 397 
 etiology of, 397 
 in pertussis and acute ex- 
 anthemata, 398 
 in teething, 412 
 prognosis of, 398 
 treatment of, 398 
 crouposa, 407 
 diphtheritica, 407 
 diagnosis of, 408 
 primary, in mouth, 408 
 prognosis of, 408 
 treatment of, 408 
 follicular, in chronic intes- 
 tinal indigestion, 468 
 gangrenosa, 405 
 etiology of, 405 
 pathology of, 405 
 prognosis of, 407 
 treatment of, 407 
 in subacute milk infection, 
 
 481 
 mycosa, 400 
 etiology of, 401 
 in chronic gastric catarrh, 
 
 448 
 pathology of, 401 
 prognosis of, 407 
 treatment of, 402 
 syphilitica, 408 
 
 treatment of, 409 
 ulcerosa, 402 
 chronic, 404 
 etiology of, 402 
 pathology of, 403 
 prognosis of, 404 
 treatment of, 404 
 Stomodseum, 477 
 Stone in bladder, symptoms of, 
 
 1008 
 Stools in acute intestinal indi- 
 gestion, 466 
 in acute milk infection, 476 
 in amoebic dysentery, 491 
 in catarrhal dysentery, 488 
 in cholera, 237 
 
 in chronic intestinal indi- 
 gestion, 468 
 in simple atrophy. 505 
 in subacute milk infection, 
 479 
 Strabismus, 1102 
 after acute illness. 1103 
 concomitant convergent. 1102 
 
1238 
 
 INDEX. 
 
 Strabismus, concomitant con- 
 vergent, causes of, 1103 
 diagnosis of, from par- 
 alytic, 1103 
 treatment of, 1103 
 convergent, 1102 
 divergent, 1102 
 in cerebral meningitis, 599 
 in cerebro-spinal meningitis, 
 
 210 
 in idiocy, 674 
 in simple cerebro-spinal 
 
 meningitis, 606 
 in tuberculous meningitis, 
 
 617 
 in typboid fever, 200 
 paralytic convergent, 1102 
 upward or downward, 1102 
 Stramonium in astbma, 961 
 Strangulation, internal, by ap- 
 pendix, 516 
 Strapping in hydrocephalus, 
 
 629 
 Streptococci associated with 
 bacillus of diphtheria, 
 252 
 in diphtheria, 266 
 in septic infection of new- 
 born, 89 
 Streptococcus erysipelatis, 223 
 in acute folliculous tonsillitis, 
 
 418 
 infection by, in pustules of 
 
 variola, 167 
 in peritonitis, 564 
 in pseudo-membrane of vari- 
 ola, 165 
 invasion of, in variola, 167 
 lanceolatus in pleurisy, 939 
 pyogenes aureus in pleurisy, 
 939 
 in acute folliculous tonsil- 
 litis, 418 
 in broncho-pneumonia, 904 
 in croupous pneumonia, 914 
 in pleurisy, 939 
 Stretcher-bed for ambulatory 
 treatment of Pott's dis- 
 ease, 1069 
 Stricture of anus, 587 
 
 of rectum, 589 
 " Strippings," 25 
 
 value of, 38 
 Strontium lactate in chronic 
 interstitial nephritis, 
 1026 
 Strophanthus in atelectasis, 
 903 
 in chronic tubal nephritis, 
 
 1023 
 in peritonitis, 567 
 Strophulus albidus. See Mil- 
 ium. 
 in simple atrophy, 505 
 Strumous keratitis and con- 
 junctivitis. See Kerato- 
 conjunctivitis, phlyctenu- 
 lar. 
 Strychnine in acute poliomye- 
 litis, 795 
 in asphyxia of new-born, 80 
 in asthma, 962 
 in broncho-pneumonia, 911 
 in chronic heart disease, 985 
 in croupous pneumonia, 918 
 in diphtheria, 261 
 in diphtheritic paralysis, 268 
 
 Strychnine in incontinence of 
 urine, 997 
 in pulmonary emphysema, 
 
 954 
 in variola, 170 
 Stupes in peritonitis, 566 
 Stupor in invasion of variola, 
 164 
 in tuberculous meningitis, 
 611, 616 
 Stuttering, 664 
 Stye. See Hordeolum. 
 Subcutaneous nodes in chorea, 
 
 755 
 Subsultus tendinum in cerebro- 
 spinal meningitis, 210 
 Succussion sound in pyopneu- 
 mothorax, 945 
 Sucrose, 46 
 
 Suction, act of, significance of 
 its diminution, 6 
 significance of its re-estab- 
 lishment, 6 
 Sudamina in typhoid fever, 
 
 199 
 Sugar in urine in simple atro- 
 phy, 506 
 proportion of, in milk and 
 
 cream mixtures, 59 
 tests for, in diabetic urine, 
 1000 
 Sugars, digestion of, 45 
 Suggestion in hysteria, 740 
 Sulphonal in diabetes mellitus, 
 1004 
 in variola, 169 
 Sulphur in scabies, 1155 
 
 in pertussis, 193 
 Sulphuric acid in cholera, 244 
 
 in night-sweats, 302 
 Sulphur-vapor after diphthe- 
 ria, 261 
 Summer diarrhoea. See Milk 
 
 infection, subacute. 
 Superficial cervical fascia, 872 
 Suppositories in constipation, 
 499 
 in prolapse of rectum, 591 
 Suppuration, chronic, in etiol- 
 ogy of chronic tubal 
 nephritis, 1018 
 fever of, in variola, 165 
 in etiologv of amyloid kid- 
 ney, 1024 
 in hydatid of liver, 556 
 in typhlitis, 511 
 Suppurative pleurisy, 935 
 Supraglottic laryngitis. See 
 Laryngitis catarrhalw sim- 
 plex. 
 Suprapubic lithotomy, 1047 
 Surf-bathing in etiology of 
 middle ear inflamma- 
 tion, 1166 
 Surgical treatment in infantile 
 cerebral palsies, 657 
 of brain tumors, 644 
 of epilepsy, 753 
 Sweating in gangrene of lung, 
 921 
 in pulmonary tuberculosis, 
 296 
 Sweats in rheumatism, 352 
 Sylvester's method of artificial 
 
 respiration, 79 
 Symblepharon, 1182 
 treatment of, 1182 
 
 Sympathetic irritation, 1199 
 
 ophthalmitis, 1199 
 Syncope, 988 
 
 in secondary anaemia, 361 
 local, 821 
 Synechia, anterior, 1195 
 Synechias, posterior, 1198 
 Synovitis in chicken-pox, 159 
 Syphilide, papular, of eyelid, 
 
 1180 
 Syphilis, acquired, 103 
 after vaccination, 175 
 as a cause of rickets, 323 
 hsemorrhagica neonatorum, 
 
 110 
 hereditary, 103 
 alopecia in, 112 
 blood in, 110 
 bone-lesions in, 106 
 
 diagnosis of, from 
 rickets, 113 
 from tubercular, 
 113 
 concept ion al, 103 
 coryza in, 109 
 definition of, 103 
 diagnosis of, 112 
 
 from scrofula, 112 
 disturbance of nutrition 
 
 in, 110 
 glandular enlargements in, 
 
 110 
 in etiology of splenic anae- 
 mia, 368 
 in infancy, 103 
 involvement of bones in, 
 
 111 
 lesions of heart in, 106 
 of kidneys in, 106 
 of liver in, 106 
 of lungs in, 105 
 of mucous membranes 
 
 in, 105, 109 
 of pancreas in, 106 
 of spleen in, 106 
 of testicles in, 106 
 maternal influence in, 128 
 morbid anatomy of, 105 
 mucous patches in, 110 
 myositis in. 111 
 nervous disturbances in, 
 
 111 
 of nose and throat, 842 
 paternal influence in, 103 
 placenta in, 105 
 prognosis of, 103 
 rashes of. 109 
 skin symptoms of, 109 
 symptoms of, 108 
 teeth in, 111 
 treatment of, 115 
 visceral lesions of, 105 
 in etiology of acquired laby- 
 rinthine deafness. 1176 
 of amyloid kidney, 1024 
 of cirrhosis of liver, 558 
 of leukaemia, 370 
 of lymphatic anaemia, 370 
 of paroxvsmal hsematuria, 
 994 
 inherited nervous affections 
 
 due to, 645 
 late hereditary, 114 
 
 bone-affections in, 114 
 genital organs, in 115 
 interstitial keratitis in, 
 115 
 
INDEX. 
 
 1239 
 
 Syphilis, late hereditary, ne- 
 phritis in, 115 
 periostitis in, 114 
 teeth in, 114 
 of eyelids. 1180 
 of rectum, 5S9 
 primary lesions of, in mouth, 
 
 403 
 pulmonary, causative of as- 
 phyxia, 77 
 secondary lesions of, in 
 
 mouth. 40S 
 skin-lesions of, 105 
 tarda. See Syphilis, late he- 
 reditary. 
 Syphilitic asthma, 954 
 headache, 722 
 lesions of auricle, 1160 
 Syphilization, double, 104 
 Syphiloderma, 1143 
 diagnosis of, 1145 
 bullous, from pemphigus 
 
 neonatorum, 1145 
 erythematous, from inter- 
 trigo, 1145 
 etiology of. 1145 
 prognosis of, 1145 
 treatment of, 1145 
 Svringins: in cerumen impac- 
 tion. 1162 
 in extracting foreign bodies 
 from auditory canal, 1164 
 Syringomyelia, 809 
 diagnosis of, 814 
 etiology of, 809 
 morbid anatomy of, 810 
 pathology of, 810 
 symptoms of, 812 
 treatment of, 914 
 Systolic mitral murmur, rela- 
 tive frequency of, 982 
 murmur in aortic stenosis, 982 
 in defect of ventricular 
 
 septum, 969 
 in mitral regurgitation, 981 
 
 Tabes mesenterica, 286 
 Tache cerebrale as a differ- 
 ential sign in tuberculous 
 meningitis, 203 
 in cerebral meningitis, 599 
 Tachycardia, 988 
 Taenia, 532 
 
 cucumerina, 534 
 mediocanellata, 533 
 nana, 534 
 solium, 533 
 Taeniae, diagnosis of, 535 
 habitat of, 534 
 method of infection by, 534 
 ova of, 534 
 treatment of, 535 
 varieties of, 533 
 Talipes calcaneus, 1083 
 equinus, 1083 
 
 in pseudo - hypertrophic 
 paralysis, 771 
 equino-varus, 1086 
 
 open incision for, 1086 
 valgus, 1083 
 varus, 1083 
 Tannin in gastro-intestinal 
 
 haemorrhage, 87 
 Tapeworm. See Tsenia. 
 Tapotement, 57 
 
 Tar-and-zinc ointment in ec- 
 zema of scalp, 1109 
 
 Tarsitis, 1181 
 
 Tarsorraphy for lagophthalmos, 
 
 1182 
 Tarsus, tuberculous disease of, 
 
 1079 
 Tartar emetic in severe spas- 
 modic laryngitis, 854 
 Tattooing in leucoderma, 1136 
 Taxis in intussusception, 521 
 Taylor's brace for Pott's dis- 
 ease, 1070 
 
 long hip-splint for -hip-dis- 
 ease, 1074, 1075 
 Tears, significance of, in prog- 
 nosis, 7 
 Teeth, eruption of, in etiology 
 of eczema, 1103 
 
 in typhoid fever, 197 
 
 milk, appearance of, 17 
 
 permanent, 17 
 
 order of appearance of, 411 
 
 premature, 411 
 
 time of eruption of, 411 
 Teething as an etiological fac- 
 tor, 409 
 
 order of, 410 
 
 symptoms of, 412 
 
 treatment of, 413 
 Temperature, 11 
 
 abnormal depression of, 12 
 
 during first week of life, 11 
 
 estimation of, 11 
 
 in acute gastric catarrh, 443 
 
 in acute intestinal indiges- 
 tion, 466 
 
 in acute milk infection, 476 
 
 in acute myelitis, 784 
 
 in acute poliomyelitis, 790 
 
 in acute spinal meningitis, 
 780 
 
 in acute tubal nephritis, 1071 
 
 in brain abscess, 631 
 
 in bronchitis, 928 
 
 in broncho-pneumonia, 906 
 
 in catarrhal dysentery, 488 
 
 in cerebral meningitis, 598 
 
 in cerebro-spinal meningitis, 
 211, 607 
 
 in chicken-pox, 158 
 
 in cholera, 238 
 
 in chronic intestinal indiges- 
 tion, 468 
 
 in chronic peritonitis, 568 
 
 in cirrhosis of liver, 558 
 
 in croupous pneumonia, 914 
 
 in diphtheria, 256 
 
 in disease, 12 
 
 in epidemic cerebro-spinal 
 meningitis, 211 
 
 in erysipelas, 225 
 
 in gangrene of lung, 921 
 
 in infectious pseudo-mem- 
 branous tonsillitis, 419 
 
 in influenza, 216, 217 
 
 in intussusception, 419 
 
 in Landry's paralysis, 799 
 
 in lithaemia, 97 
 
 in lymphatic anaemia, 387 
 
 in malignant measles, 123 
 
 in measles, 119, 121 
 
 in perinephritic abscess, 1033 
 
 in peritonitis, 565 
 
 in peritonsillar abscess, 421 
 
 in pleurisy, 940, 941 
 
 in post-natal atelectasis, 900 
 
 in rachitis, 339 
 
 in Raynaud's disease, 822 
 
 Temperature in rubella, 154 
 in scarlet fever, 137 
 in scorbutus, 392 
 in severe spasmodic laryngi- 
 tis, 583 
 in simple atrophy, 505 
 in spasmodic laryngitis, 850 
 in stomatitis catarrhalis, 398 
 in stomatitis gangraenosa, 406 
 in subacute milk infection, 
 
 479 
 in subacute purpura hseinor- 
 
 rhagica, 380 
 in syphilitic inflammation of 
 
 liver, 552 
 in tuberculous meningitis, 
 
 611, 614 
 in typhlitis, 511 
 in typhoid fever, 198, 201 
 in vaccinia, 174 
 in variola, 164 
 
 after eruption, 165 
 in whooping-cough, 185 
 maximum of, 12 
 minimum of, 12 
 oscillations of, 11 
 
 in disease, 12 
 post-mortem rise of, in ery- 
 sipelas, 223 
 post-typhoid elevation of, 221 
 variations in typical range 
 of, 12 
 Temporal bone, necrosis of, in 
 
 ear disease, 1173 
 Tenderness in intussusception, 
 519 
 in peritonitis, 565 
 in typhlitis, 510 
 of surface in rachitis, 349 
 in scorbutus, 451 
 Tendon-reflexes in pseudo-hy- 
 pertrophic paralysis, 771 
 Tenesmus, hysterical, 735 
 in intussusception, 520 
 Tenotomy in club-foot, 1084 
 in infantile cerebral palsies, 
 657 
 Terebene in pulmonary emphy- 
 sema, 955 
 in tuberculosis, 302 
 Terebinthine in tuberculosis, 
 
 301 
 Tertian intermittent fever, 310 
 chilly stage of, 310 
 diagnosis of, 315 
 fever stage of, 310 
 parasite of, 304 
 physical signs in, 312 
 sweating stage of, 311 
 temperature in, 310 
 Testicle, syphilis of, 106 
 
 tuberculosis of, 99 
 Tetanus of new-born, 91 
 
 treatment of, 91 
 Tetany, 794 
 diagnosis of, 766 
 
 from hysteria, 766 
 etiology of, 764 
 in rachitis, 341 
 morbid anatomy of, 766 
 prognosis of, 767 
 relation of, to laryngismus 
 
 stridulus. 858 
 symptoms of, 765 
 treatment of, 767 
 Theoretical formula for feeding 
 with modified milk. 55 
 
1240 
 
 INDEX. 
 
 Thermocautery in stomatitis 
 
 mycosa, 407 
 Thirst in acute milk infection, 
 476 
 in cholera, 237 
 in diabetes insipidus, 977 
 in diabetes mellitus, 971 
 in measles, 119 
 in rachitis, 339 
 in simple cerebro-spinal men- 
 ingitis, 607 
 in typhoid fever, 205, 206 
 Thomas's knee -splint, 1078, 
 
 1079 
 Thompson's mixture in rachi- 
 tis, 349 
 Thomsen's disease. See My- 
 otonia. 
 Thorax, deformity of, in ra- 
 chitis, 334 
 with adenoid vegetations, 
 432 
 rachitic deformity of, 341 
 Thread-worm. See Oxyuris ver- 
 
 micularis. 
 Thrill in mitral stenosis, 982 
 Throat, treatment of, in scarlet 
 
 fever, 146 
 Thrombosis in infantile cere- 
 bral palsies, 656 
 of dural sinuses in dysentery, 
 486 
 Thrush in chronic intestinal 
 indigestion, 486 
 in simple atrophy, 505 
 Thymol in tuberculosis, 302 
 Thymus gland, relations of, in 
 
 tracheotomy, 872 
 Thyroid extract in cretinism, 
 685 
 gland, alteration in, in cretin- 
 ism, 683 
 connection of cretinism 
 
 with, 684 
 desiccated, in cretinism, 
 
 686 
 importance of, in animal 
 
 economy, 683 
 transplantation of, in cre- 
 tinism, 685 
 Tibia, changes in, in rachitis, 
 
 337 
 Tinea circinata, 1151 
 diagnosis of, 1152 
 from psoriasis, 1152 
 from seborrhoea, 1152 
 from syphilis, 1152 
 treatment of, 1153 
 favosa, 1148 
 
 diagnosis of, 1149 
 etiology of, 1149 
 prognosis of, 1149 
 treatment of, 1150 
 tonsurans, 1151 
 
 diagnosis of, from alopecia 
 areata, 1152 
 from eczema, 1152 
 from psoriasis, 1152 
 from seborrhcea, 1152 
 disseminata, 1152 
 treatment of, 1153 
 trichophytina, 1151 
 etiology of, 1152 
 prognosis of, 1152 
 treatment of, 1153 
 Tongue, appearance of, in 
 health, 17 
 
 Tongue in acute gastric catarrh, 
 443 
 
 in catarrhal dysentery, 488 
 
 in fever, 17 
 
 in invasion of variola, 164 
 
 in malignant measles, 123 
 
 in measles, 120, 122 
 
 in peritonitis, 565 
 
 in post-natal atelectasis, 899 
 
 in rheumatism, 352 
 
 in rubella, 154 
 
 in scarlet fever, 137 
 
 in simple atrophy, 505 
 
 in stomatitis catarrhalis, 398 
 
 in stomatitis syphilitica, 409 
 
 in typhlitis, 511 
 
 in typhoid fever, 197, 199 
 
 paralysis of, in tuberculous 
 meningitis, 617 
 
 yellowish ulceration of frse- 
 num of, in pertussis, 188 
 Tongue-tie, 665 
 Tonic spasms in cerebro-spinal 
 
 meningitis, 210 
 Tonics after parotitis, 180 
 
 after pericarditis, 976 
 
 in middle-ear inflammation, 
 1169 
 Tonsillitis, acute folliculous, 
 418 
 infectious nature of, 418 
 treatment of, 420 
 
 croupous. See Tonsillitis, in- 
 fectious pseudo-membran- 
 ous. 
 
 infectious pseudo-membra- 
 nous, 418 
 diagnosis of, 419 
 
 from diphtheria, 419 
 etiology of, 418 
 
 in rheumatism, 354 
 
 lacunaris, 418 
 
 parenchymatous, 421 
 
 phlegmonous, 421 
 
 simple folliculous, 419 
 
 suppurative. See Peritonsillar 
 
 Tonsillotome, Mathieu's, 424 
 Tonsillotomy, author's method 
 
 of. 425 
 Tonsils, hypertrophy of, 422 
 etiology and pathology of, 
 
 422 
 hyperplastic form of, 422 
 symptoms of, 423 
 treatment of, 423 
 Topophobia, 704 
 Torticollis, 1062 
 brace for, 1063 
 diagnosis of, 1062 
 differentiation from cervical 
 abscess, 1063 
 from Pott's disease, 1062 
 prognosis of, 1063 
 treatment of, 1063 
 with tumors of spinal cord, 
 803 
 Toxalbumin of diphtheria, 253 
 | Trachea, relations of, in tra- 
 cheotomy, 873 
 Tracheal dilators for trache- 
 otomy, 875 
 forceps for tracheotomy, 875 
 Tracheitis, 924 
 
 Tracheo-bronchial glands, sup- 
 puration of, 286 
 tuberculosis of, 285 
 
 Tracheo-bronchial glands, tu- 
 berculosis of, symptoms 
 of, 286 
 Tracheotomy, 870 
 after-treatment of, 881 
 age in prognosis of, 874 
 anaesthetics in, 877 
 causes of death after, 884 
 choice of operations for, 876 
 complications after, 885 
 
 during operation of, 881 
 condition of patients after, 
 
 889 
 feeding after, 884 
 immediate results of, 881 
 indications for operation of, 
 
 873 
 in diphtheritic or membran- 
 ous laryngitis, 872 
 instruments required for, 874 
 in treatment of foreign bodies 
 in larynx and trachea, 867 
 in very advanced cases, 871 
 position of patient for, 877 
 prognosis of, 873 
 rapid, 889 
 
 removal of membrane in, 880 
 statistics of, 873 
 technique of, 878 
 thermo-cautery in, 889 
 time for operation of, 871 
 without tubes, 888 
 Tracheotomy-tube, care of, 883 
 change of, 883 
 
 difficulties in permanent re- 
 moval of, 886 
 disinfection of, 883 
 permanent removal of, 883 
 Tracheotomy-tubes, 875 
 Trachoma. See Conjunctivitis, 
 
 granular. 
 Trachoma-coccus, 1190 
 Traction upon prepuce in stone 
 
 cases, 779 
 Tragus-pressure in chronic 
 
 tympanic catarrh, 1175 
 Training in treatment of 
 
 speech-defects, 666 
 Transitory frenzy, 699 
 
 psychoses, 698 
 Transpositionofarterial 
 
 trunks, 972 
 Traumatic iritis, 1198 
 Traumatism in etiology of 
 acute peritonitis, 563 
 of acute tubal nephritis, 
 
 1011 
 of hysteria, 729 
 of pleurisy, 938 
 Treatment, general remarks on, 
 
 35 
 Tremor in hereditary ataxia, 
 818 
 in hysteria, 735 
 Trephining in hydrocephalus, 
 
 629 
 Trichiasis, 1182 
 Trichocephalus dispar, 537 
 Trichophyton fungus, 1152 
 Tricuspid regurgitant murmur, 
 983 
 regurgitation, 983 
 prognosis of, 984 
 valve, anomalies of, 970 
 Trigeminal pulsation, 988 
 Trional in typhoid fever, 206 
 Trommer's test for sugar, 1001 
 
INDEX. 
 
 1241 
 
 Trophic disturbance in infan- 
 tile cerebral palsies, 652 
 lesions in syringomyelia, 813 
 with tumors of spinal cord, 
 803 
 Tropical dysentery. See Dys- 
 entery, amoebic. 
 malaria. See JsIsUvo-autum- 
 nal fevers. 
 Trousseau sign in tetany, 765 
 Trousseau's diuretic wine, 1023 
 Trypsin in diphtheria, 264 
 Tubercle bacilli. See Bacillus 
 tuberculosis. 
 in air, 274 
 in dust, 274 
 in milk, 286 
 diffuse infiltrated. 278 
 in etiology of typhlitis, 510 
 of conjunctiva, 1192 
 secondary inflammatory pro- 
 cesses with, 279 
 Tubercular infection of new- 
 born, 90 
 iritis, 1198 
 syphiloderm, 1144 
 tumors of brain and menin- 
 ges, 635 
 Tuberculin, Hunter's modifi- 
 cation of, 301 
 in lupus vulgaris, 1033 
 in tuberculosis, 301 
 Tuberculocidin in treatment 
 
 of brain tumors, 643 
 Tuberculosis, 270 
 acute, Ehrlich's reaction in, 
 281 
 following operation, 277 
 miliary, 279 
 diagnosis of, 281 
 prognosis of, 281 
 pulmonary type of, 280 
 typhoid type of, 280 
 bacillus of, 271 
 chronic diffuse, 282 
 diagnosis of, 283 
 from gastro-intestinal 
 
 catarrh, 283 
 from rickets, 283 
 from syphilis, 283 
 complicating broncho-pneu- 
 monia, 908 
 conditions favoring, 276 
 congenital, 273 
 experimental, 272 
 following acute gastro-intes- 
 tinal catarrh, 282 
 following infectious disor- 
 ders, 276 
 following measles, 282 
 following wheoping-cough, 
 
 282 " 
 general etiology and morbid 
 
 anatomy of, 270 
 generalized forms of, 279 
 haemoptysis in, 277 
 hereditary transmission of, 
 
 theories of, 273 
 immunity of, 277 
 incidence of, statistics of, 
 271 
 in infancy and childhood, 
 270 
 in dairies, 275 
 in diabetes, 1000 
 individual predisposition to, 
 276 
 
 Tuberculosis in etiology of 
 fibroid phthisis, 964 
 inoculation of, 274 
 local epidemics of, 274 
 localized, 283 
 
 modes of transmission of, 272 
 mortality of, 271 
 in prison, 274 
 of abdominal organs, 287 
 of ankle, 1079. See Ankle- 
 joint disease. 
 of elbow-joint, 1080. See 
 
 Elbow-joint disease. 
 of Fallopian tubes, 299 
 of hip-joint, 1072. See Hip- 
 joint disease. 
 of intestines, 287, 288 
 of joints, 1071 
 of kidneys, 298 
 of knee-joint, 1076 
 of liver, 288 
 of lungs, 292 
 of lymph-glands, 283 
 of ovaries, 299 
 of pericardium, 298 
 of pleura, 298 
 of shoulder-joint, 1081 
 of spine, 1064. See Pott's 
 
 disease. 
 of testis, 299 
 of wrist-joint, 1080. See 
 
 Wrist-joint disease. 
 prophylaxis of, 299 
 pulmonary, 294 
 course of, 297 
 diagnosis of, 297 
 in etiology of bronchitis, 
 
 925 
 morbid anatomy of, 295 
 physical signs of, 296 
 prognosis of, 297 
 symptoms of, 295 
 relation of broncho-pneu- 
 monia to, 293 
 relation of scrofula to, 277 
 spontaneous cure of, 300 
 transmission of, by food, 275 
 by inhalation, 274 
 by meat, 275 
 by milk, 275 
 treatment of, 300 
 uro-genital, 298 
 Tuberculous diathesis, 276 
 characteristics of, 15 
 inflammation of middle-ear, 
 
 1171 
 meningitis, 600, 610. See 
 Meningitis, tuberculous. 
 in Pott's disease, 1067 
 ulcer, description of, 287 
 virus in foetus, 273 
 Tumor in hydatid of liver, 556 
 in hydronephrosis, 1030 
 in intussusception, 520 
 in suppurative hepatitis, 503 
 Tumors about crura cerebri, 
 641 
 at base of brain, 643 
 in causation of headache, 
 
 721 
 of brain and meninges, 634 
 comparative frequency 
 
 of, 634 
 differential diagnosis of, 
 
 643 
 etiology of, 634 
 pathology of, 634 
 
 Tumors of brain and meninges, 
 prognosis of, 643 
 symptoms of, 636 
 treatment of, 643 
 of cerebellum, 643 
 of conjunctiva, 1136 
 of cortical and subcortical 
 
 regions, 638 
 of eyelids, 1180 
 of frontal lobe, 641 
 of kidney, 1034 
 diagnosis of, 1036 
 from ovarian cysts, 1036 
 from perityphlitic ab- 
 scess, 1036 
 etiology and pathology of, 
 
 1034 
 prognosis of, 1036 
 symptoms of, 1035 
 treatment of, 1036 
 of medulla oblongata, 643 
 of motor area, 640 
 of occipital lobe, 640 
 of parietal lobe, 640 
 of pons, 642 
 
 of quadrigeminal region, 642 
 of spinal cord, 801 
 diagnosis of, 806 
 
 from fracture of ver- 
 tebra?., 806 
 from haemorrhage, 806 
 from hysteria, 806 
 from neuritis, 806 
 from pachymeningitis, 
 
 806 
 from spinal caries, 806 
 from transverse my- 
 elitis, 806 
 etiology of, 801 
 favorite sites of, 804 
 morbid anatomy of, 805 
 prognosis of, 807 
 surgical treatment of, 897 
 symptoms of, 801 
 type of, in cervical re- 
 gion, 805 
 in dorsal region, 805 
 in lumbar region and 
 cauda, 805 
 of temporo-sphenoidal lobe, 
 
 641 
 of third frontal convolution, 
 640 
 Tuning-fork tests in young pa- 
 tients, 1176 
 Turpentine as a cause of hee- 
 
 maturia, 932 
 Tympanic attic, inflammation 
 
 of. 1169 
 Tympanites in intussusception, 
 519 
 in peritonitis, 565 
 Typhlitis, 509 
 Typho-bacillose, 281 
 Typhoid condition in purpura 
 hemorrhagica, 381 
 fever, 194, 207 
 bacillus of, 195 
 in milk, 195 
 in water, 195 
 brain symptoms in, 200 
 Brand's treatment of, 206 
 convalescence in. 198 
 definition of, 194 
 diagnosis of. 203 
 
 from cerebral pneumo- 
 nia, 204 
 
1242 
 
 INDEX. 
 
 Typhoid fever, diagnosis of, 
 from cerebro-spinal 
 fever, 204 
 from frank pneumonia, 
 
 204 
 from general tubercu- 
 losis, 204 
 from grippe, 204 
 from malaria, 204 
 from tuberculous menin- 
 gitis, 203 
 digestive symptoms of, 199 
 drinking-water as a cause 
 
 of, 195 
 duration of fever in, 202 
 enlargement of spleen iu, 
 
 200 
 etiology of, 194 
 family predisposition to, 
 
 195 
 history of, 194 
 in children, 194 
 influence of climate upon, 
 194 
 of sex on, 194 
 intestinal lesions in, 196 
 mesenteric glands in, 196 
 morbid anatomy of, 196 
 nervous symptoms of, 200 
 period of incubation of, 196 
 prognosis of, 205 
 prophylaxis of, 207 
 relapse in, 198 
 symptoms of, 197 
 respiratory svmptoms in, 
 
 198 
 synonyms of, 194 
 treatment of, 205 
 ulcerations of intestine in, 
 
 196 
 urine in, 200 
 
 Widal's blood-serum test, 
 205 
 infection of new-born, 90 
 state in jaundice, 543 
 symptoms in rheumatism, 352 
 Typho-tuberculose, 281 
 Tyrotoxicon, 473 
 
 Ulcer of cornea, 1194 
 treatment of, 1195 
 post-variolous, of lid, 1179 
 tuberculous, description of, 
 287 
 Ulceration of intestine in ca- 
 tarrhal dysentery, 486 
 Ulcerations of intestine in ty- 
 phoid fever, 196 
 of laryngeal cartilages in 
 
 typhoid fever, 197 
 of rectum, 589 
 of trachea after tracheotomy, 
 886 
 Ulcerous lesions of scrofulo- 
 derma, 1141 
 Ulcers of amajbic dysentery, 
 490 
 phlyctenular, 1193 
 Ulna, changes in, in rachitis, 
 
 336 
 Umbilical cord. See Cord, 
 umbilical. 
 haemorrhage, 85 
 hernia, 86 
 polyp, 86 
 Umbilicus, wartv tumors of, 
 575 
 
 Unguentum vaselini plumbi- 
 
 cum, 1107 
 Uraemia in acute tubal nephri- 
 tis, 1011 
 Uraemic convulsions in acute 
 
 tubal nephritis, 1016 
 Urea in urine of chronic tubal 
 
 nephritis, 1019 
 Urethra, diagnosis of hemor- 
 rhage from, 981 
 dilatation of, for stone, 1052 
 in females, 1046 
 in males, 1045 
 Uric acid as a cause of incon- 
 tinence of urine, 998 
 of lithaemia, 95 
 in the blood, 94 
 in urine of new-born, 1006 
 Uric-acid calculus, 1038 
 Uric-acid sediments in urine, 
 
 1006 
 Uricacidaemia, 94 
 Uricaemia, 94 
 Urinary organs, anatomy of, 
 
 in children, 1045 
 Urination, diminished fre- 
 quency of, 9 
 involuntary, during sleep, 9 
 painful, in lithaemia, 95 
 Urine. See, also, Urine in 
 health. 
 examination of, in scarlet 
 
 fever, 147 
 frequency of passage of, 8 
 in acute gastric catarrh, 443 
 in acute tubal nephritis, 1011 
 in catarrhal dysentery, 488 
 in chlorosis, 363 
 in cholera, 238 
 in chronic tubal nephritis, 
 
 1019 
 in cirrhosis of liver, 558 
 incontinence of. See Incon- 
 tinence of urine. 
 in variola, 164 
 in vesical calculus, 1042 
 with seat-worms, 530 
 in diabetes mellitus, 1000 
 in diphtheria, 256 
 in disease, 8 
 in erysipelas, 226 
 in health, 8 
 characteristics of, 9 
 daily amount of, 9 
 reaction of, 9 
 specific gravity of, 9 
 in jaundice, 543 
 in leukaemia. 374 
 in lithaemia, 96, 99 
 in measles, 122 
 in perinephritic abscess, 1033 
 in peritonitis, 565 
 in pyonephrosis, 1032 
 in rachitis, 327 
 in rheumatism, 352 
 in scarlatinal nephritis, 141 
 in simple atrophy, 506 
 in tumors of kidney, 1036 
 in typhoid fever, 197, 200 
 in whooping-cough, 187 
 incontinence of, in lithaemia, 
 96 
 in tuberculous meningitis, 
 618 
 partial suppression of, in 
 chronic tubal nephritis, 
 1020 
 
 Urine, partial suppression of, 
 in intussusception, 519 
 quantity of, in diabetes in- 
 sipidus, 1005 
 in diabetes mellitus, 1000 
 selection of specimen of, for 
 
 analysis for sugar, 1001 
 specific gravity of, in acute 
 tubal nephritis, 1011 
 in diabetes insipidus, 
 
 1005 
 in diabetes mellitus, 1000 
 Urostealith, 1038 
 Urticaria, 1120 
 bullosa, 3120 
 diagnosis of, 1121 
 etiology of, 1120 
 factitia, 1120 
 haemorrhagica, 1120 
 in simple atrophy, 505 
 papulosa, 1120 
 pigmentosa, 1121 
 prognosis of, 1121 
 treatment of, 1121 
 tuberosa, 1120 
 vesiculosa, 1120 
 with scarlet fever, 128 
 Uvula, abscission of, 417 
 
 elongation of, 417 
 Uvulatome, 417 
 
 V-shaped indenture of jaw, 
 
 421 
 Vaccination, 171 
 after exposure to variola, 
 168 
 . age at which to perform, 
 176 
 arm-to-arm, 175 
 by animal virus, 176 
 complications of, 174 
 constitutional symptoms of, 
 
 174 
 history of, 171 
 methods of, 175 
 points for, 176 
 protective power of, 176 
 
 exceptions to, 176 
 recent studies in, 173 
 secondary constitutional 
 
 symptoms in, 174 
 secondary fever in, 174 
 Vaccine-blepharitis, 1179 
 Vaccine-lymph, animal, 1173 
 superiority of, to human- 
 ized, 174 
 from spontaneous cow-pox, 
 
 173 
 humanized, 173 
 
 transmission of svphilis by, 
 174 
 impurities of, 175 
 micro-organisms in, 173 
 selection of, 174 
 varieties of, 173 
 Vaccine-pock, areola of, 174 
 cicatrix of, 174 
 desiccation of, 174 
 injury to, 175 
 structure of, 173 
 Vaccine-syphilis. See Syphilis 
 
 after vaccination. 
 Vaccinia, 171 
 auto-inoculation of, 174 
 coccus of, 173 
 eruptive, 174 
 etiology of, 171 
 
INDEX. 
 
 1243 
 
 Vaccinia.irregularities in course 
 of. 174^ 
 Jenner's theory of, 172 
 lvmph of, characteristics of, 
 
 173 
 pathological anatomy of, 173 
 symptoms of, 174 
 theories of nature of, 172 
 theorv of specific contagium 
 
 of, 172 
 traditions of dairy-hands con- 
 cerning, 171 
 variolation theory of, 172 
 vesicle of, 174 
 Vagi, compression of, by en- 
 larged glands, 276 
 Vaginal lithotomy, 1052 
 Vaginismus in hysteria, 735 
 Valerian in diabetes insipidus, 
 
 1006 
 Valsalva inflation in chronic 
 
 tympanic catarrh, 1175 
 Valve - segments, numerical 
 
 anomalies, 972 
 Valvular disease of heart. See 
 Heart disease, chronic. 
 drains in empyema, 948 
 Van Swieten's liquid, 116 
 in syphiloderma, 1146 
 Vapor-baths in ascites, 573 
 Varicella. See Chicken-pox. 
 gangrenosa, 160 
 with pertussis, 188 
 Varicella-prurigo, relation of, 
 
 to eczema, 1120 
 Variola and varioloid, 163 
 complications and sequelse 
 
 of, 167 
 confluent, 166 
 course of, 165 
 definition of, 163 
 diagnosis of, 167 
 from measles, 167 
 from pneumonia, 167 
 from scarlatina, 167 
 from varicella, 167 
 discrete, 166 
 eruptive stage of, 164 
 etiology of, 163 
 hemorrhagic, 166 
 incubation of, 164 
 
 after inoculation, 164 
 influence of vaccination, 168 
 inoculation for, 171 
 invasion of, duration of, 164 
 Jenner's theory of, 172 
 mortality of, without vac- 
 cination, 176 
 pathological anatomy of, 163 
 prognosis of, 168 
 quarantine of, 170 
 second attacks of, 163 
 secondary fever in, 165 
 stage of invasion of, 164 
 striking distance of, 163 
 susceptibility to, 163 
 symptoms of, 164 
 transmission of, 163 
 treatment of, 168 
 typhoid symptoms in, 165 
 vaccination after exposure to, 
 
 168 
 varieties of, 166 
 Variola-lymph, 172 
 Variolation of cow, 172 
 Variola-vaccine, 173 
 Varioloid, definition of, 167 
 
 Varioloid, types of, 167 
 Vascular keratitis, 1196 
 Vaso-motor disturbance in sy- 
 ringomyelia, 813 
 involvement with tumors of 
 spinal cord, 804 
 Vegetables in diabetic diet, 
 1003 
 in lithgemic diet, 99 
 Vegetations in endocarditis, 977 
 
 post-tracheotomic, 888 
 Vein, meningeal, rupture of, 83 
 superficial anterior jugular, 
 872 
 Veins, jugular, fulness of, in 
 
 rachitis, 339 
 Venous hum in chlorosis, 363 
 obstruction in etiology of 
 ascites, 511 
 Ventilation in typhoid fever, 
 
 205 
 Ventricular septum, defect of, 
 
 969 
 Vernix caseosa, 1091 
 Verruca, 1130 
 diagnosis of, 1130 
 etiology of, 1130 
 necrogenica, 98 
 treatment of, 1131 
 Vertebrae, changes in, in rachi- 
 tis, 332 
 Vertigo in acute tubal neph- 
 ritis, 961 
 in brain tumors, 637 
 in leukaemia, 374 
 Vesical calculus, 1038 
 
 irritation in adherent pre- 
 puce, 1057 
 Vesicles of chicken-pox, 1057 
 diagnosis of, from variola, 
 1057 
 Vesicular syphiloderm, 1144 
 Villous growths in bladder a 
 cause of hematuria, 982 
 Virchow's theory of congenital 
 cystic degeneration of 
 kidney, 1027 
 of cretinism, 683 
 Visual fields, narrowing of, in 
 
 hysteria, 733 
 Vocal cords, hyperemia of, in 
 chicken-pox, 157 
 resonance in pleural effusion, 
 942 
 Voice in cholera, 238 
 
 in simple catarrhal laryngi- 
 tis, 846 
 Volatile antiseptics in diphthe- 
 ria, 263 
 drugs in pertussis, 193 
 Volvulus due to ascarides, 528 
 Vomit, lumbricoid worms in, 9 
 Vomiting, 9 
 beef-juice in, 29 
 character of ejecta of, 9 
 chronic. See Gastric catarrh, 
 
 chronic. 
 in acute gastric catarrh, 443 
 in acute milk infection, 476 
 in acute poliomyelitis, 791 
 in acute spinal leptomenin- 
 gitis, 779 
 in broncho-pneumonia, 907 
 in cerebral meningitis, 599 
 in cerebro-spinal meningitis, 
 
 607 
 in childhood, 9 
 
 Vomiting in cholera, 237 
 
 in chronic gastric catarrh, 
 448 
 
 in chronic intestinal indiges- 
 tion, 469 
 
 in infancy, causes of, 9 
 
 in intussusception, 519 
 
 in lithemia, 96, 97 
 
 in malarial fever, 314 
 
 in measles, 122 
 
 in migraine, 719 
 
 in onset of croupous pneu- 
 monia, 914 
 
 in peritonitis, 564 
 
 in pertussis, 188 
 
 in scarlet fever, 136 
 
 in simple atrophy, 505 
 
 in subacute milk infection, 
 480 
 
 in tuberculous meningitis, 
 611, 612 
 
 in typhlitis, 570 
 
 in typhoid fever, 197 
 
 in variola, 164 
 
 in whooping-cough, 187 
 
 of blood in lithemia, 97 
 
 uremic, in acute tubal neph- 
 ritis, 1011 
 Vulvo-vaginitis, 1055 
 
 catarrhal, 1055 
 treatment of, 1056 
 
 from seat-worms, 530 
 
 gonorrheal, 1055 
 
 diagnosis of, from catarrhal, 
 
 1055 
 treatment of, 1056 
 
 symptoms of, 1053 
 
 treatment of, 1056 
 
 Walker-Gordon milk labora- 
 tories, 55 
 Wandering pneumonia, 916 
 Warner-Langenbeck method 
 of staphylorrhaphy, 437 
 Warner's post-nasal douche, 
 
 836 
 Wart, post-mortem, 274 
 Warts of anus, 585 
 Washburn spine-brace for 
 
 Pott's disease, 1070 
 " Washerwoman's hands " in 
 
 cholera, 238 
 Washing prohibited in eczema, 
 
 1105 
 Wasting in artificially-fed chil- 
 dren, 503 
 in nursing infants, 504 
 Water as a source of typhoid 
 fever, 195 
 drinking of, in lithernia, 101 
 in cholera, 246 
 in diet, 20 
 in lithiasis, 1010 
 in scarlatinal nephritis, 147 
 in treatment of vesical cal- 
 culus, 1045 
 in typhoid fever. 206 
 lack of, in etiology of con- 
 stipation. 497 
 Water-bed in acute myelitis, 
 
 787 
 Waxy kidney. See Amyloid 
 
 disease of kidney. 
 Weaning, date of, 19 
 
 early, as a cause of rachitis, 
 
 *344 
 gradual, 19 
 
1244 
 
 INDEX 
 
 Weaning, methods of, 19 
 
 premature, indications for, 
 
 20 
 sudden, indications for, 19 
 Weight, average, of new-horn 
 child, 12 
 daily increase in, 12 
 Werlhof's disease. See Pur- 
 pura hemorrhagica. 
 Wet-nurse, age of, 20 
 feeding by, 20 
 
 disadvantages of, 20 
 for syphilitic infant, 116 
 health of, 20 
 qualifications of, 20 
 rules for selection of, 20 
 Wharton's grooved director, 
 
 874 
 Whip-worm. See Trichoceph- 
 
 alus dispar. 
 White liquefying germ, prod- 
 ucts obtained from, 473 
 swelling of knee, 1076. See 
 Knee-joint disease. 
 Whooping-cough, 182 
 association of, with measles, 
 
 183 
 auscultation in, 187 
 catarrhal stage of, 185 
 complications and sequela? 
 
 of, 187 
 conditions of contagion in, 
 
 183 
 diagnosis of, 188 
 from bronchitis, 189 
 
 Whooping-cough, diagnosis of, 
 from broncho-pneumo- 
 nia, 189 
 from pulmonary tuberculo- 
 sis, 189 
 from tuberculosis of bron- 
 chial glands, 189 
 during foetal life, 183 
 etiology of, 182 
 followed by tuberculosis, 282 
 history of, 182 
 hygienic treatment of, 190 
 incubation of, 185 
 local treatment of, 192 
 mortality of, 189 
 paroxysmal stage of, 186 
 pathology of, 183 
 prognosis of, 189 
 prophylaxis of, 190 
 quarantine in, 190 
 second attacks of, 182 
 symptoms of, 185 
 
 mechanism of, 184 
 synonyms of, 182 
 terminal stage of, 187 
 theories of nature of, 184 
 treatment of, 190 
 Widal's blood-serum test for 
 
 typhoid fever, 205 
 Winckel's disease, 92 
 Wire loop for foreign body in 
 
 auditory canal, 1165 
 Wooden resistance in pleural 
 
 effusion, 942 
 Wormwood, oil of, in reflex vom- 
 iting of diphtheria, 262 
 
 Wounds of cornea, 1197 
 of eyelids, 1183 
 of rectum, 594 
 Wright's adaptation of Mac- 
 kenzie tonsillotome, 425 
 Wrist-joint disease, 1080 
 diagnosis of, 1080 
 prognosis of, 1080 
 symptoms of, 1080 
 treatment of, 1080 
 Wry neck, 1062. See Tor- 
 ticollis. 
 
 Xanthic-oxide calculus, 1038 
 
 Xeroderma pigmentosum, 
 
 1137. See Kaposi's dis- 
 ease. 
 
 Xerophthalmos, 1196 
 
 Xerosis of conjunctiva, 1190, 
 1196 
 
 Yawning, significance of, 10 
 Yellow-oxide-of-mercury oint- 
 ment in eczema of lids, 
 1110 
 
 Zinc-and-tar salve, 1107 
 Zinc oxide in jaundice, 548 
 Zona. See Herpes zoster. 
 
 capillitii, 1116 
 
 facialis, 1116 
 
 frontalis, 1116 
 
 nuchse, 1116 
 
 ophthalmicus, 1116 
 Zonular cataract. See Cata- 
 ract, congenital. 
 
CATALOGUE 
 
 OF THE 
 
 MEDICAL PUBLICATIONS 
 
 OF 
 
 W- B. SAUNDERS, 
 
 No. 925 WALNUT STREET, PHILADELPHIA* 
 
 Arranged Alphabetically and Classified under Subjects* 
 
 'T f HE books advertised in this Catalogue as being sold by subscription are usually to be 
 A obtained from traveling solicitors* but they will be sent direct from the office of pub- 
 lication (charges of shipment prepaid) upon receipt of the prices given. All the other 
 books advertised are commonly for sale by booksellers in all parts of the United States; 
 but any book will be sent by the publisher to any address, carriage prepaid, on receipt ol 
 the published price. 
 
 Money may be sent at the risk of the publisher in either of the following ways r 
 A post-office money order, an express money order, a bank check, and in a registered 
 letter. Money sent in any other way is at the risk of the sender. 
 
 See pages 30, 31, for a List of Contents classified according to subjects. 
 
 LATEST PUBLICATIONS. 
 
 American Text-Book of Genito-Urinary and Skin Diseases. Page 4. 
 
 American Text-Book of Diseases of Children — Rev. Edition. Page 3. 
 
 American Text-Book of Gynecology — Revised Edition. See page 4. 
 
 American Year-Book of Medicine and Surgery. See page 6. 
 
 Anders' Practice of Medicine — Revised Edition. See page 6. 
 
 Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 28. 
 
 Van Valzah and Nisbet's Diseases of the Stomach. See page 28. 
 
 Church and Peterson's Nervous and Mental Diseases. See page 9. 
 
 Da Costa's Surgery — Revised and Enlarged Edition. See page 10. 
 
 Saunders' Medical Hand-Atlases. See page 2. 
 
 Saunders' Pocket Formulary — Fifth (Revised) Edition. See page 24. 
 
 Keen's Surgical Complications of Typhoid Fever. See page 15. 
 
 Griffith on The Baby — Revised Edition. See page 12. 
 
 Butler's Materia Medica and Therapeutics — Revised Edition. Page 8. 
 
 Stevens' Practice of Medicine — Fifth (Revised) Edition. See page 27. 
 
 De Schweinitz' Diseases of the Eye — Revised Edition. See page 10. 
 
 Chapin's Compendium of Insanity. See page 8. 
 
 Senn's Genito-Urinary Tuberculosis. See page 25. 
 
 Penrose's Diseases of Women. See page 18. 
 
 McFarland's Pathogenic Bacteria — Revised Edition. See page 17. 
 
 Macdonald's Surgical Diagnosis. See page 16. 
 
 Moore's Orthopedic Surgery. See page 17. 
 
 Mallory and Wright's Pathological Technique. See page 16. 
 
Saunders' Medical Hand-Atlases. 
 
 The series of books included under this title are authorized translations into English 
 of the world-famous 
 
 Lehmann Medicinische Hand=atlanten. 
 
 For scientific accuracy, pictorial beauty, compactness, and cheapness these books 
 surpass any similar volumes ever published. Each volume contains from 
 
 50 to 100 Colored Plates, 
 
 besides numerous other illustrations in the text. These colored plates have been executed 
 by the most skilful German lithographers, in some cases twenty or more impressions being 
 required to obtain the desired result. There is a full and appropriate description of each 
 plate (printed, for convenience, opposite the plate) , together with a condensed outline of 
 the subject to which the book is devoted. 
 
 The same careful and competent editorial supervision will be secured in the 
 English edition as in the originals. The translations will be directed and edited by the 
 leading American specialists in the different subjects. 
 
 The great advantage of natural pictorial representation is indisputable. For lasting and 
 practical knowledge, one accurate illustration is better than several pages of dry 
 description. 
 
 These Atlases offer a ready and satisfactory substitute for clinical observation, avail- 
 able only to the residents of large medical centers ; and with such persons the requisite 
 variety is seen only after long years of routine hospital service. 
 
 By reason of their projected universal translation and reproduction, affording inter- 
 national distribution, the publishers have been enabled to secure for these Atlases the best 
 artistic and professional talent, to produce them in the most elegant style, and yet to 
 offer them at a price heretofore unapproached in cheapness. The success of the under- 
 taking is demonstrated by the fact that volumes have already appeared in German, English, 
 French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 
 
 While appreciating the value of such colored plates, the profession has heretofore been 
 practically debarred from purchasing similar works because of their extremely high price, 
 made necessary by the limited sale and the enormous expense of production. The very 
 low price of these Atlases will place them within the reach of even the novice in practice. 
 
 NOW READY. 
 
 Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited 
 by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic ; At- 
 tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations'in the text. 
 Cloth, $3.00 net. 
 
 Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter- 
 son, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chief 
 of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig- 
 ures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, #3.50 net. 
 
 Atlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P. 
 Grayson, M.D., Lecturer on Laryngology and Rhinologv in the University of Pennsylvania; 
 Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. 
 With i®7 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. 
 
 Atlas of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers 
 DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia ; Surgeon 
 to the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. Cloth, $3.00 net. 
 
 Atlas of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited 
 by L. Bolton Bangs, M.D., late Professor of Genito-Urinary and Venereal Diseases, New York 
 Post-Graduate Medical School and Hospital. With 71 colored plates from original water-colors, 
 and 16 black-and-white illustrations. Cloth, $3.50 net. 
 
 IN PREPARATION, 
 
 Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited bv G. E. 
 de Schweinitz, M.D., Professor of Ophthalmologv, Jefferson Medical College, Phila'delphia. 
 With 100 colored illustrations. 
 
 Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. With 80 colored plates from 
 original water-colors. 
 
 Atlas of Pathological Histology. Atlas of Operative Gynecology. 
 
 Atlas of Orthopedic Surgery. Atlas of Psychiatry. 
 
 Atlas of General Surgery. Atlas of Diseases of the Ear. 
 
THE AMERICAN TEXT-BOOK SERIES. 
 
 AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. 
 
 By 43 Distinguished Practitioners and Teachers. Edited by James C. 
 Wilson, M.D., Professor of the Practice of Medicine and of Clinical 
 Medicine in the Jefferson Medical College, Philadelphia. One hand- 
 some imperial octavo volume of 1326 pages. Illustrated. Cloth, 
 $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. 
 
 "Asa work either for study or reference it will be of great value to the practitioner, as 
 it is virtually an exposition of such clinical therapeutics as experience has taught to be oi 
 the most value. Taking it all in all, no recent publication on therapeutics can be compared 
 with this one in practical value to the working physician." — Chicago Clinical Review. 
 
 " The whole field of medicine has been well covered. The work is thoroughly prac- 
 tical, and while it is intended for practitioners and students, it is a better book for the general 
 practitioner than for the student. The young practitioner especially will find it extremely 
 suggestive and helpful." — The Indian Lancet. 
 
 AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. 
 Second Edition, Revised. 
 
 By 63 Eminent Contributors. Edited by Louis Starr, M.D., Physi- 
 cian to the Children's Hospital, Philadelphia, etc.; assisted by 
 Thompson S. Westcott, M.D., Attending Physician to the Dispen- 
 sary for Diseases of Children, Hospital of the University of Pennsyl- 
 vania. In one handsome imperial octavo volume of 1250 pages, 
 profusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco, 
 $8.00 net. Sold by Subscription. 
 
 " This is far and away the best text-book on children's diseases ever published in the 
 English language, and is certainly the one which is best adapted to American readers. 
 We congratulate the editor upon the result of his work, and heartily commend it to the 
 attention of every student and practitioner. ' ' — American Journal of the Medical Sciences. 
 
 AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
 NOSE, AND THROAT. 
 
 By 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D., 
 Professor of Ophthalmology in the Jefferson Medical College, Phila- 
 delphia ; and B. Alexander Randall, M.D., Professor of Diseases 
 of the Ear in the University of Pennsylvania and in the Philadelphia 
 Polyclinic. Ready soon. 
 
 Illustrated Catalogue of the " American Text-Books" sent free upon application. 
 
i Medical Publications of W. B. Saunders. 
 
 AN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN 
 DISEASES. 
 
 By 47 Eminent Specialists and Teachers. Edited by L. Bolton 
 Bangs, M.D., Late Professor of Genito-Urinary and Venereal Diseases, 
 New York Post-Graduate Medical School and Hospital ; and W. 
 A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri 
 Medical College. Imperial octavo volume of 1229 pages, with 300 en- 
 gravings and 20 full-page colored plates. Cloth, $7.00 net; Sheep 
 or Half Morocco, $8.00 net. Sold by Subscription. 
 
 " This volume is one of the best yet issued of the publisher's series of ' American Text- 
 Books.' The list of contributors represents an extraordinary array of talent and extended 
 experience. The book will easily take the place in comprehensiveness and value of the 
 half dozen or more costly works on these subjects which have heretofore been necessary to 
 a well-equipped library." — New York Polyclinic. 
 
 AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND 
 SURGICAL. Second Edition, Revised. 
 
 By 10 of the Leading Gynecologists of America. Edited by J. M. 
 Baldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic, 
 etc. Handsome imperial octavo volume of over 700 pages, with 341 
 illustrations in the text, and 38 colored and half-tone plates. Cloth, 
 $6.00 net; Sheep or Half Morocco, $7.00 net. Sold by Subscription. 
 
 " It is practical from beginning to end. Its descriptions of conditions, its recommen- 
 dations for treatment, and above all the necessary technique of different operations, are 
 clearly and admirably presented. . . . It is well up to the most advanced views of the 
 day, and embodies all the essential points of advanced American gynecology. It is destined 
 to make and hold a place in gynecological literature which will be peculiarly its own." — 
 Medical Record, New York. 
 
 AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI- 
 COLOGY. 
 
 Edited by Frederick Peterson, M.D., Clinical Professor of Mental 
 Diseases in the Woman's Medical College, New York; Chief of Clinic, 
 Nervous Department, College of Physicians and Surgeons, New York ; 
 and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, 
 and Toxicology in Rush Medical College, Chicago. In Preparation. 
 
 AN AMERICAN TEXT=BOOK OF OBSTETRICS. 
 
 By 15 Eminent American Obstetricians. Edited by Richard C. Nor- 
 ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome 
 imperial octavo volume of over 1000 pages, with nearly 900 beautiful 
 colored and half-tone illustrations. Cloth, $7.00 net; Sheep or Half 
 Morocco, $8.00 net. Sold by Subscription. 
 
 " Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
 medical work that I have ever seen. I congratulate you and thank you for this superb work, 
 which alone is sufficient to place you first in the ranks of medical publishers." — Alexander 
 J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. 
 
 " This is the most sumptuously illustrated work on midwifery that has yet appeared. In 
 the number, the excellence, and the beauty of production of the illustrations it far surpasses 
 every other book upon the subject. This feature alone makes it a work which no medical 
 library should omit to purchase." — British Medical Journal. 
 
 "As an authority, as a book of reference, as a ' working book ' for the student or prac- 
 titioner, we commend it because we believe there is no better." — American Journal of the 
 Medical Sciences. 
 
 Illustrated Catalogue of the "American Text-Books " sent free upon application. 
 
3Iedical Publications of W. B. Saunders. 5 
 
 AN AMERICAN TEXT=BOOK OF PATHOLOGY. 
 
 Edited by John Guiteras, M.D., Professor of General Pathology and 
 of Morbid Anatomy in the University of Pennsylvania ; and David 
 Riesman, M.D., Demonstrator of Pathological Histology in the 
 University of Pennsylvania. In Preparation. 
 
 AN AMERICAN TEXT=BOOK OF PHYSIOLOGY. 
 
 By i o of the Leading Physiologists of America. Edited by William 
 H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- 
 kins University, Baltimore, Md. One handsome imperial octavo 
 volume of 1052 pages. Illustrated. Cloth, $6.00 net; Sheep or Half 
 Morocco, $7.00 net. Sold by Subscription. 
 
 " We can commend it most heartily, not only to all students of physiology, but to every 
 physician and pathologist, as a valuable and comprehensive work of reference, written by 
 men who are of eminent authority in their own special subjects." — London Lancet. 
 
 " To the practitioner of medicine and to the advanced student this volume constitutes, 
 we believe, the best exposition of the present status of the science of physiology in the 
 English language." — A??ierican Journal of the Medical Sciences. 
 
 AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition. 
 
 By 13 Eminent Professors of Surgery. Edited by William W. Keen, 
 M.D., LL.D., and J. William White, M.D., Ph.D. Handsome 
 imperial octavo volume of 1250 pages, with 500 wood-cuts in the text, 
 and 39 colored and half-tone plates. Thoroughly revised and enlarged, 
 with a section devoted to " The Use of the Rontgen Rays in Surgery." 
 Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Sub- 
 scription. 
 
 " Personally, I should not mind it being called THE Text-Book (instead of A Text- 
 Book) , for I know of no single volume which contains so readable and complete an account 
 of the science and art of Surgery as this does." — Edmund Owen, F.R.C.S., Member of 
 the Board of Examiners of the Royal College of Surgeons, England. 
 
 " If this text-book is a fair reflex of the present position of American surgery, we must 
 admit it is of a very high order of merit, and that English surgeons will have to look very 
 carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
 London Lancet. 
 
 AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
 OF MEDICINE. 
 
 By 12 Distinguished American Practitioners. Edited by William 
 Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- 
 cine and of Clinical Medicine in the University of Pennsylvania. Two 
 handsome imperial octavo volumes of about 1000 pages each. Illus- 
 trated. Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco, 
 $6.00 net. Sold by Subscription. 
 
 " I am quite sure it will commend itself both to practitioners and students of medicine, 
 and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- 
 fessor of Pathology and Practice of Medicine, University of the City of A T ew York. 
 
 " We reviewed the first volume of this work, and said : * It is undoubtedly one of the 
 best text-books on the practice of medicine which we possess.' A consideration of the 
 second and last volume leads us to modify that verdict and to say that the completed work 
 is in our opinion the best of its kind it has ever been our fortune to see." — New York Medical 
 Journal. 
 
 Illustrated Catalogue of the "American Text-Books" sent free upon application. 
 
6 Medical Publications of W. B. Saunders. 
 
 AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 
 
 A Yearly Digest of Scientific Progress and Authoritative Opinion in all 
 branches of Medicine and Surgery, drawn from journals, monographs, 
 and text-books of the leading American and Foreign authors and 
 investigators. Collected and arranged, with critical editorial com- 
 ments, by eminent American specialists and teachers, under the general 
 editorial charge of George M. Gould, M.D. One handsome imperial 
 octavo volume of about 1200 pages. Uniform in style, size, and 
 general make-up with the " American Text-Book" Series. Cloth, 
 $6.50 net ; Half Morocco, $7.50 net. Sold by Subscription. 
 
 " It is difficult to know which to admire most — the research and industry of the distin- 
 guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
 wealth and abundance of the contributions to every department of science that have been 
 deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, 
 for, as each section is entrusted to experienced and able contributors, the reader has the 
 advantage of certain critical commentaries and expositions . . . proceeding from writers 
 fully qualified to perform these tasks. . . . It is emphatically a book which should find 
 a place in every medical library, and is in several respects more useful than the famous 
 'Jahrbiicher' of Germany." — London Lancet. 
 
 ANDERS' PRACTICE OF MEDICINE. Second Edition. 
 
 AText=Book of the Practice oi Medicine. By James M. Anders, 
 M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
 Clinical Medicine, Medico- Chirurgical College, Philadelphia. In one 
 handsome octavo volume of 1287 pages, fully illustrated. Cloth, 
 $5.50 net; Sheep or Half Morocco, $6.50 net. 
 
 "It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a 
 credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
 James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson 
 Medical College, Philadelphia. 
 
 " I consider Dr. Anders' book not only the best late work on Medical Practice, but by 
 far the best that has ever been published. It is concise, systematic, thorough, and fully up 
 to date in everything. I consider it a great credit to both the author and the publisher." — 
 A. C. Cowperthwaite, President of the Lllinois Homeopathic Medical Association. 
 
 ASHTON'S OBSTETRICS. Fourth Edition, Revised. 
 
 Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- 
 fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
 Crown octavo, 2 5 2 pages ; 75 illustrations. Cloth, $1. 00; interleaved 
 for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Embodies the whole subject in a nut-shell. We cordially recommend it to our read- 
 ers." — Chicago Medical Times. 
 
 BALL'S BACTERIOLOGY. Third Edition, Revised. 
 
 Essentials of Bacteriology ; a Concise and Systematic Introduction 
 to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
 ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
 pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; 
 interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends ', page 21.] 
 
 " The student or practitioner can readily obtain a knowledge of the subject from a perusal 
 of this book. The illustrations are clear and satisfactory." — Medical Record, New York. 
 
 
Medical Publications of W. B. Saunders. 7 
 
 BASTIN'S BOTANY. 
 
 Laboratory Exercises in Botany. By Edson S. Bastin, M.A., 
 late Professor of Materia Medica and Botany, Philadelphia College of 
 Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. 
 
 "It is unquestionably the best text-book on the subject that has yet appeared. The 
 work is eminently a practical one. We regard the issuance of this book as an important 
 event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
 fied success." — Alumni Report to the Philadelphia College of Pharmacy. 
 
 ' ' There is no work like it in the pharmaceutical or botanical literature of this country, 
 and we predict for it a wide circulation." — American Journal of Pharmacy. 
 
 BECK'S SURGICAL ASEPSIS. 
 
 A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
 St. Mark's Hospital and the New York German Poliklinik, etc. 306 
 pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net. 
 
 " An excellent exposition of the ' very latest ' in the treatment of wounds as practised 
 by leading German and American surgeons." — Birmingham (Eng.) Medical Review. 
 
 "This little volume can be recommended to any who are desirous of learning the details 
 of asepsis in surgery, for it will serve as a trust worthy guide." — London Lancet. 
 
 BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
 OPERATIONS. 
 Obstetric Accidents, Emergencies, and Operations. By L. Ch. 
 
 Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis 
 Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. 
 
 " It is clearly and concisely written, and is evidently the work of a teacher and practi- 
 tioner of large experience." — British Medical Journal. 
 
 " A manual so useful to the student or the general practitioner has not been brought to 
 our notice in a long time. The field embraced in the title is covered in a terse, interesting 
 way." — Yale Medical Journal. 
 
 BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
 Essentials of Medical Physics. By Fred J. Brockway, M.D., 
 Assistant Demonstrator of Anatomy in the College of Physicians and 
 Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. 
 Cloth, $ 1. 00 net ; interleaved for notes, $1.25 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " The student who is well versed in these pages will certainly prove qualified to com- 
 prehend with ease and pleasure the great majority of questions involving physical principles 
 likely to be met with in his medical studies." — American Practitioner and News. 
 
 "We know of no manual that affords the medical student a better or more concise 
 exposition of physics, and the book may be commended as a most satisfactory presentation 
 of those essentials that are requisite in a course in medicine." — New York Medical Journal. 
 
 " It contains all that one need know on the subject, is well written, and is copiously 
 illustrated." — Medical Record, New York. 
 
 BURR ON NERVOUS DISEASES. 
 
 A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
 Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
 Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary 
 for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
 In Preparation. 
 
8 Medical Publications of W. B. Saunders. 
 
 BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
 MACOLOGY. Second Edition, Revised. 
 A Text=Book of Materia Medica, Therapeutics, and Pharma= 
 cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
 Medica and of Clinical Medicine in the College of Physicians and 
 Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, 
 Northwestern University, Woman's Medical School, etc. Octavo, 860 
 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 
 
 " Taken as a whole, the book may fairly be considered as one of the most satisfactory 
 of any single-volume works on materia medica in the market," — Journal of the American 
 Medical Association. 
 
 "The work is executed in a clear, concise, and practical manner, and should meet with 
 a hearty endorsement from the students of our up-to-date colleges. The book will be found 
 a valuable work of reference for the practitioner." — American Medico-Surgical Bulletin. 
 
 CASSELBERRY ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By W. E. Casselberry, Pro- 
 fessor of -Laryngology and Rhinology in the Northwestern University 
 Medical School, Chicago. In Preparation. 
 
 CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
 Notes on the Newer Remedies, their Therapeutic Applications 
 and Modes of Administration. By David Cerna, M.D., Ph.D., 
 formerly Demonstrator of and Lecturer on Experimental Therapeutics 
 in the University of Pennsylvania ; Demonstrator of Physiology in the 
 Medical Department of the University of Texas. Rewritten and 
 greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. 
 
 " The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
 is properly appreciated. The book ought to be in the possession of every practising physi- 
 cian." — New York Medical Journal. 
 
 CHAPIN ON INSANITY. 
 
 A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 
 Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
 cian-Superintendent of the Willard State Hospital, New York ; Hon- 
 orary Member of the Medico-Psychological Society of Great Britain, 
 of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
 illustrated. Cloth, $1.25 net. 
 
 The author has given, in a condensed and concise form, a compendium of Diseases of 
 the Mind, for the convenient use and aid of physicians and students. The work will also 
 prove valuable to members of the legal profession and to those who, in their relations to the 
 insane and to those supposed to be insane, often desire to acquire some practical knowledge 
 of insanity presented in a form that may be understood by the non-professional reader. 
 
 CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
 Second Edition, Revised. 
 Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
 M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
 in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
 illustrations and 3 full-page plates in colors. Cloth, $1.50 net. 
 
 "The best book of its class for the undergraduate that we know of." — New York 
 Medical Times. 
 
Medical Publications of W. B. Saunders. 9 
 
 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
 Nervous and Mental Diseases. By Archibald Church, M.D., 
 Professor of Mental Diseases and Medical Jurisprudence in the North- 
 western University Medical School, Chicago ; and Frederick Peter- 
 son, M.D., Clinical Professor of Mental Diseases in the Woman's 
 Medical College, New York ; Chief of Clinic, Nervous Department, 
 College of Physicians and Surgeons, New York. In Preparation. 
 
 CLARKSON'S HISTOLOGY. 
 
 A Text=Book of Histology, Descriptive and Practical. By 
 
 Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
 Physiology in the Owen's College, Manchester; late Demonstrator of 
 Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
 22 engravings in the text, and 174 beautifully colored original illustra- 
 tions. Cloth, strongly bound, $6.00 net. 
 
 " The work must be considered a valuable addition to the list of available text- books, 
 and is to be highly recommended." — New York Medical Journal. 
 
 "This is one of the best works for students we have ever noticed. We predict that the 
 book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 
 
 "The volume is a most valuable addition to the armamentarium of the teacher." — 
 Brooklyn Medical J ottrnal. 
 
 CLIMATOLOGY. 
 
 Transactions of the Eighth Annual Meeting of the American 
 Climatological Association, held in Washington, September 22-25, 
 1 89 1. Forming a handsome octavo volume of 276 pages, uniform with 
 remainder of series. (A limited quantity only.) Cloth, $1.50. 
 
 COHEN AND ESHNER'S DIAGNOSIS. 
 
 Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
 fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
 phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
 Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 
 illustrations. Cloth, $1.50 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "We can heartily commend the book to all those who contemplate purchasing a 'com- 
 pend ' It is modern and complete, and will give more satisfaction than many other works 
 which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 
 
 CORWIN'S PHYSICAL DIAGNOSIS. 
 
 Essentials of Physical Diagnosis of the Thorax. By Arthur 
 M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
 Medical College, Chicago ; Attending Physician to Central Free Dis- 
 pensary, Department of Rhinology, Laryngology, and Diseases of the 
 Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. 
 
 "It is excellent. The student who shall use it as his guide to the careful study of 
 physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
 working knowledge of the subject." — Philadelphia Polyclinic. 
 
 "A most excellent little work. It brightens the memory of the differential diagnostic 
 signs, and it arranges orderly and in sequence the various objective phenomena to logical 
 solution of a careful diagnosis. "—Journal of Nervous and Mental Diseases. 
 
10 Medical Publications of W. B. Saunders. 
 
 CRAGIN'S GYNECOLOGY. Fourth Edition, Revised. 
 
 Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- 
 ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New 
 York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, 
 $1.00; interleaved for notes, $1.25. 
 
 [See Saunders 1 Question- Compends, page 21.] 
 
 " A handy volume, and a distinct improvement on students' compends in general. No 
 author who was not himself a practical gynecologist could have consulted the student's needs 
 so thoroughly as Dr. Cragin has done." — Medical Record, New York. 
 
 CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 
 
 A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
 Professor of Comparative Pathology and Bacteriology, King's College, 
 London. Octavo volume of 700 pages, with 273 engravings and 22 
 original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 
 
 " To the student who wishes to obtain a good resume of what has been done in bacteri- 
 ology, or who wishes an accurate account of the various methods of research, the book may 
 be recommended with confidence that he will find there what he requires." — London Lancet. 
 
 Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
 Modern Surgery, General and Operative. By John Chalmers 
 DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical 
 College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 
 Handsome octavo volume of 900 pages, profusely illustrated. Cloth, 
 $4.00 net; Half Morocco, $5.00 net. 
 
 "We know of no small work on surgery in the English language which so well fulfils 
 the requirements of the modern student." — Me die o-Chirnrgical Journal, Bristol, England. 
 
 DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
 Revised. 
 Diseases of the Eye, A Handbook of Ophthalmic Practice. 
 
 By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the 
 Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
 volume of 700 pages, with 256 fine illustrations and 2 chromo-litho- 
 graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. 
 
 " A clearly written, comprehensive manual. One which we can commend to students 
 as a reliable text-book, written with an evident knowledge of the wants of those entering 
 upon the study of this special branch of medical science."- — British Medical Journal. 
 
 ' ' A work that will meet the requirements not only of the specialist, but of the general 
 practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
 Pepper, M.D., Professor of the Theory and Pi'actice of Medicine and Clinical Medicine, 
 University of Pennsylvania. 
 
 DORLANDS OBSTETRICS. 
 
 A Manual of Obstetrics. By W. A. Newman Dorland, M.D., 
 Assistant Demonstrator of Obstetrics, University of Pennsylvania ; 
 Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 
 
 " By far the best book on this subject that has ever come to our notice." — American 
 Medical Review. 
 
 " It has rarely been our duty to review a book which has given us more pleasure in its 
 perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge,. 
 a gold mine of practical, concise thoughts." — American Medico- Surgical Bulletin. 
 
Medical Publications of W. B. Saunders. 11 
 
 FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 
 
 Laboratory Guide for the Bacteriologist. By Langdon Froth- 
 ingham, M.D.V., Assistant in Bacteriology and Veterinary Science, 
 Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 
 
 " It is a convenient and useful little work, and will more than repay the outlay neces- 
 sary for its purchase in the saving of time which would otherwise be consumed in looking 
 up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
 can Medico- Surgical Bulletin. 
 
 GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
 Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
 fessor of Gynecology in the New York School of Clinical Medicine ; 
 Gynecologist to St. Mark's Hospital and to the German Dispensary, 
 New York City, etc. Handsome octavo volume of 728 pages, illus- 
 trated by 335 engravings and colored plates. Cloth, $4.00 net; 
 Sheep or Half Morocco, $5.00 net. 
 
 " One of the best text-books for students and practitioners which has been published in 
 the English language ; it is condensed, clear, and comprehensive. The profound learning 
 and great clinical experience of the distinguished author find expression in this book in a 
 most attractive and instructive form. Young practitioners to whom experienced consultants 
 may not be available will find in this book invaluable counsel and help." — Thad. A. 
 Reamy, M.D., LL.D., Professor of Clinical Gynecology ', Medical College of Ohio. 
 
 GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
 Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
 M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
 Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
 ment of the Northern Dispensary, Philadelphia. 208 pages, with 
 114 illustrations. Cloth, $1. 00; interleaved for notes, .#1.25. 
 [See Saunders'' Question- Co?np ends, page 21.] 
 
 " It is just the book to put into the hands of a student, and cannot fail to give him a 
 useful introduction to ear-affections ; while the style of question and answer which is adopted 
 throughout the book is, we believe, the best method of impressing facts permanently on the 
 mind. " — Liverpool Medico- Chirurgical Journal. 
 
 GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 
 
 Anomalies and Curiosities of Medicine. By George M. Gould, 
 M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
 rare and extraordinary cases and of the most striking instances of 
 abnormality in all branches of Medicine and Surgery, derived from an 
 exhaustive research of medical literature from its origin to the present 
 day, abstracted, classified, annotated, and indexed. Handsome im- 
 perial octavo volume of 968 pages, with 295 engravings in the text, 
 and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. 
 Sold by Subscription. 
 
 " One of the most valuable contributions ever made to medical literature. It is, so far 
 as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
 the medical profession has this volume value : it will serve as a book of reference for all who 
 are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
 Journal. 
 
 "This is certainly a most remarkable and interesting volume. It stands alone among 
 medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
 medical literature. It is a book full of revelations from its first to its last page, and cannot 
 but interest and sometimes almost horrify its readers." — American Medico-Surgical Bulletin. 
 
12 Medical Publications of W. B. Saunders. 
 
 GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. 
 
 Manual of Materia Medica and Therapeutics. By Henry A. 
 Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital, 
 Out-Patient Department, New York City. In Preparatio7i. 
 
 GRIFFITH ON THE BABY. Second Edition, Revised. 
 
 The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
 cal Professor of Diseases of Children, University of Pennsylvania ; 
 Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 
 pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. 
 
 " The best book for the use of the young mother with which we are acquainted. . . . 
 There are very few general practitioners who could not read the book through with advan- 
 tage. ' ' — Archives of Pediatrics. 
 
 "The whole book is characterized by rare good sense, and is evidently written by a 
 master hand. It can be read with benefit not only by mothers but by medical students and 
 by any practitioners who have not had large opportunities for observing children." — Ameri- 
 can Journal of Obstetrics. 
 
 GRIFFITH'S WEIGHT CHART. 
 
 Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., 
 Clinical Professor of Diseases of Children in the University of Penn- 
 sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 
 
 A convenient blank for keeping a record of the child's weight during the first two years 
 of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
 so that any deviation from the normal can readily be detected. 
 
 GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 
 
 Autobiography of Samuel D. Gross, M.D., Emeritus Professor of 
 Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
 niscences of His Times and Contemporaries. Edited by his Sons, 
 Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- 
 gery and of Clinical Surgery in the Jefferson Medical College, and 
 A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a 
 Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
 two handsome volumes, each containing over 400 pages, demy octavo, 
 extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
 per volume, $2.50 net. 
 
 "Dr. Gross was perhaps the most eminent exponent of medical science that America 
 has yet produced. His Autobiography, related as it is with a fulness and completeness 
 seldom to be found in such works, is an interesting and valuable book. He comments on 
 many things, especially, of course, on medical men and medical practice, in a very interest- 
 ing way." — The Spectator, London, England. 
 
 HAMPTON'S NURSING. 
 
 Nursing : Its Principles and Practice. By Isabel Adams Hamp- 
 ton, Graduate of the New York Training School for Nurses attached 
 to Bellevue Hospital ; Superintendent of Nurses, and Principal of the 
 Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 
 i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net. 
 
 " Seldom have we perused a book upon the subject that has given us so much pleasure 
 as the one before us. We would strongly urge upon the members of our own profession the 
 need of a book like this, for it will enable each of us to become a training school in him- 
 self. ' ' — Ontario Medical Journal. 
 
Medical Publications of W. B. Saunders. 13 
 
 HARE'S PHYSIOLOGY. Third Edition, Revised. 
 
 Essentials of Physiology. By H. A. Hare, M.D., Professor of 
 Therapeutics and Materia Medica in the Jefferson Medical College of 
 Philadelphia; Physician to the Jefferson Medical College Hospital. 
 Containing a series of handsome illustrations from the celebrated 
 " Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. 
 Cloth, Si. 00 net; interleaved for notes, $1.25 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " The best condensation of physiological knowledge we have yet seen. '''—Medical 
 Record, Xew York. 
 
 HARTS DIET IN SICKNESS AND IN HEALTH. 
 
 Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
 Student of the Faculty of Medicine of Paris and of the London School 
 of Medicine for Women ; with an Introduction by Sir Henry 
 Thompson, F. R. C. S. , M. D. , London. 220 pages ; illustrated. Cloth, 
 $1.50. 
 
 " We recommend it cordially to the attention of all practitioners ; both to them and to 
 their patients it may be of the greatest service." — New York Medical Journal. 
 
 HAYNES' ANATOMY. 
 
 A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
 Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
 ment of the New York University, etc. 680 pages, illustrated with 42 
 diagrams in the text, and 134 full-page half-tone illustrations from 
 original photographs of the author's dissections. Cloth, $2.50 net. 
 
 " This book is the work of a practical instructor — one who knows by experience the 
 requirements of the average student, and is able to meet these requirements in a very satis- 
 factory way. The book is one that can be commended." — Medical Record, New York. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
 fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
 In Preparation. 
 
 HIRST'S OBSTETRICS. 
 
 A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., 
 Professor of Obstetrics in the University of Pennsylvania. In Prepa- 
 ration. 
 
 HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
 DISEASES. 
 Syphilis and the Venereal Diseases. By James Nevins Hyde, 
 M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
 gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases 
 in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. 
 Cloth, $2.50 net. 
 
 " We can commend this manual to the student as a help to him in his study of venereal 
 diseases. ' ' — Liverpool Medico- Chirurgical Journal. 
 
 "The best student's manual which has appeared on the subject." — St. Louis Medical 
 and Surgical Journal. 
 
14 Medical Publications of W. B. Saunders. 
 
 JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
 THROAT. Second Edition, Revised. 
 Essentials of Refraction and Diseases of the Eye. By Edward 
 Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
 delphia Polyclinic and College for Graduates in Medicine ; and — 
 Essentials of Diseases of the Nose and Throat. By E. Bald- 
 win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
 Ear Department of the Northern Dispensary of Philadelphia. Two 
 volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
 $1.00; interleaved for notes, $1.25. 
 
 [See Saunders" 1 Question- Compends, page 21.] 
 
 " Of great value to the beginner in these branches. The authors are both capable men, 
 and know what a student most needs." — Medical Record, New York. 
 
 KEATING'S DICTIONARY. Second Edition, Revised. 
 
 A New Pronouncing Dictionary of Medicine, with Phonetic 
 Pronunciation, Accentuation, Etymology, etc. By John M. 
 
 Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
 delphia ; Vice-President of the American Psediatric Society ; Editor 
 "Cyclopaedia of the Diseases of" Children," etc.; and Henry 
 Hamilton, Author of '-'A New Translation of Virgil's ^Eneid into 
 English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
 Costa, M.D., and Frederick A. Packard, M.D. With an Appendix 
 containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; 
 Drugs and Materials used in Antiseptic Surgery; Poisons and their 
 Antidotes ; Weights and Measures ; Thermometric Scales ; New 
 Official and Unofficial Drugs, etc. One volume of over 800 pages. 
 Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 
 net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. 
 Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
 $5.00 net. 
 
 " I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
 ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practice 
 of Medicine, Rush Medical College, Chicago, III. 
 
 " I am convinced that it will be a very valuable adjunct to my study-table, convenient 
 in size and sufficiently full for ordinary use." — C. A. LiNDSLEY, M.D., Professor of the 
 Theory and Practice of Medicine, Medical Dept. Yale University. 
 
 KEATING'S LIFE INSURANCE. 
 
 How to Examine for Life Insurance. By John M. Keating, 
 M.D., Fellow of the College of Physicians of Philadelphia; Vice- 
 President of the American Pediatric Society ; Ex-President of the 
 Association of Life Insurance Medical Directors. Royal octavo, 211 
 pages ; with two large half-tone illustrations, and a plate prepared by 
 Dr. McClellan from special dissections ; also, numerous other illustra- 
 tions. Cloth, $2.00 net. 
 
 " This is by far the most useful book which has yet appeared on insurance examination, 
 a subject of growing interest and importance. Not the least valuable portion of the volume 
 is Part II, which consists of instructions issued to their examining physicians by twenty-four 
 representative companies of this country. If for these alone, the book should be at the right 
 hand of every physician interested in this special branch of medical science. ' ' — The Medical 
 News. 
 
Medical Publications of W. B. Saunders. 15 
 
 KEEN ON THE SURGERY OF TYPHOID FEVER. 
 
 The Surgical Complications and Sequels of Typhoid Fever. 
 
 By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
 gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
 Corresponding Member of the Societe de Chirurgie, Paris ; Honorary 
 Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
 386 pages, illustrated. Cloth, $3.00 net. 
 
 This monograph is the only one in any language covering the entire subject of the 
 Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance 
 and interest not only to the general surgeon and physician, but also to many specialists — laryn- 
 gologists, gynecologists, pathologists, and bacteriologists. 
 
 KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
 An Operation Blank, with Lists of Instruments, etc. Required 
 in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
 Professor of the Principles of Surgery in Jefferson Medical College, 
 Philadelphia. Price per pad, containing blanks for fifty operations, 
 50 cents net. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
 Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
 College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
 Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia 
 Orthopedic Hospital. In Preparation. 
 
 LAINE'S TEMPERATURE CHART. 
 
 Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x i^A 
 inches. A conveniently arranged Chart for recording Temperature, 
 with columns for daily amounts of Urinary and Fecal Excretions, 
 Food, Remarks, etc. On the back of each chart is given in full the 
 method of Brand in the treatment of Typhoid Fever. Price, per pad 
 of 25 charts, 50 cents net. 
 
 " To the busy practitioner this chart will be found of great value in fever cases, and 
 especially for cases of typhoid." — Indian Lancet, Calcutta. 
 
 LOCKWOOD'S PRACTICE OF MEDICINE. 
 
 A Manual of the Practice of Medicine. By George Roe Lock- 
 wood, M.D., Professor of Practice in the Woman's Medical College 
 of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
 the text, and 22 full-page plates. Cloth, $2.50 net. 
 
 " Gives in a most concise manner the points essential to treatment usually enumerated 
 in the most elaborate works." — Massachusetts Medical Journal. 
 
 LONGS SYLLABUS OF GYNECOLOGY. 
 
 A Syllabus of Gynecology, arranged in Conformity with " An 
 American Text=Book of Gynecology." By J. W. Long, M.D., 
 Professor of Diseases of Women and Children, Medical College of 
 Virginia, etc. Cloth, interleaved, $1.00 net. 
 
 " The book is certainly an admirable resume of what every gynecological student and 
 practitioner should know, and will prove of value not only to those who have the ' American 
 Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 
 
16 Medical Publications of W. B. Saunders. 
 
 MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 
 
 Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
 Edin., L.R. C.S., Edin., Professor of the Practice of Surgery and of 
 Clinical Surgery in Hamline University; Visiting Surgeon to St. 
 Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
 $6.00 net. 
 
 "A thorough and complete work on surgical diagnosis and treatment, free from pad- 
 ding, full of valuable material, and in accord with the surgical teaching of the day." — The 
 Medical News, New York. 
 
 " The work is brimful of just the kind of practical information that is useful alike to 
 students and practitioners. It is a pleasure to commend the book because of its intrinsic 
 value to the medical practitioner." — Cincinnati Lancet- Clinic. 
 
 MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 
 
 Pathological Technique. A Practical Manual for Laboratory Work 
 in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
 Post-Mortem Technique and the Performance of Autopsies. By Frank 
 B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard 
 University Medical School, Boston; and James H. Wright, A.M., 
 M.D., Instructor in Pathology, Harvard University Medical School, 
 Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
 $2.50 net. 
 
 " I have been looking forward to the publication of this book, and I am glad to say that 
 I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
 and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- 
 versity, Baltimore, Md. 
 
 MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
 DISEASES. Second Edition, Revised. 
 Essentials of Minor Surgery, Bandaging, and Venereal 
 Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
 Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
 octavo, 166 pages, with 78 illustrations. Cloth, #1.00; interleaved for 
 notes, #1.25. 
 
 [See Saunders'' Question- Compends, page 21.] 
 
 "A very practical and systematic study of the subjects, and shows the author's famil- 
 iarity with the needs of students." — Therapeutic Gazette. 
 
 MARTIN'S SURGERY. Sixth Edition, Revised. 
 
 Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
 cal Landmarks, Minor and Operative Surgery, and a complete de- 
 scription, with illustrations, of the Handkerchief and Roller Bandages. 
 By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
 Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
 pages, illustrated. With an Appendix containing full directions for the 
 preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
 $1.00; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Contains all necessary essentials of modern surgery in a comparatively small space. 
 Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. 
 
 
Medical Publications of W. B. Saunders. 17 
 
 McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re= 
 vised and Greatly Enlarged. 
 Text=Book upon the Pathogenic Bacteria. By Joseph McFar- 
 land, M. D. , Professor of Pathology and Bacteriology in the Medico- 
 Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
 finely illustrated. Cloth, $2.50 net. 
 
 " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
 presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
 gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
 students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- 
 teriology, Trinity Medical College, Toronto. 
 
 MEIGS ON FEEDING IN INFANCY. 
 
 Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
 in limp cloth, flush edges, 25 cents net. 
 
 "This pamphlet is worth many times over its price to the physician. The author's 
 experiments and conclusions are original, and have been the means of doing much good." — 
 Medical Bulletin. m 
 
 MOORE'S ORTHOPEDIC SURGERY. 
 
 A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
 Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
 University of Minnesota, College of Medicine and Surgery. Octavo 
 volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. 
 
 A practical book based upon the author's experience, in which special stress is laid 
 upon early diagnosis, and treatment such as can be carried out by the general practitioner. 
 The teachings of the author are in accordance with his belief that true conservatism is to 
 be found in the middle course between the surgeon who operates too frequently and the 
 orthopedist who seldom operates. 
 
 MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
 Edition, Revised. 
 Essentials of Materia Medica, Therapeutics, and Prescription 
 Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
 peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
 of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
 $1.00 ; interleaved for notes, #1.25. 
 
 [See Saunders' Question- Comf ends, page 21.] 
 
 " This work, already excellent in the old edition, has been largely improved by revi- 
 sion. " — American Practitioner and News. 
 
 MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
 Third Edition, Revised. 
 Essentials of the Practice of Medicine. By Henry Morris, M.D., 
 late Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
 delphia ; with an Appendix on the Clinical and Microscopic Examina- 
 tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry, 
 Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
 tial formulae collected and arranged by William M. Powell, M.D. 
 Post-octavo, 488 pages. Cloth, $2.00. 
 
 [See Saunders' Question- Commends, page 21.] 
 
 . " The teaching is sound, the presentation graphic ; matter full as can be desired, and 
 style attractive." — American Practitioner and News. 
 
18 Medical Publications of W. B. Saunders. 
 
 MORTEN'S NURSE'S DICTIONARY. 
 
 Nurse's Dictionary of Medical Terms and Nursing Treat- 
 ment. Containing Definitions of the Principal Medical and Nursing 
 Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
 dents, Treatments, Operations, Foods, Appliances, etc. encountered 
 in the ward or in the sick-room. By Honnor Morten, author of 
 "How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00. 
 
 " A handy, compact little volume, containing a large amount of general information, all 
 of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
 It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 
 
 NANCREDE'S ANATOMY. Fifth Edition. 
 
 Essentials of Anatomy, including the Anatomy of the Viscera. 
 By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- 
 cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 
 388 pages; .180 illustrations. With an Appendix containing over 60 
 illustrations of the osteology of the human body. Based upon Gray 's 
 Anatomy. Cloth, $1.00; interleaved for notes, #1.25. 
 [See Saunders 1 Question- Compends , page 21.] 
 
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 school, it would not be easy to speak of it in terms too favorable." — American Practitioner. 
 
 NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
 Essentials of Anatomy and Manual of Practical Dissection. 
 
 By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical 
 Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, 
 with full-page lithographic plates in colors, and nearly 200 illustrations. 
 Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. 
 
 " It may in many respects be considered an epitome of Gray's popular work on general 
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 it. The plates are of more than ordinary excellence, and are of especial value to students 
 in their work in the dissecting room." — Journal of the Americati Medical Association. 
 
 NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
 Syllabus of Obstetrical Lectures in the Medical Department 
 of the University of Pennsylvania. By Richard C. Norris, 
 A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. 
 Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 
 
 " This work is so far superior to others on the same subject that we take pleasure in 
 calling attention briefly to its excellent features. It covers the subject thoroughly, and will 
 prove invaluable both to the student and the practitioner." — Medical Record, New York. 
 
 PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. 
 A Text=Book of Diseases of Women. By Charles B. Penrose, 
 M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- 
 vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
 volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. 
 
 "I shall value very highly the copy of Penrose's 'Diseases of Women' received. 
 I have already recommended it to my class as THE BEST book." — Howard A. Kelly, 
 Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 
 
 " The book is to be commended without reserve, not only to the student but to the 
 general practitioner who wishes to have the latest and best modes of treatment explained 
 with absolute clearness." — Therapeutic Gazette. 
 
Medical Publications of W. B. Saunders. 19 
 
 POWELL'S DISEASES OF CHILDREN. Second Edition. 
 
 Essentials of Diseases of Children. By William M. Powell, 
 M.D., Attending Physician to the Mercer House for Invalid Women 
 at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
 Children in the Hospital of the University of Pennsylvania. Crown 
 octavo, 222 pages. Cloth, $1.00; interleaved for notes, $1.25. 
 
 [See Saunders 7 Question- Compends, page 21.] 
 
 "Contains the gist of all the best works in the department to which it relates."— 
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 PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
 Pictorial Atlas of Skin Diseases and Syphilitic Affections 
 (American Edition). Translation from the French. Edited by 
 J. J. Pringle, M.B., F.R. C.P., Assistant Physician to the Middlesex 
 Hospital, London. Photo-lithochromes from the famous models in 
 the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
 cuts and text. In 12 Parts. Price per Part, $3.00. Complete in 
 one volume, Half Morocco binding, $40.00 net. 
 
 "I strongly recommend this Atlas. The plates are exceedingly well executed, and 
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 "The introduction of explanatory wood-cuts in the text is a novel and most important 
 feature which greatly furthers the easier understanding of the excellent plates, than which 
 nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
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 PYES BANDAGING. 
 
 Elementary Bandaging and Surgical Dressing. With Direc- 
 tions concerning the Immediate Treatment of Cases of Emergency. 
 For the use of Dressers and Nurses. By Walter Pve, F.R.C.S., late 
 Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
 illustrations. Cloth, flexible covers, 75 cents net. 
 
 " The directions are clear and the illustrations are good." — London Lancet. 
 " The author writes well, the diagrams are clear, and the book itself is small and port- 
 able, although the paper and type are good." — British Medical Journal. 
 
 RAYMOND'S PHYSIOLOGY. 
 
 A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
 Professor of Physiology and Hygiene and Lecturer on Gynecology in 
 the Long Island College Hospital ; Director of Physiology in the 
 Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
 text, and 4 full-page colored plates. Cloth, $1.25 net. 
 
 " Extremely well gotten up, and the illustrations have been selected with care. The 
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 RONTGEN RAYS. 
 
 Archives of the Rontgen Ray (Formerly Archives of Clinical 
 Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and 
 W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, 
 with descriptive text, illustrating the applications of the new photo- 
 graphy to Medicine and Surgery. Price per Part, $1.00. Now ready: 
 Vol. I., Parts I. to IV.; Vol. II., Parts L, II. 
 
►AUNDERS' 
 
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 C^rMUTDTmiTlC ILLUSTRATED SERIES OF 
 
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 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition, 
 
 revised and enlarged. ($1.00 net.) 
 
 2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 
 
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 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth 
 
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 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 
 
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 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 
 
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 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 
 
 Armand Semple, M.D. 
 
 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 
 
 SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 
 
 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 
 
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 Third edition, enlarged by some 300 Essential Formulae, selected from eminent 
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 10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth 
 
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 By C. E. Armand Semple, M.D. 
 
 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 
 
 By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 
 
 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 
 
 M.D. Second edition. 
 
 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 
 
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 1 7. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D. , and A. A. Eshner, 
 
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 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 
 
 Second edition, revised and enlarged. 
 
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 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 
 
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 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. 
 
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 23. ESSENTIALS OF MEDICAL ELECTRICITY. By Dayid D. Stewart, M.D., 
 
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 Second edition, revised and greatly enlarged. 
 
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Saunders' . - A 
 
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 New Series and 
 
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 ^f^HAT there exists a need for thoroughly reliable hand-books on the leading branches 
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 the SAUNDERS NEW SERIES OF MANUALS have been received by medical 
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 Any of these Manuals will be mailed on receipt of price (see next page for List). 
 
Saunders' New Series of Manuals. 
 
 VOLUMES PUBLISHED. 
 
 PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
 and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; 
 Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. 
 
 SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- 
 cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the 
 Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. 
 Octavo, 900 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5.00 net. 
 
 DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. 
 
 Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
 delphia. Illustrated. Cloth, $1.25 net. 
 
 SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
 to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. 
 
 MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
 tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
 delphia. Illustrated. Cloth, $1.50 net. 
 
 SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
 Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
 Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
 Chicago. Profusely illustrated. (Double number.) Cloth, $2.50 net. 
 
 PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
 Practice in the Woman's Medical College of the New York Infirmary; Instructor in 
 Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
 (Double number.) Cloth, $2.50 net. 
 
 MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
 Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
 University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net. 
 
 MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
 Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
 pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, 
 $2.50 net. 
 
 DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to 
 Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E. 
 Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
 London. Handsomely illustrated. (Double number.) Cloth, $2.50 net. 
 
 VOLUMES IN PREPARATION. 
 
 NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- 
 gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo- 
 gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel- 
 phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 
 
 NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
 Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopedic 
 Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph 
 Hospital, etc. 
 
 *** There will be published in the same series, at short intervals, carefully-prepared works 
 on various subjects by prominent specialists. 
 
 Pamphlet containing specimen pages, etc* sent free upon application* 
 
24 Medical Publications of W. B. Saunders. 
 
 SAUNDBY'S RENAL AND URINARY DISEASES. 
 
 Lectures on Renal and Urinary Diseases. By Robert Saundby, 
 M.D. Edin., Fellow of the Royal College of Physicians, London, and 
 of the Royal Medico-Chirurgical Society ; Physician to the General 
 Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
 pital for Diseases of Women; Professor of Medicine in Mason College, 
 Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
 trations and 4 colored plates. Cloth, $2.50 net. 
 
 " The volume makes a favorable impression at once. The style is clear and succinct. 
 We cannot find any part of the subject in which the views expressed are not carefully thought 
 out and fortified by evidence drawn from the most recent sources. The book may be cordially 
 recommended.' ' — British Medical Journal. 
 
 SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, 
 Revised. 
 
 By William M. Powell, M.D., Attending Physician to the Mercer 
 House for Invalid Women at Atlantic City, N. J. Containing 1800 
 formulae selected from the best-known authorities. With an Appen- 
 dix containing Posological Table, Formulae and Doses for Hypo- 
 dermic Medication, Poisons and their Antidotes, Diameters of the 
 Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
 Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
 of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
 Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
 somely bound in flexible morocco, with side index, wallet, and flap. 
 
 £i.75 net - 
 
 " This little book, that can be conveniently carried in the pocket, contains an immense 
 amount of material. It is very useful, and, as the name of the author of each prescription 
 is given, is unusually reliable." — Medical Record, New York. 
 
 SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition, 
 Revised. 
 A Dictionary of Terms and Words used in Medicine and 
 Surgery. By John M. Keating, M.D., Fellow of the College of 
 Physicians of Philadelphia; Editor of the "Cyclopaedia of Diseases 
 of Children," etc.; Author of the "New Pronouncing Dictionary of 
 Medicine;" and Henry Hamilton, Author of "A New Translation 
 of Virgil's ^Eneid into English Verse;" Co- Author of the "New 
 Pronouncing Dictionary of Medicine." 32mo, 280 pages. Cloth, 
 75 cents; Leather Tucks, $1.00. 
 
 "Remarkably accurate in terminology, accentuation, and definition." — Journal of the 
 American Medical Association . 
 
 SAYRE'S PHARMACY. Second Edition, Revised. 
 
 Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
 M.D., Professor of Pharmacy and Materia Medica in the University of 
 Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for 
 notes, $1.25. 
 
 [See Saunders'' Question- Compends, page 21.] 
 
 "The topics are treated in a simple, practical manner, and the work forms a very useful 
 student's manual." — Boston Medical and Surgical Journal. 
 
Medical Publications of W. B. Saunders. 25 
 
 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
 Essentials of Legal Medicine, Toxicology, and Hygiene. By 
 
 C. E. Armand Semple, B.A., M. B. Cantab., M. R. C. P. Lond., 
 Physician to the Northeastern Hospital for Children, Hackney, etc. 
 Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00; interleaved 
 for notes, S 1 • 2 5 . 
 
 [See Saunders 1 Question- Compends, page 21.] 
 
 " No general practitioner or student can afford to be without this valuable work. The 
 subjects are dealt with by a masterly hand." — London Hospital Gazette. 
 
 SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 
 
 Essentials of Pathology and Morbid Anatomy. By C. E. 
 
 Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
 the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 
 174 pages; illustrated. Cloth, $1. 00; interleaved for notes, $1.25. 
 [See Saunders 1 Question- Compends, page 21.] 
 
 " Should take its place among the standard volumes on the bookshelf of both student 
 and practitioner." — London Hospital Gazette. 
 
 SENN'S GENITOURINARY TUBERCULOSIS. 
 
 Tuberculosis of the Genito-Urinary Organs, Male and Female. 
 
 By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
 Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
 Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. 
 
 " An important book upon an important subject, and written by a man of mature judg- 
 ment and wide experience. The author has given us an instructive book upon one of the 
 most important subjects of the day." — Clinical Reporter. 
 
 " A work which adds another to the many obligations the profession owes the talented 
 author." — Chicago Medical Recorder. 
 
 SENN'S SYLLABUS OF SURGERY. 
 
 A Syllabus of Lectures on the Practice of Surgery, arranged 
 in conformity with «« An American Text=Book of Surgery." By 
 
 Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
 of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. 
 
 " This syllabus will be found of service by the teacher as well as the student, the work 
 being superbly done. There is no praise too high for it. No surgeon should be without 
 it. " — New York Medical Times. 
 
 SENN'S TUMORS. 
 
 Pathology and Surgical Treatment of Tumors. By N. Senn, 
 
 M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
 Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
 Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
 Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
 engravings, including full-page colored plates. Cloth, $6.00 net; 
 Half Morocco, $7.00 net. 
 
 " The most exhaustive of any recent book in English on this subject. It is well illus- 
 trated, and will doubtless remain as the principal monograph on the subject in our language 
 for some years. The book is handsomely illustrated and printed, and the author has given a 
 notable and lasting contribution to surgery." — Journal of the American Medical Association. 
 
26 Medical Publications of W. B. Saunders. 
 
 SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
 Revised. 
 Essentials of Nervous Diseases and Insanity. By John C. 
 Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
 System, Long Island College Hospital Medical School ; Consulting 
 Neurologist to St. Catherine's Hospital and to the Long Island College 
 Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, 
 #1.00 ; interleaved for notes, #1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 "Clearly and intelligently written." — Boston Medical and Surgical Journal. 
 
 "There is a mass of valuable material crowded into this small compass." — American- 
 Medico- Surgical Bulletin. 
 
 STARR'S DIETS FOR INFANTS AND CHILDREN. 
 
 Diets for Infants and Children in Health and in Disease. By 
 
 Louis Starr, M.D., Editor of "An American Text-Book of the 
 Diseases of Children." 230 blanks (pocket-book size), perforated 
 and neatly bound in flexible morocco. $1.25 net. 
 
 The first series of blanks are prepared for the first seven months of infant life ; each 
 blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
 left for the physician. After the seventh month, modifications being less necessary, the diet 
 lists are printed in full. Formulas for the preparation of diluents and foods are appended. 
 
 STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised. 
 Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
 M.D., Clinical Professor of Dermatology in the Jefferson Medical 
 College, Philadelphia; Dermatologist to the Philadelphia Hospital; 
 Physician to the Skin Department of the Howard Hospital, etc. 
 Crown octavo, 270 pages; 86 illustrations. Cloth, $1. 00 net; inter- 
 leaved for notes, #1.25 net. , 
 
 [See Saunders' Question- Compends, page 21.] 
 " The best student's manual on skin diseases we have yet seen." — Times and Register. 
 
 STENGEL'S PATHOLOGY. 
 
 A Manual of Pathology. By Alfred Stengel, M.D., Physician 
 to the Philadelphia Hospital; Professor of Clinical Medicine in the 
 Woman's Medical College; Physician to the Children's Hospital; 
 late Pathologist to the German Hospital, Philadelphia, etc. In 
 Preparation. 
 
 STEVENS' MATERIA MEDIC A AND THERAPEUTICS. Second 
 Edition, Revised. 
 A Manual of Materia Medica and Therapeutics. By A. A. 
 
 Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
 Physical Diagnosis in the University of Pennsylvania ; Demonstrator 
 of Pathology in the Woman's Medical College of Philadelphia. Post- 
 octavo, 445 pages. Cloth, $2.25. 
 
 "The author has faithfully presented modern therapeutics in a comprehensive work, 
 and, while intended particularly for the use of students, it will be found a reliable guide and 
 sufficiently comprehensive for the physician in practice." — University Medical Magazine. 
 
Medical Publications of W. B. Saunders. 27 
 
 STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
 A Manual of the Practice of Medicine. By A. A. Stevens, A.M., 
 M.D., Lecturer on Terminology and Instructor in Physical Diagnosis 
 in the University of Pennsylvania ; Demonstrator of Pathology in 
 the Woman's Medical College of Philadelphia, Specially intended 
 for students preparing for graduation and hospital examinations. Post- 
 octavo, 511 pages; illustrated. Flexible leather, $2.50. 
 
 " The frequency with which new editions of this manual are demanded bespeaks its 
 popularity. It is an excellent condensation of the essentials of medical practice for the 
 student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
 Medical Journal. 
 
 STEWART'S PHYSIOLOGY. 
 
 A Manual of Physiology, with Practical Exercises. For 
 Students and Practitioners. By G. N. Stewart, M.A., M.D., 
 D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
 of the New Museums, Cambridge University ; Professor of Physiology 
 in the Western Reserve University, Cleveland, Ohio. Octavo volume 
 of 800 pages; 278 illustrations in the text, and 5 colored plates. 
 Cloth, $3.50 net. 
 
 " It will make its way by sheer force of merit, and amply deserves to do so. It is one 
 of the very best English text-books on the subject." — London Lancet. 
 
 "Of the many text-books of physiology published, we do not know of one that so 
 nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. 
 
 STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 
 
 Essentials of Medical Electricity. By D. D. Stewart, M.D., 
 Demonstrator of Diseases of the Nervous System and Chief of the 
 Neurological Clinic in the Jefferson Medical College; and E. S. 
 Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
 strator of Diseases of the Nervous System in the Jefferson Medical 
 College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
 $1.00; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Throughout the whole brief space at their command the authors show a discriminating 
 knowledge of their subject." — Medical News. 
 
 STONEY'S NURSING. Second Edition, Revised. 
 
 Practical Points in Nursing. For Nurses in Private Practice. 
 
 By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
 Lawrence, Mass.; late Superintendent of the Training-School for 
 Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
 with 73 engravings in the text, and 8 colored and half-tone plates. 
 Cloth, $1.75 net. 
 
 " There are few books intended for non-professional readers which can be so cordially 
 endorsed by a medical journal as can this one." — Therapeutic Gazette. 
 
 " This is a well-written, eminently practical volume, which covers the entire range of 
 private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
 meet the various emergencies which may arise, and how to prepare everything ordinarily 
 needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
 Wotnen and Children. 
 
 " It is a work that the physician can place in the hands of his private nurses with the 
 assurance of benefit." — Ohio Medical Journal. 
 
28 Medical Publications of W. B. Saunders. 
 
 SUTTON AND GILES' DISEASES OF WOMEN. 
 
 Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
 Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
 London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., 
 Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
 somely illustrated. Cloth, $2.50 net. 
 
 ' • The book is very well prepared, and is certain to be well received by the medical 
 public. " — British Medical Journal. 
 
 "The text has been carefully prepared. Nothing essential has been omitted, and its 
 teachings are those recommended by the leading authorities of the day." — Journal of tht 
 American Medical Association. 
 
 THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 
 
 Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
 M.D., Visiting Physician to the Home for Friendless Women and 
 Children and to the Newsboys' Home ; Assistant Visiting Physician 
 to the Kings County Hospital. Cloth, #1.50. Send for sample sheet. 
 
 " The idea is good, and the lists are copious." — London Lancet. 
 
 "Its practical usefulness places it among the requirements of every practitioner." — 
 Chicago Medical Recorder. 
 
 THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING. 
 
 Dose=Book and Manual of Prescription=Writing. By E. Q. 
 
 Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
 College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 
 
 "Full of practical suggestions; will take its place in the front rank of works of this 
 sort." — Medical Record, New York. 
 
 VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
 Diseases of the Stomach. By William W. Van Valzah, M.D. , 
 Professor of General Medicine and Diseases of the Digestive System 
 and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
 Adjunct Professor of General Medicine and Diseases of the Digestive 
 System and the Blood, New York Polyclinic. Octavo volume of 674 
 pages, illustrated. Cloth, $3.50 net. 
 
 VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
 Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
 cine at the University of Heidelberg. Translated, with additions, 
 from the fifth enlarged German edition, with the author's permission, 
 by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
 of 600 pages; 194 fine wood-cuts in text, many of them in colors. 
 Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia, 
 $5.50 net. 
 
 " A treasury of practical information which will be found of daily use to every busy 
 practitioner who will consult it." — C. A. LiNDSLEY, M.D., Professor of the Theory and 
 Practice of Medicine, Yale University. 
 
 " Rarely is a book published with which a reviewer can find so little fault as with the 
 volume before us. Each particular item in the consideration of an organ or apparatus, which 
 is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
 seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
 nervous system are especially full and valuable. The reviewer would repeat that the book is 
 one of the best — probably the best — which has fallen into his hands." — University Medical 
 Magazine. 
 
Medical Publications of W. B. Saunders. 29 
 
 WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 
 
 Surgical Pathology and Therapeutics. By John Collins Warren, 
 M.D., LL.D., Professor of Surgery, Medical Department Harvard 
 University; Surgeon to the Massachusetts General Hospital, etc. 
 Handsome octavo volume of 832 pages; 136 relief and lithographic 
 illustrations, 33 of which are printed in colors, and all of which were 
 drawn by William J. Kaula from original specimens. Cloth, $6.00 
 net; Half Morocco, $7.00 net. 
 
 "There is the work of Dr. Warren, which I think is the most creditable book on 
 Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
 has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
 Graduate Magazine. 
 
 " The handsomest specimen of bookmaking that has ever been issued from the American 
 medical press." — American Journal of the Medical Sciences. 
 
 "A most striking and very excellent feature of this book is its illustrations. Without 
 exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
 of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
 and detail as almost to give the beholder the impression that he is looking down the barrel 
 of a microscope at a well-mounted section." — Annals of Surgery.- 
 
 WEST'S NURSING. 
 
 An American Text=Book of Nursing. By American Teachers. 
 Edited by Roberta M. West, late Superintendent of Nurses in the 
 Hospital of the University of Pennsylvania. In Preparation. 
 
 WOLFF ON EXAMINATION OF URINE. 
 
 Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
 Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
 etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
 octavo. Cloth, 75 cents. 
 
 [See Saunders' Question- Compends, page 21.] 
 " A very good work of its kind — very well suited to its purpose." — Times and Register. 
 
 WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. 
 Essentials of Medical Chemistry, Organic and Inorganic. 
 
 Containing also Questions on Medical Physics, Chemical Physiology, 
 Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
 Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
 Philadelphia, etc. Crown octavo, 218 pages. Cloth, #1.90; inter- 
 leaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " The scope of this work is certainly equal to that of the best course of lectures on 
 Medical Chemistry." — Pharmaceutical Era. 
 
CLASSIFIED LIST 
 
 Medical Publications 
 
 W. B, SAUNDERS, 
 
 925 Walnut Street, Philadelphia, 
 
 ANATOMY, EMBRYOLOGY, 
 HISTOLOGY. 
 
 Clarkson — A Text-Book of Histology, 9 
 Haynes — A Manual of Anatomy, . . . 13 
 Heisler — A Text- Book of Embryology, 13 
 Nancrede — Essentials of Anatomy, . . 18 
 Nancrede — Essentials of Anatomy and 
 
 Manual of Practical Dissection, ... 18 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, 25 
 
 BACTERIOLOGY. 
 
 Ball — Essentials of Bacteriology, ... 6 
 Crookshank — A Text- Book of Bacteri- 
 ology, 10 
 
 Frothingham — Laboratory Guide, . . II 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 McFarland — Pathogenic Bacteria, . . 17 
 
 CHARTS, DIET-LISTS, ETC. 
 
 Griffith — Infant's Weight Chart, . . 12 
 
 Hart — Diet in Sickness and in Health, . 13 
 
 Keen — Operation Blank, 15 
 
 Laine — Temperature Chart, . . . 15 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Starr — Diets for Infants and Children, . 26 
 Thomas — Diet-Lists and Sick-Room 
 
 Dietary, 28 
 
 CHEMISTRY AND PHYSICS. 
 
 Brockway — Essentials of Medical Phys- 
 ics, 7 
 
 Wolff — Essentials of Medical Chemistry, 29 
 
 CHILDREN. 
 
 An American Text-Book of Diseases 
 
 of Children, . . 3 
 
 Griffith— Care of the Baby 12 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Powell — Essentials of Dis. of Children, 19 
 
 Starr — Diets for Infants and Children, . 26 
 
 DIAGNOSIS. 
 
 Cohen and Eshner— Essentials of Di- 
 agnosis, 9 
 
 Corwin — Physical Diagnosis, .... 9 
 
 Macdonald — Surgical Diagnosis and 
 Treatment, 16 
 
 Vierordt— Medical Diagnosis, .... 28 
 
 DICTIONARIES. 
 
 Keating — Pronouncing Dictionary, . . 14 
 
 Morten — Nurse's Dictionary, .... 18 
 
 Saunders' Pocket Medical Lexicon, . 24 
 
 EYE, EAR, NOSE, AND THROAT. 
 
 An American Text- Book of Diseases 
 
 of the Eye, Ear, Nose, and Throat, . 3 
 Casselberry — Dis. of Nose and Throat, 8 
 De Schweinitz — Diseases of the Eye, . 10 
 Gleason — Essentials of Dis. of the Ear, II 
 Jackson and Gleason — Essentials of 
 
 Diseases of the Eye, Nose, and Throat, 14 
 Kyle — Diseases of the Nose and Throat, 15 
 
 GENITOURINARY. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 4 
 
 Hyde and Montgomery — Syphilis and 
 the Venereal Diseases, ... ... 13 
 
 Martin — Essentials of Minor Surgery. 
 Bandaging, and Venereal Diseases, . 16 
 
 Saundby — Renal and Urinary Diseases, 24 
 
 Senn — Genito- Urinary Tuberculosis, . 25 
 
 GYNECOLOGY. 
 
 American Text-Book of Gynecology, 4 
 Cragin — Essentials of Gynecology, . . 10 
 Garrigues — Diseases of Women, . . . 11 
 Long — Syllabus of Gynecology, ... 15 
 Penrose — Diseases of Women, .... 18 
 Sutton and Giles — Diseases of Women, 28 
 
 MATERIA MEDICA, PHARMACOL- 
 OGY, AND THERAPEUTICS. 
 
 An American Text-Book of Applied 
 
 Therapeutics, .... 3 
 
 Butler — Text-Book of Materia Medica, 
 
 Therapeutics and Pharmacology, ... 8 
 Cerna — Notes on the Newer Remedies, 8 
 Griffin — Materia Med. and Therapeutics, 12 
 Morris — Essentials of Materia Medica 
 
 and Therapeutics, . . 17 
 
 Saunders' Pocket Medical Formulary, 24 
 Sayre — Essentials of Pharmacy, ... 24 
 Stevens — Essentials of Materia Medica 
 
 and Therapeutics, 26 
 
 Thornton — Dose-Book and Manual of 
 
 Prescription-Writing, 28 
 
 Warren — Surgical Pathology and Ther- 
 apeutics, 29 
 
 MEDICAL JURISPRUDENCE AND 
 TOXICOLOGY. 
 
 An American Text-Book of Legal 
 Medicine and Toxicology, 4 
 
 Chapman — Medical Jurisprudence and 
 Toxicology, 8 
 
 Semple — Essentials of Legal Medicine, 
 Toxicology, and Hygiene, 25 
 
Medical Publications of W. B. Saunders. 
 
 31 
 
 NERVOUS AND MENTAL 
 DISEASES, ETC. 
 
 Burr — Nervous Diseases, 7 
 
 Chapin — Compendium of Insanity, . . 8 
 Church and Peterson — Nervous and 
 
 Mental Diseases, 9 
 
 Shaw — Essentials of Nervous Diseases 
 
 and Insanity, 26 
 
 NURSING. 
 
 An American Text-Book of Nursing, 29 
 
 Griffith— The Care of the Baby, ... 12 
 
 Hampton — Nursing, 12 
 
 Hart — Diet in Sickness and in Health, 13 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Morten — Nurse's Dictionary, .... 18 
 
 Stoney — Practical Points in Nursing, . 27 
 
 OBSTETRICS. 
 
 An American Text-Book of Obstetrics, 4 
 Ashton — Essentials of Obstetrics, . . 6 
 Boisliniere— Obstetric Accidents, Emer- 
 gencies, and Operations, 7 
 
 Dorland — Manual of Obstetrics, . . . io 
 
 Hirst — Text-Book of Obstetrics, ... 13 
 
 Norris — Syllabus of Obstetrics, .... 18 
 
 PATHOLOGY. 
 
 An American Text-Bcok of Pathology, 5 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, . . . 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 Stengel — Manual of Pathology, ... 26 
 Warren — Surgical Pathology and Thera- 
 peutics, 29 
 
 PHYSIOLOGY. 
 
 An American Text-Book of Physi- 
 ology, 5 
 
 Hare — Essentials of Physiology, ... 13 
 Raymond — Manual of Physiology, . . 19 
 Stewart — Manual of Physiology, ... 27 
 
 PRACTICE OF MEDICINE. 
 
 An American Text-Book of the The- 
 ory and Practice of Medicine, .... 5 
 
 An American Year-Book of Medicine 
 and Surgery, . 6 
 
 Anders — Text-Book of the Practice of 
 Medicine, 6 
 
 Lockwood — Manual of the Practice of 
 Medicine, . 15 
 
 Morris — Essentials of the Practice of 
 Medicine, ... 17 
 
 Rowland and Hedley — Archives of 
 the Roentgen Ray, 19 
 
 Stevens — Manual of the Practice of 
 Medicine, 27 
 
 SKIN AND VENEREAL. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 3 
 
 Hyde and Montgomery — Syphilis and 
 the Venereal Diseases, 13 
 
 Martin — Essentials of Minor Surgery, 
 Bandaging, and Venereal Diseases, . 16 
 
 Pringle — Pictorial Atlas of Skin Dis- 
 eases and Syphilitic Affections, ... 19 
 
 Stelwagon — Essentials of Diseases of 
 the Skin, 26 
 
 SURGERY. 
 
 An American Text-Book of Surgery, 5 
 An American Year-Book of Medicine 
 
 and Surgery, 6 
 
 Beck — Manual of Surgical Asepsis, . . 7 
 DaCosta — Manual of Surgery, .... 10 
 Keen— Operation Blank, ... . . 15 
 Keen — The Surgical Complications and 
 
 Sequels of Typhoid Fever, 15 
 
 Macdonald — Surgical Diagnosis and 
 
 Treatment, 16 
 
 Martin — Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . 16 
 Martin — Essentials of Surgery, .... 16 
 
 Moore — Orthopedic Surgery, 17 
 
 Pye — Elementary Bandaging and Surgi- 
 cal Dressing, 19 
 
 Rowland and Hedley— Archives of 
 
 the Roentgen Ray, 19 
 
 Senn — Genito-Urinary Tuberculosis, . 25 
 
 Senn - Syllabus of Surgery, 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, . . 25 
 
 Warren — Surgical Pathology and Ther- 
 apeutics, 29 
 
 URINE AND URINARY DISEASES. 
 
 Saundby — Renal and Urinary Diseases, 24 
 Wolff — Essentials of Examination of 
 Urine, 29 
 
 MISCELLANEOUS. 
 
 Bastin — Laboratory Exercises in Bot- 
 any, 7 
 
 Gould and Pyle — Anomalies and Curi- 
 osities of Medicine, 11 
 
 Keating — How to Examine for Life 
 Insurance, 14 
 
 Keen — Surgical Complications and Se- 
 quels of Typhoid Fever, 15 
 
 Rowland and Hedley — Archives of 
 the Roentgen Ray, 19 
 
 Saunders' Medical Hand-Atlases, . . 2 
 
 Saunders' New Series of Manuals, 22, 23 
 
 Saunders' Pocket Medical Formulary, . 24 
 
 Saunders' Question-Compends, . . 20, 21 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, ... . .25 
 
 Stewart and Lawrance — Essentials of 
 Medical Electricity, 27 
 
 Thornton — Dose-Book and Manual of 
 Prescription-Writing, . 28 
 
 Van Valzah and Nisbet— Diseases of 
 the Stomach, 28 
 
In Preparation for Early Publication. 
 
 AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, 
 AND THROAT. 
 
 Edited by G. E. de Schweinitz, M.D. , Professor of Ophthalmology in the Jeffer- 
 son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor 
 of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia 
 Polyclinic. 
 
 AN AMERICAN TEXT=BOOK OF PATHOLOGY. 
 
 Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid 
 Anatomy in the University of Pennsylvania; and David Riesman, M.D., Demon- 
 strator of Pathological Histology in the University of Pennsylvania. 
 
 AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXICOLOGY. 
 
 Edited by Frederick Peterson, M.D., Clinical ; Professor of Mental Di; 
 the Woman's Medical College, New York ; Chief of Clinic, Nervous Dei 
 College of Physicians and Surgeons, New York ; and Walter S. Haines, .D., 
 Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago, 
 Illinois. 
 
 STENGEL'S PATHOLOGY. 
 
 A Manual of Pathology. By Alfred Stengel, M. D., Physician to the 
 Philadelphia Hospital; Professor of Clinical Medicine in the Woman's Medical 
 College ; Physician to the Children's Hospital ; late Pathologist to the German 
 Hospital, Philadelphia, etc. 
 
 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
 
 Nervous and Mental Diseases. By Archibald Church, M.D., Professor of 
 
 Mental Diseases and Medical Jurisprudence in the Northwestern University Medical 
 School, Chicago ; and Frederick Peterson, M.D., Clinical Professor of Mental 
 Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous 
 Department, College of Physicians and Surgeons, New York. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Professor of 
 Anatomy in the Medico-Chirurgical College, Philadelphia. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- 
 fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- 
 sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital; Bacteriologist 
 to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 
 
 HIRST'S OBSTETRICS. 
 
 A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of 
 Obstetrics in the University of Pennsylvania. 
 
 WEST'S NURSING. 
 
 An American Text-Book of Nursing. By American Teachers. Edited by 
 Roberta M. West, Late Superintendent of Nurses in the Hospital of the University 
 of Pennsylvania. 
 
 LB S TO 
 
 E 906 
 
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